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May/June 2004

Inside This Issue:


Dental Access Lacking for Low-Income Rural Populations
Dental access for low-income populations in rural Pennsylvania can be described in one word: insufficient. According to research sponsored by the Center for Rural Pennsylvania and conducted by researchers at Penn State University and East Stroudsburg University, the supply of and demand for dental services among indigent rural populations in Pennsylvania is insufficient.

The research found that the inadequate supply of and demand for services is a consequence of an insufficient supply of dentists and a variety of barriers that contribute to low demands for services, despite the great need for this service.

Analyzing the data
To analyze the supply of dental services among indigent populations in rural Pennsylvania, researchers Lisa Davis and Myron Schwartz of the Pennsylvania Office of Rural Health at Penn State University and Dr. Alberto Cardelle and Kristina Whitmire of East Stroudsburg University evaluated state license data for dental providers and Medical Assistance (MA) fee-for-service dental provider and use data.

To analyze the demand for dental services, the researchers used secondary data from the Pennsylvania Department of Health, which described mandated dental screenings in Pennsylvania schools; Head Start Program dental screening data; in-school records for selected school districts; and MA fee-for-service claims data. The researchers also administered a survey of school nurses and a survey of parents with children in selected schools.

Dental supply factors
The researchers found that the low use of services among indigent populations is the result of a variety of supply factors. Overall, the general supply of dentists in Pennsylvania is declining. In general, dentists are generating sufficient caseloads from high-paying and insured patients and do not need MA enrollees to reach a full patient load.

The supply of dentists by county and across local areas varies greatly. Dentists are in shorter supply in rural counties, counties with a manufacturing base, counties with a high degree of non-professional employment, counties with lower than average incomes, and counties with high poverty.

The researchers also found that, while the supply of dental hygienists is increasing in Pennsylvania, hygienists are in shorter supply in counties with high non-white populations, counties with low average incomes, and counties with high poverty rates.

Also, since dentist participation rates in the fee-for-service MA program are low, dental service rates among the indigent population are much lower than those of the general population.

Dental demand factors
According to the research, low-income populations have minimal expectations of receiving care. Structural factors, such as low dentist availability, a client’s inability to pay for care, and transportation problems, contribute to and maintain low expectations of receiving care.

Public school and Head Start screening programs are essential since they may be the only contact that many students have with oral health care providers. However, referral compliance with these programs is low.

Research recommendations
To remedy the low use of oral health care services among indigent populations, the researchers suggest that improvement efforts must incorporate factors that affect both supply and demand.

Two potential goals on the supply side are to make sure that the general supply of dentists does not decline further and to increase the participation rates of dentists in the MA program. Efforts to have a geographically equitable distribution of MA and general dentists is especially important to address the undersupply in the most rural areas of the state.

On the demand side, the researchers suggest eliminating the structural barriers that contribute to low care-seeking behavior and increasing the cultural importance of dental care among the indigent population. These two demand side goals are not only interdependent, but are partly dependent on the achievement of the goals on the supply side.

Increasing the expectation of care can only be accomplished by eliminating structural barriers, one of which is the availability of local or program dentists. Again, the most effective solutions must incorporate policies that address both supply and demand issues.

More information available
For a copy of the report, Dental Service Supply and Demand for the Indigent Populations in Rural Pennsylvania, call the Center for Rural Pennsylvania at (717) 787-9555 or email


Chairman’s Message
Short in supply and demand. That is the analysis of dental services for rural Pennsylvania’s low-income residents, according to a recent research report sponsored by the Center for Rural Pennsylvania. Identifying this supply and demand scenario as a problem may be somewhat confusing until you understand why demand is low; specifically, it is a short supply of dentists who are available to provide services to low-income populations and Medical Assistance enrollees. This situation sets the stage for indigent people to expect not to receive the dental care they need. The fact is that the need for dental services far exceeds supply in many rural areas of our state. Rural residents who cannot afford dental care just do without it. This is then interpreted as insufficient demand.

How do we break this cycle of interdependent supply and demand? The university researchers tell us that barriers need to be broken down. More dentists who are willing to accept MA patients, educating the population on the health benefits of regular dental care, and greater availability of practitioners throughout rural Pennsylvania are also key parts of the solution, as outlined in our feature story.

