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May/June 2010

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Research Uses Behavioral Risk Factor Surveillance Data to Assess Health Conditions of Rural Residents
Hypertension, high blood cholesterol levels, and arthritis are the most common health conditions among rural Pennsylvania adults. And, compared to urban residents, rural residents are more likely to be overweight and obese, according to recently released research sponsored by the Center for Rural Pennsylvania.

The research provides more information about the frequency of health conditions, chronic disease or injury risk factors, and the use of preventive health care services among Pennsylvania rural residents. It also may help to inform policies for health care in rural Pennsylvania.

Drs. Kimberly Forrest and Yi Lin of Slippery Rock University of Pennsylvania completed the research in 2007. They compared common health conditions, risk factors for chronic diseases, and the use of preventive health care services between rural and urban Pennsylvania residents using data from the Behavioral Risk Factor Surveillance System (BRFSS).

The BRFSS, administered and supported by the Centers for Disease Control and Prevention (CDC), is an ongoing state-specific data collection program designed to measure behavioral risk factors in the non-institutionalized U.S. population age 18 years or older.

Pennsylvania began the BRFSS in 1989 and has continued data collection every year since. The BRFSS data are collected by state health departments and managed by the CDC for public use.

Research background
Forrest and Yin’s research analyzed the BRFSS data files from 1996 through 2006.

The research compared rural and urban residents in terms of their health conditions, including cardiovascular disease, hypertension, high blood cholesterol levels, diabetes, overweight, obesity, disability, asthma, and arthritis; risk factors, including smoking, alcohol use, insufficient physical activity, and insufficient fruit/vegetable consumption; preventive services use, including flu and pneumonia vaccination in seniors, blood cholesterol screenings, mammograms and Pap tests for women aged 40 years or older, prostate cancer screenings for men aged 40 years or older, colorectal cancer screenings in individuals aged 50 years or older, and dental checkups; and access to health care, measured as any health insurance coverage.

The research examined changes and trends for these health related measurements for emerging health issues. It also compared the Pennsylvania BRFSS data with national averages and objectives of the Healthy People 2010.

Healthy People 2010 is a national initiative designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats.

Findings for rural and urban residents
According to the 2005 Pennsylvania BRFSS data, about 37 percent of respondents lived in rural areas.

Compared to urban residents, rural residents were more likely to suffer from heart disease, especially rural males aged 45 to 64 years.

Rural residents aged 45 to 65 years also had a higher prevalence of overweight, obesity and arthritis than urban residents in the same age group.

Rural seniors were more likely to have high blood cholesterol levels and rural women were more likely to have a disability compared to their urban counterparts.

The research also noted an increase in overweight and obesity among Pennsylvanians, and especially rural Pennsylvanians.

Certain risk factors were more common among rural residents, including smoking, binge drinking and insufficient fruit/vegetable consumption.

Rural women also were less likely than urban women to have had a mammogram and rural males were less likely than urban males to have had dental checkups.

Rural residents also were less likely to have been screened for colorectal cancer than urban residents.

Compared to the national average, rural Pennsylvanians had a higher prevalence of arthritis, smoking, and binge drinking.

Rural women obtained mammograms less often than the national average.

While rural and urban Pennsylvania residents had many similar health outcomes, there were certain areas in which rural residents displayed more negative results.

Hypertension, high blood cholesterol levels, and arthritis were the most common health conditions among rural adults and rural residents were more likely to be overweight and obese than urban residents.

Some prevalent risk factors observed among rural residents were smoking, binge drinking, lack of physical activity, and insufficient fruit/vegetable consumption.

Most of the measures of preventive services use were similar between rural and urban residents; however, rural residents were less likely to use certain cancer screenings, such as screenings for breast cancer and colorectal cancer.

