2023-04-22

The CDC Lacks a Rural Focus. Researchers Hope a Newly Funded Office Will Help.

In 2017, the Centers for Disease Control and Prevention published multiple reports analyzing health disparities between rural and urban populations.

That effort pleased researchers and advocates for improving rural health because the dozen or so examinations of rural health data provided important details about the 46 million Americans who live away from the nation’s population centers. It began to fill a gap in the information used by those who study and address the issues that affect people in rural communities.

But those reports, the Morbidity and Mortality Weekly Report rural health series, began and ended in 2017. And though the CDC has addressed rural health in other weekly reports and data briefs, the agency hasn’t examined it in such depth since.

That’s one reason rural health advocates successfully pushed for the CDC to extend its rural health focus by creating an Office of Rural Health at the agency. The office is operational as of March 2023, and advocates hope the agency will commit to rural health research and provide analyses that lead to good public health policies for rural communities.

“What we’re seeing is rural continually getting left behind,” said Alan Morgan, CEO of the National Rural Health Association, which urged Congress to fund the office. “They’re communities at risk, communities that may not be employing public health safety measures, and we are flying blind,” he said.

“What’s needed is an ongoing look at rural communities, their populations, to better direct both state and federal efforts to address health disparities,” he said.

The omnibus appropriations bill signed by President Joe Biden in December 2022 gave the CDC $5 million for the 2023 fiscal year to create the Office of Rural Health inside the agency, which has a $9.3 billion budget this year. Congress directed the CDC to sharpen its focus on public health in rural areas with the new office, after covid-19 had an outsize impact on rural America.

Though the CDC is a data-driven public health agency, it’s unlikely the new office will solve preexisting rural data challenges. But CDC officials have said in-depth rural health initiatives that require collaborations across the CDC — like the Morbidity and Mortality Weekly Report rural health series — could become more common practice at the agency.

“Instead of comparing rural and non-rural, it was looking within rural,” said Diane Hall, acting director of the office, about the 2017 reports. “That MMWR sort of laid out some things that we can be thinking about doing more of so that within rural variation, [there’s] better understanding of how race and ethnicity play out in rural communities.”

In addition to ethnic disparities, the series examined illicit drug use, causes of death, and suicide trends, among other things. Those topics are already part of what the CDC tracks, but typically the agency compares rural data for those topics with urban data rather than creating a stand-alone analysis.

Hall said having an Office of Rural Health will also help the CDC continue collaborating with the Federal Office of Rural Health Policy, part of the Health Resources and Services Administration. That office has existed since 1987 and has been the primary federal office dedicated to rural health care. But its focus is on increasing access to health care rather than monitoring public health.

At the CDC’s Office of Rural Health, “we’re more likely to be focusing on prevention,” Hall said.

What the office is unlikely to do, she said, is create new surveys and collect data that the CDC does not already track. It would be a “pretty costly” undertaking, she said. “I think what would be more impactful is to work with the people that are already doing that and help them better understand that rural context.”

Rural data analysis poses challenges because of the smaller size of rural population centers compared with the larger populations of urban areas. For instance, small communities might not have adequate response rates to surveys, which can limit the conclusions researchers can make about the data.

Michael Meit, co-director of the Center for Rural Health Research at East Tennessee State University, said the 2017 series helped to mitigate the “small numbers” challenge, wherein samples aren’t large enough to be properly analyzed because rural areas have smaller populations.

Each of the series’ reports outlined data limitations such as small numbers and their effect on the analysis, which shows the CDC was “already pushing forward and trying to bring voice to these issues,” Meit said. “I think that by itself is huge.”

Hall, the acting director, said there isn’t a simple solution to challenges like small sample sizes but that the “CDC’s Office of Rural Health can work to highlight creative solutions being developed, such as our PLACES project.” PLACES, or Population Level Analysis and Community Estimates, is a collaboration among the CDC, Robert Wood Johnson Foundation, and CDC Foundation that releases data for smaller cities and rural areas. (KFF Health News receives funding support from the Robert Wood Johnson Foundation.)

Another challenge with rural health data is that small numbers can make it possible to identify who in a particular community is included in data. But the CDC has restrictions in place to prevent that from happening.

Sometimes, though, the agency does allow researchers to access files containing details like “race or ethnicity for small and highly visible groups” and “extreme values of income and age.”

Keith Mueller, director of the Rural Policy Research Institute, hopes the Office of Rural Health will make it easier for researchers to access that more detailed data.

“There would be somebody at the agency who can get at the data, who can help us answer the research question,” he said. “Collaborative work between people in the field and people in the agency who have the direct access to the data is far more readily available or likely to happen with this new office.”

Since the office is based in the CDC’s new Public Health Infrastructure Center, which launched in February, Hall said it’s well positioned to partner with researchers. The center manages the agency’s partnership grants, which are awarded to organizations that plan to improve public health services.

Hall said the office’s most immediate priorities, though, are to grow the staff beyond its current three members and to develop the CDC’s strategic plan for rural health.

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