Pennsylvania’s Department of Health recently released a series of reports to provide lawmakers, researchers, and other state agencies with data on the characteristics of various health professionals in the Commonwealth. Information that may be vital for decision makers when dealing with the state’s healthcare issues is available online at the department’s website. On page six, we share some of those statistics.

Water, as we know, is something no one can live without. Much of rural Pennsylvania gets drinking water from private wells rather than public water supplies. A recent Penn State study looked at well construction standards for private wells, and the practices and policies that could ensure these wells are less vulnerable to bacterial contamination. This is an important issue for policy makers in Pennsylvania, since roughly 20,000 new water wells are dug each year in this state.

As we turn our attention to the summer holidays, many of us are looking for a unique vacation idea. My daughter, Emilie, would argue that living on a farm is no vacation! But for the 98 percent of the population who don’t wake up to daily farm chores, spending some time on a farm can be a fun break from daily routines. The Pennsylvania Farm Vacation Association is helping to link families with farms in the same way other travel associations help people flock to the sunny sea shore for relaxation.

The association is encouraged that agritourism continues to strengthen in popularity in the Commonwealth, as urban and suburban folks come to the farm for some fresh country air. Visitors are especially welcomed by farmers who know that any additional hand is helpful when it is time to put in the first cutting of hay.

While most farm vacation hosts don’t really put their guests to work in the fields, visitors are offered a great opportunity to learn more about this state’s leading industry by spending a few days on the farm. This is a wonderful opportunity for farmers, too, as they realize the financial and social benefits of welcoming visitors to their home (after complying with all the local and state regulations, of course). Like the children’s story about the country mouse and the city mouse, this experience will help strengthen the understanding between both farmer and non-farmer by the time they bid each other farewell!

I hope your summer is filled with golden days, quiet times, and happy endings.

Representative Sheila Miller


Research Offers Insights
Well Construction Influences on Bacterial Contamination
Pennsylvania is one of only four states that does not have construction standards for private wells. Unlike community water systems, which are permitted and strictly regulated, all aspects of private water system management, including construction, testing and treatment, are the voluntary responsibility of the homeowner. This is a particular rural concern since private wells serve a third of all rural households compared to 12 percent in urban Pennsylvania.

In 2002, Penn State researchers Dr. William Sharpe, Bryan Swistock and Dr. Paul Robillard examined a sample of private water wells in South Central Pennsylvania to determine whether retrofitted or new sanitary well construction could influence bacterial contamination rates.

The results of this study suggest that well construction practices influence bacterial contamination of private wells but significant bacterial contamination of wells can be expected even in properly constructed wells. The researchers also concluded that aquifer contamination is a significant source of bacterial contamination in private wells. Wells influenced by aquifer contamination cannot be addressed with improved well construction practices alone. Variations in the levels of contamination showed that bacterial concentrations in wells vary considerably over time, perhaps responding to climate or seasonal variations. Also, the methodology used to detect contamination in the study showed that drinking water standards for public water supplies currently in use might not adequately detect small numbers of bacteria in household supply wells.

Results from this study warrant recommending shock chlorination and retrofitting of existing wells with a sanitary well cap for homeowners with wells contaminated with coliform bacteria. This is especially true for homeowners with wells that have small numbers of coliform bacteria and no E. coli bacteria and wells located in noncarbonate bedrock where aquifer contamination is less likely. Retrofitting existing wells with a grout seal is usually not feasible and the benefits are questionable.
Results from this study also have implications for policy makers regarding the construction of about 20,000 new water wells each year in Pennsylvania. To significantly, but not completely, reduce bacterial contamination of private wells, regulations are recommended that require new wells to be constructed with a sanitary well cap as well as shock chlorination following completion of the well. The researchers also recommend implementing regulations that require existing wells to be retrofitted with a sanitary well cap at the completion of well maintenance or repairs, including installation of new submersible pumps, well redevelopment or drilling. This research along with past studies also supports the requirement of a grout seal on new well construction to reduce E. coli contamination of wells.

