An Interview with Jan Probst

by Beth Blevins

Jan ProbstJanice C. Probst, PhD is a professor in the Department of Health Services Policy and Management at the University of South Carolina’s Arnold School of Public Health, and Director of the South Carolina Rural Health Research Center (SCRHRC). Probst received her undergraduate training at Duke University and her graduate training at Purdue University and the University of South Carolina.

Probst has extensive experience in health services research, with an emphasis on rural vulnerable populations and the institutions that serve them. She received the Outstanding Researcher Award from the National Rural Health Association in 2008.

In her spare time, Probst enjoys playing guitar at her church, playing tennis in the USTA women’s league, running triathlons and taking photographs. She and her husband, Bob, live in a house on a large lake where they hope to retire. They have three grown sons.

For more information on Probst, and for a list of publications, see her Arnold School of Public Health Faculty Page.

The focus of SCRHRC is “investigating persistent inequities in health status within the population of the rural United States.” Can you summarize what those are?

Our center concentrates on disparities experienced by rural poor and minority populations—groups that are typically not seen as rural. “Urban” is code for “African American” in the music industry, reflecting both population concentration and popular perception. However, many rural counties in the South remain majority Black and there is a significant Black population across the region. Similarly, there are high Hispanic concentrations in rural counties across the South and West, and American Indian populations are typically concentrated in the rural West and Northwest.

“Summarizing” the disparities experienced by these populations would take volumes. Seriously. But you can generally say that rural populations are: more likely to be poor, less likely to have health insurance, more likely to be in poor health, more likely to report delaying care because of cost, and more likely to live in counties with low physician/population ratios. In persistent poverty counties, these factors are markedly exacerbated. For example, while 18.5 percent of all rural residents lack health insurance, 25.8 percent of residents of persistent poverty counties are uninsured.

What is a persistent poverty county?

There are big two categories of persistent poverty counties—Appalachia and high minority counties, where 20 percent or more of the population has fallen below the federal poverty level since about 1960. A lot of these counties are in the historic South.

What are the most prevalent health care inequities in rural areas? Do they differ by region or do all U.S. rural areas face similar challenges?

Wow, this is a big picture question that I can only answer from my area of expertise. While some challenges are common across all rural counties (the economics of distance, for example), I am most familiar with the problems faced by counties with high minority populations. These counties are quite distinct from counties in the largely White swathes of the Midwest.

In many rural counties with historic minority populations there is a Gordian Knot of the socioeconomic factors that drive health: income imbalance, low education and high poverty, all combining to create a poor economic base, large uninsured populations, inability to attract providers and overall gaps in health status. This pattern repeats across regions with high Black, high Hispanic, or high American Indian populations (it is less dramatic in high Asian rural counties, perhaps because there are so few outside of Hawaii). The knot was created over the past century for a variety of historic reasons—the present question is how/whether it can be disentangled and what the role of public health may be in addressing the consequences of the knot.

Are there any differences in health status inequities among minorities, or between minority and non-minority rural populations?

Possible long answer, so I’ll stick to the short stuff: African Americans and American Indians generally have worse health indicators than Whites, in both rural and urban settings, and the rural population measures tend to be a tad worse (a double disparity). The evidence for Hispanics and Asian Americans is less clear. Frequently, Hispanic American do not differ from “White” Americans in health status, though they are generally far worse off economically. Asian Americans, who constitute a very mixed set of backgrounds, are generally better off than Whites as a whole, even in rural areas. There are, of course, exceptions.

Has there been any improvement in the health status of rural minority women?

We’ve done a good job of spreading some public health messages to women—a larger percentage of Black women than White women are getting mammograms and pap smears, according to self-reported data. Black and White women are identical on getting mammography in all regions, including rural. The one where you have more rural and Black disparities is in colonoscopy and that’s because a), it’s a pain in the butt, literally, and b), it takes more expensive equipment.

Where improvement falls apart is with Hispanic women—they’re still close to White women as regards preventive services in urban locales, but lagging in rural. In getting things like a pap and mammogram, it’s real important that you have a regular source of care. Having that source of care is less likely if you don’t speak English. Of course, there’s a big difference between Hispanic folks who arrived in the U.S. fairly recently and Hispanic folks whose families have been here for generations.

If you had to name one major health care challenge for rural African Americans, what would it be?

Obesity, obesity, obesity. Obesity affects health, affects job prospects (there is a bias against obese women, less so for men), affects self-image. Our focus is on the effects of excess weight on health.