Report available
For a copy of the report, Analyses of Behavioral Risk Factor Surveillance System Data for Rural Health Outcomes, call or email the Center for Rural Pennsylvania at (717) 787-9555 or, or visit


Research Finds Little Evidence to Support Use of Geographic Targeting for Public Health Resources
In 2007-2008, the Center for Rural Pennsylvania sponsored a second research project to analyze patterns in health status, healthy behaviors, and health care access and use in rural Pennsylvania using the Behavioral Risk Factor Surveillance System (BRFSS). The goal of this research was to determine the validity of geographic targeting of public health programming in rural Pennsylvania.

In general, the research found little evidence to support the use of geographic targeting of public health resources. It also determined that local primary care physician and dentist supplies do not largely affect health care use.

The research, which was conducted by Dr. William Curry and Myron Schwartz from Pennsylvania State University, consisted of three analyses:

a description of the geographic distribution of total and primary care physicians in Pennsylvania;

an exploration of the effect of local primary care physician supply on health care access and use in rural Pennsylvania; and

a documentation of urban-rural differences for selected public health indicators, changes in the indicators over time for the rural sample, and patterns in the indicators by community characteristics for the rural sample.

The research details and findings are included in the report, Analyses of Behavioral Risk Factor Surveillance System Data for Rural Health Outcomes. For a copy, call or email the Center for Rural Pennsylvania at (717) 787-9555 or or visit


Chairman’s Message
Over the years, the Center for Rural Pennsylvania has sponsored a number of research projects that focused on rural small businesses. And for good reason. As the opening line of the article on Page 4 states, small businesses are the backbone of economic activity and employment in most rural Pennsylvania communities.

According to 2007 Census Bureau data, 74 percent of all businesses in rural Pennsylvania have fewer than 10 employees each. And these businesses are quite diverse. According to the same data source, the most common types of rural small businesses employing 10 or fewer persons are in the following sectors: fishing, forestry and agriculture; real estate, rental and leasing; construction; professional, scientific and technical; finance and insurance; and arts, entertainment and recreation.

Through my work as chairman of the Senate Labor and Industry Committee, board member of the Ben Franklin Technology Development Authority and supporter of the Pennsylvania Small Business Development Centers, I am reminded daily of the impact that small businesses have on Pennsylvania’s economy and on rural communities. And I have come to rely on the Center for Rural Pennsylvania’s research to inform the policy and program decisions that I make in state government, particularly as they relate to entrepreneurship and small business development.

The Center’s most recent research on small business owners provides some good statistics and options to consider as the state works to recover from the national recession.

For example, the research found that 28 percent of small businesses were home-based and two-thirds of all businesses were related to the owners’ previous work. This provides good insight into entrepreneurial options for those who have lost their jobs in businesses or positions that may not come back.

The research also noted that the average age of small business owners was 53 and few had a business transition or succession plan. This may present an opportunity for economic development agencies to build their education and outreach services about the importance of transition planning. They could also review the infrastructure and available capital in their communities that might support a local entrepreneur’s efforts to start a new business or continue an existing business that may be in transition.

Often, small businesses are initially financed through personal investment and credit lines. Taking a cue from the Center’s 2008 Wealth Transfer in Pennsylvania research, communities could establish a fund of affordable capital for local entrepreneurs that supports an environment of risk taking and entrepreneurial growth. The wealth transfer study, which provided estimates on the amount of personal wealth that is likely to be transferred from one generation to the next over a 50-year period, has been sparking further conversations about the magnitude of assets present in every county of the commonwealth and the opportunities to invest a small portion of those assets toward community betterment projects.

The challenges resulting from this recession provide us with the opportunity to continue conversations to find practical solutions that will grow and sustain Pennsylvania’s economy. Clearly, small businesses should be part of those solutions.

Senator John Gordner


A Closer Look at Rural Small Business Owners
Small businesses are the backbone of economic activity and employment in most rural Pennsylvania communities. However, information about small business owners and whether or not they benefit from the use of publicly provided business assistance programs was scarce. Until now.