For a copy of the report entitled, The Influence of Well Construction on Bacterial Contamination, contact the Center for Rural Pennsylvania at (717) 787-9555 or


Trends in Rural Pennsylvania: Infrastructure Makes It All Work
Trends in Rural Pennsylvania is a series of articles that examines nine major areas of interest in rural Pennsylvania including: agriculture; economic development; local government capacity and fiscal stress indicators; transportation; socio-demographics; health care and human services; environment and natural resources; education; and the condition of existing local infrastructure.

A more detailed fact sheet on each featured topic is available upon request by calling or emailing the Center for Rural Pennsylvania at (717) 787-9555 or

This is the eighth article in the series. The others examined health care access and affordability, transportation, socio-demographics, education, local government capacity, natural resources and the environment, and agriculture.

Infrastructure is the stuff that helps communities function. According to the American Heritage® Dictionary of the English Language, the term has been used since 1927 to refer collectively to roads, bridges, rail lines, and similar public works.

For a more detailed look at some of the infrastructure that makes rural Pennsylvania function, this Trends issue focuses on the physical infrastructure of water/wastewater and telecommunications in rural Pennsylvania.

In relation to infrastructure, water is relevant in two areas – the supply of fresh water and the collection and treatment of wastewater/storm water.

According to 1990 Census data1, 58 percent of the total housing units in rural Pennsylvania get fresh water supplies from a public system or private company, 36 percent use individual wells, and the balance use “some other source.” For the disposal of wastewater, 49 percent of rural housing units have public sewer, 48 percent have a septic tank or cesspool, and the remainder use “other means.”

Drinking Water
The Pennsylvania Department of Environmental Protection (DEP) maintains a database of information on drinking water systems in the Commonwealth. According to data from December 2003, nearly 5,700 active drinking water systems exist in Pennsylvania’s rural counties, 21 percent of which are community systems. Sixty-seven percent are transient, non-community systems, while 11 percent are non-transient, non-community systems. Most rural drinking water systems are very small – half serve fewer than 100 people each while 12 percent serve more than 500. Although about 95 percent of the system sources draw from ground water, the 5 percent that draw from surface sources have the capacity to yield twice as much water as the ground sources.

Rural water is transmitted along some 2,500 active transmission mains averaging about 2,000 feet in length for a total of approximately 5.5 million feet of mainlines. The primary construction materials of this pipe are cast iron (26 percent), PVC (23 percent), and ductile iron (22 percent). Copper, steel, and other materials are also used. Twenty percent of the rural water pipelines were installed prior to 1950, while 18 percent have been installed since 1980.

Water is distributed locally through nearly 5,300 active distribution systems with an average length of 7,865 feet, for a total of more than 41.5 million feet of pipeline. Construction materials are similar to those for transmission mains. The most common material is PVC, which makes up 31 percent of the total length. Cast iron accounts for 24 percent and ductile iron for another 19 percent. Ages of these systems also vary widely with 28 percent built before 1950 and 25 percent built since 1980.

Wastewater and Storm Water
Wastewater utilities collect and treat sewage and process water from domestic, commercial, and industrial sources. Some utilities collect and treat storm water runoff. There is no data available for rural Pennsylvania about storm water since this is handled at the local level through best management practices and is not reported or tracked.

DEP data report nearly 3,300 wastewater systems in Pennsylvania’s rural counties. Municipal, or public, sewage systems account for 17 percent of these systems while non-municipal sewage systems make up 59 percent. Industrial waste systems make up 23 percent.

The telecommunications industry includes the transfer of voice and data through both public and private systems. Services include telephone, radio, television, and Internet access. Without these, communities would be quite disconnected from what is going on in the world.

Although the Pennsylvania Public Utilities Commission (PUC) has no data available about physical telephone infrastructure, such as miles of phone line, number of poles, or age of the cable, it notes that telephone service is universally available throughout rural Pennsylvania and that most people take advantage of the service. Census 2000 data show that 98 percent of rural Pennsylvania households have telephone service available.

Radio and Television
The Pennsylvania Manual lists about 200 radio stations located in rural Pennsylvania, 60 percent of which are FM frequencies. In rural Pennsylvania, there are, on average, fewer than six stations per 1,000 square miles. In addition, rural Pennsylvania has seven television stations. Five rural counties have no radio or television station located in the county. Radio and television broadcasts are far reaching, however, and for those outside a particular television station’s viewing area, a cable connection is usually available.