Is obesity getting worse for all rural populations? Does a rural environment contribute to obesity?

Jan Probst Triathlons

In her spare time, Jan Probst participates in triathlons.

In every population we’ve looked at, kids and adults, the prevalence of obesity is higher in rural than urban except in places like Colorado—we don’t know why Colorado does so well, except that it’s one of the most amenity-packed states in the union.

We really don’t know why people are heavier in rural. We speculate that it’s a combination of things: less time for food prep after long commutes to urban areas for work, fattening foods are cheaper, opportunities for healthy exercise in rural are more limited. You can’t have “walk your kid to school day” when the school is 30 miles away. It can be hazardous to walk in rural areas.

There is a myth out there that everybody who is rural grows their own food. But not everyone in rural owns land—a large portion of people in small towns work in the service industry and small factories. If you’re working two jobs that are relatively sedentary, you just want food at the end of the day, and the nutritional quality of that food may be the last thing on your mind.

And there can be lack of perception that obesity is a problem that needs to be addressed, given competing priorities. One of my graduate students is looking at how engaged rural public health agencies are in obesity prevention. There are so many other health issues already demanding these agencies’ attention, like tobacco and flu shots.

If you could clarify one misperception about rural minorities, what would it be?

The misperception that there are no rural minorities. Relatedly, that if there are minorities in rural areas, they are just like urban populations.

When you talk to people on the coasts, their mental pictures are something like this: all Black people live in the inner city, all Hispanics are picking in the fields or working construction. There’s not a recognition that in places like Texas, Arizona and New Mexico, the Spanish-speaking population has roots that go back before the foundation of this country. When these coastal folks think about rural Hispanics, they think about migrant workers rather than the problems of ordinary people who have been living in a community for a couple of generations. The Hispanic population in the U.S. now is a mix of both of the stereotypical (we still have migrant agricultural workers) and the ordinary.

Similarly, with the Black population. African Americans do tend to live in urban areas, though hardly confined to the “inner city.” Basically, in the 1920s and 1930s African Americans were pulled out of their rural homes by the promise of better economics and pushed out by acts of terrorism on the part of White people. But many stayed. The counties in the U.S. that are more than 45 percent Black are still in the historic South, because that’s where you had the huge slave populations.

These high minority counties are areas that we feel are underrepresented in the discussion on rural. There is a general feeling that the archetypal rural resident is a White person in Iowa living on a farm. That may be perfectly typical of Iowa, but it’s not typical of the whole U.S.

Your publications have been on a wide area of topics, including diabetes and obesity, breastfeeding and prenatal care, depression and alcohol abuse. Is there a common thread that connects all these topics for you?

My personal interest is in disadvantaged populations, and this theme permeates most of my own research. With a few forays into care issues (I used to be in a family medicine department—the underdogs of medicine), and management (I teach management and actually believe management studies have value), most of my research examines problems across these populations. As a teacher, I’m also engaged in supervising students, which means following them into whatever worlds they are interested in (e.g. breastfeeding).

Why did you choose rural hospital closure as your dissertation topic?

Ancient history and my standard explanation: I began my doctoral studies during the Reagan administration, when concern for the poor was not exactly at the forefront of the national agenda. However, I reasoned that policymakers would be interested in economic topics, leading me to rural hospital closures as a health-related event that had marked economic consequences. Once I was into the world of rural, I pretty much stayed there. My first academic job was in a Department of Family and Preventive Medicine—and FP docs are more likely than others to practice in rural areas.

Did you grow up in a rural area?

I grew up in Robbinsville, NJ, which definitely wasn’t Jersey Shore! It was a community that revolved around truck vegetables, orchards and chickens/eggs. The region was just switching to part-time farmers and low-intensity crops like soy beans when I was a kid. (For the record, I still hate chickens.)

What motivates your concern for the poor and underrepresented?

I grew up in a solid, middle-class Catholic family where I was taught to take care of others. The whole ethos of the 1960s, from the Kennedy/Johnson administration through the Civil Rights movement, taught us to worry about the vulnerable, and there was a historic concern for the poor. We were taught to aspire to help those who can’t help themselves

Is there anything else that gives your work passion?

If there is one thing I’ve emphasized about our center it’s that it’s a real university department with real live students. Instead of running it with just staff, we have four to five doctoral students working here all the time. Students are great—they’re deeply excited about everything! They learn to do research but I also try to instill in them that rural health is an important thing. A lot of us in rural health are in our late fifties and early sixties. We need our successors.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Summer 2011 Issue