Community Capitals Approach to Improving Maternal Child Health in Rural Areas of the U.S.

Introduction: Disparities in maternal and child health (MCH) outcomes are increasingly evident across the rural/urban continuum. Limited access to healthcare and community services, compounded with a changing economic environment and increasing devolution of government responsibilities, has contributed to poor MCH outcomes in rural geographies. By delivering care to families in the home, home visiting (HV) services present an opportunity to mitigate health-related challenges common in low-density and under-resourced communities. Though HV programs are designed to specifically address health, little research has explored how rural home visitors may adapt delivery of evidence-based health programs to account for strengths and constraints found in rural settings. Using a community capitals framework, we explore unique factors shaping the role of HV in rural areas with data from a statewide evaluation of Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funded programs in Pennsylvania.

Methods: Interviews with administrators, home visitors, and clients were conducted at 11 of 32 MIECHV-funded HV sites representing 4 evidence-based models across a range of geographic densities as defined by Rural-Urban Continuum Codes. Interviews were recorded, transcribed, de-identified, and imported into NVivo10. Data were analyzed for themes and patterns using modified grounded theory and mapped onto the community capitals framework.

Results: Our analysis included interviews with administrators, home visitors, and clients at 7 HV sites serving 11 rural counties (n = 81) contrasted against 4 HV sites serving 3 urban counties (n=69). Presented data illustrate findings unique to rural sites illustrating how rural home visitors engage in adaptive strategies to address multiple community capitals, such a built, cultural, financial, and social capital, far beyond and outside their assigned health-based curriculum. For example, rural HV programs use funding to creatively employ a mental health consultant for home visits, purchased a van to address transportation access, and structured co-occurring family visits to combat the social isolation noted within their communities.

Conclusions: By presenting a community capitals approach to MCH, we demonstrate how home visitors adapt federal evidence based programs to occupy critical capacity building spaces within their own rural communities. Their program enhancements shore up community strengths and address structural gaps in public systems, including inaccessible transportation, unsafe housing conditions, and weak social connections. Study findings highlight how other civic stakeholders, particularly local elected officials and policymakers, could act to strengthen the community ecosystem and decrease disparities in rural MCH by investing in HV programming.