The Center For Rural Pennsylvania’s recently released report, Broadband Internet Service in Rural and Urban Pennsylvania: A Common Wealth or Digital Divide, provides information about infrastructure for high-speed cable and telephone access to the Internet for computer users. For more information, request a copy of the report or view it online at

Rural: The 48 counties with a population density less than the statewide average of 274 persons per square mile.

Water System: A group of facilities used to provide water for human consumption, including facilities used for collection, treatment, storage and distribution. Systems are usually one of the following three types:

Community water system — A public water system that serves at least 15 service connections used by year-round residents or regularly serves at least 25 year-round residents.

Non-transient non-community water system — A public water system that is not a community water system but regularly serves at least 25 of the same persons over 6 months per year.

Transient non-community water system — A public water system which is not a community, nontransient noncommunity, bottled or vended water system, nor a retail water facility or a bulk water hauling system.

Water Source: The place from which water for a public water system originates or is derived, including, but not limited to, a well, spring, stream, reservoir, pond, lake or interconnection.


Reaping ‘New Economy’ Benefits
Emerging technology sparked a boom of economic activity and optimism in the mid- to late-1990s. The significant growth and change of the last decade did not, however, buoy all regions and industries to the same level. “New economy” activity, defined as emerging service and technology sectors fueling growth, was centered in southeastern and urban Pennsylvania. Many rural, northern tier and western Pennsylvania counties grew relatively slowly, and the gap between the average wage of rural and urban workers increased.

Research sponsored by the Center for Rural Pennsylvania and conducted by Penn State researchers Dr. Martin Shields and Carolina Vivanco, examined the economic transformation and how the Commonwealth’s rural counties fared. Using a variety of economic and other data collected between 1990 and 2000, the researchers documented the growing rural/urban per-worker earnings gap. The study compared the economic performance of Pennsylvania and its rural counties to that of similar states and their rural areas and suggests specific industries that hold potential for economic expansion efforts in rural Pennsylvania counties.

While Pennsylvania’s economy did not show growth as dramatic as the national economy, urban counties experienced greater growth in employment, business establishments, and per-worker earnings than rural counties. The drivers of rural economic growth were primarily industries in the service sector, including health, educational and social services, and eating and drinking places. Some manufacturing industries added significant numbers of jobs, including lumber and wood products and fabricated metal products.

Both rural and urban Pennsylvania added jobs over the decade, but the average wage for rural workers did not keep pace with that of urban workers.

Because the addition of low-paying jobs actually pulled down the average wages for rural workers, the researchers suggest that economic development efforts in rural Pennsylvania should center on job quality rather than job quantity, so that workers earn higher wages for their households and, in turn, stimulate the economy through their increased buying power. To attract high-quality jobs, the researchers recommend investment in higher education and workforce training and the promotion of local networks and linkages of businesses that supply goods and services to one another that might otherwise be purchased from outside the county or state.

For a copy of the report, Rural Pennsylvania in the New Economy, call the Center at (717) 787-9555 or email


Keystone Ag Innovation Center Open for Business
The Keystone Agricultural Innovation Center, a joint program of Penn State’s College of Agricultural Sciences and the Pennsylvania Department of Agriculture, is now open for business. The center, funded by a $1 million grant from the U.S. Department of Agriculture (USDA), will help innovative agricultural producers increase marketing opportunities and revenue for their “value-added” products. Pennsylvania was one of just 10 states selected by USDA for the initiative, which is part of the 2002 Farm Bill.

Satellite offices will open at Penn State Cooperative Extension offices in Blair, Cumberland and Lebanon counties. Each office will have a specialist in business management and marketing and community agriculture.

“We will give farmers and producers access to the technical, business and marketing expertise to identify and take advantage of agricultural opportunities, says Tim Kelsey, professor of agricultural economics and Keystone Ag Innovation Center project leader. “We’ll help them to explore alternatives to their agricultural business, help them perform an analysis to determine feasibility, and then direct them to a funding source if one is available to launch a new business initiative.”

Agriculture Secretary Dennis Wolff adds that the new center will help the department fulfill its mission to keep Pennsylvania farmers on the cutting edge of new opportunities.

“If farmers can develop products that allow them to earn a larger share of consumers’ food and energy dollars, then the whole rural economy will win, because farmers tend to spend their money locally,” Wolff says.

For more information, interested participants should call the nearest Keystone Agricultural Innovation Center office at (800) 909-5242 (Altoona); (800) 709-5242 (Carlisle); or (800) 690-5242 (Lebanon).



Farm Vacations Offer Something for Everyone
Farmers looking to generate some extra income and families looking for a new and exciting summer get-away should be thinking, “farm.” That’s the message that the Pennsylvania Farm Vacation Association is emphasizing to farmers and families as summer nears.

The association notes that the public’s desire to experience life on small, family owned and operated farms is strong and growing. Couple that with a farmer’s desire to educate the public about the many aspects of farm living and you have a recipe for a great family vacation.

Association members who participate in farm vacationing or agritourism, which merges the worlds of tourism and farming, offer a range of experiences and accommodations from horse back riding and ostrich herding to traditional farm comforts and contemporary log home luxuries.

“There is no single formula of how to make agritourism work,” says Marcy Tudor, association president. “Each of our member farms offers a distinct visitor experience. But what we all have in common is a genuine desire to educate visitors and create an atmosphere that is welcoming and fun.”

For more information on this form of agritourism, visit the association’s website at


Health Department Reports Offer Data on Docs, Dentists, Nurses
The Pennsylvania Department of Health has introduced a series of reports to provide lawmakers, researchers, academics, and state agencies with data on the characteristics of various health professional populations in the Commonwealth. The publications are supplemental reports to the State Health Improvement Plan (SHIP) and offer the results of surveys that accompanied license renewal applications. Here's a sampling of the information available in the reports:

For more information, see the individual reports at
* This data represents surveys that went out to just half of all RNs.


Did You Know . . .



Just the Facts: Going Hog Wild!
Remember The Wild One, the 1954 flick starring Marlon Brando as a young, leather-clad biker who terrorizes a small town? Fifty years later, the only aspect left of that bad biker image is the leather. Today, according to the Motorcycle Industry Council, the average biker is likely to be middle aged, married and working in a professional, managerial or technical job earning about $44,250 a year.

Motorcycling today is definitely more mainstream, attracting enthusiasts in record numbers. According to the Federal Highway Administration, in 2001, there were 4.8 million registered motorcycles. From 1997 to 2001, the number of registered motorcycles increased 28 percent.

For their part, rural Pennsylvanians have been riding on the crest of the biker wave for quite some time. According to data from the Pennsylvania Department of Transportation (PennDOT), more than 95,800 motorcycles are registered in rural counties, or 28 motorcycles for every 1,000 residents. Between 1995 and 2003, the number of motorcycles registered in rural counties increased 60 percent, or nearly five times faster than the percent change in passenger cars.

Pennsylvania’s urban areas have also seen an increase in the number of registered motorcycles. From 1995 to 2003, the number of motorcycles in urban areas increased 52 percent. In urban areas there are more motorcycles, numbering 167,280, but fewer bikes per capita, registering at a rate of 19 motorcycles for every 1,000 residents. Nationally, there are 17 motorcycles for every 1,000 residents, according to the Federal Highway Administration. Compared to other states, Pennsylvania ranks 23 in the number of motorcycles for every 1,000 residents. The states with the most motorcycles were Iowa, Colorado, New Hampshire, and Wyoming, each registering more than 42 motorcycles for every 1,000 residents.

Within Pennsylvania, county motorcycle registration has a positive and significant correlation with median age, the percent of married couple households without children, and the percent of persons employed in blue-collar jobs. This means that in counties with a higher ratio of motorcycles per capita, there are likely to be more older residents, more empty-nest couples, and more persons working in manufacturing and related industries. In addition, these counties are likely to have lower incomes, higher unemployment, and fewer adults with a college degree.

Counties with the highest rate of motorcycles per capita are Forest, Cameron, and Somerset. In 2003, each of these counties had more than 37 motorcycles for every 1,000 residents. Counties with the lowest rate of motorcycles per capita were Allegheny, Delaware, and Philadelphia, each with less than 16 motorcycles for every 1,000 residents.