Recent research published by the Center for Rural Pennsylvania and conducted by faculty of Indiana University of Pennsylvania sheds some light on rural small business owners, their use of business assistance services, and their future business plans.

Research background
The study was conducted in 2008 by Dr. Prashanth Bharadwaj, Dr. Stephen Osborne, Eric Palmer, Dr. Ramesh Soni and Dr. Joette Wisnieski.

The study goal was to create a profile of rural small business owners, including demographic characteristics, their businesses’ history and the owners’ future plans. As part of the profile, the researchers asked small business owners about the barriers and opportunities they currently face as they plan to expand or transition their business.

The researchers also identified federal, state, and local government providers of small business assistance services and examined the small business owners’ perceptions and use of these services.

The research also surveyed the service providers to learn more about small business use of the services.

The research found that 28 percent of small businesses were home-based and two-thirds of all businesses were related to the owners’ previous work or occupation.

The average age of entrepreneurs was 53 and the majority was white. More than half of all respondents possessed a college degree.

Businesses had an average of 11 employees, although the median number was four.

About 47 percent of businesses were professional service, healthcare, finance, insurance and real-estate; 28 percent were retail, wholesale and transportation; and 25 percent were manufacturing, construction, agriculture, and mining.

Nearly half of all small businesses were sole proprietorships.

The research also found that small businesses in rural Pennsylvania were very “local” in nature, with 90 percent of all sales revenues coming from within Pennsylvania. The respondents also indicated about 2 percent of sales came from online sales.

Small business owner respondents said the regional economy, general economy and energy prices were barriers to their business, and they did not find infrastructure or international competition to be barriers.

The respondents’ awareness of service providers in rural Pennsylvania was low and their use of service providers was correlated with their awareness.

There was a strong correlation between the types of services small businesses use and the types offered by the service providers.

The most popular services used by respondents were marketing, human resources/training, funding assistance, and feasibility studies.

A small number of small businesses used services in the areas of export assistance, engineering/product design, and accounting and legal.

Few respondents had a business transition plan. Of those that did, most relied on private entities for assistance with the plans.

From the survey of service providers, the research results showed that service providers rated their own importance as average to slightly above average (3.0 to 3.9 on a 1 to 5 scale).

The service providers used the least by the small business respondents were rated lower by the providers.

Although the greatest level of service was provided during the growth stage of the businesses, the service provider respondents said services were provided at all business stages.

To increase awareness of available small business services, the researchers suggest that the state increase its promotion of state and federal resources. It should also continue to promote interagency communication among and between service agencies and business clients.

As few respondents had business transition plans in place, the researchers also suggest that the state offer additional support to those service providers that offer planning services.

Also, since rural communities are diverse and could benefit from more customized programs, the researchers suggest that state-level economic development efforts focus on entrepreneurial development and provide the education, infrastructure, and affordable capital to rural communities to grow local entrepreneurs.

Report available
For a copy of the report, Examination of Small Business Owners in Rural Pennsylvania, call the Center at (717) 787-9555, email or visit


Visitors to State's Heritage Areas Explore Past, Provide Boost to Local Economies
Pennsylvania’s Heritage Areas offer residents and visitors a unique opportunity to explore the commonwealth’s rich legacy.

In turn, these visitors provide the local areas with a substantive economic boost of about $256 million in direct sales, according to an analysis of survey data by the Center for Rural Pennsylvania.

Pennsylvania’s Heritage Areas Program encompasses 12 large geographic regions that contain a multitude of historic, recreational, natural and scenic resources of state and national significance.

In 2008, eight heritage areas conducted surveys to gather more information about their visitors, including the duration of their stay in the heritage area, the number of people in their travel party, and their home Zip code.

The Center for Rural Pennsylvania used data from the 4,078 visitor surveys to develop a profile of the visitors and to measure the economic impact of visitor spending in these heritage areas.

The Center paired the survey data with visitor statistics for specific sites within each heritage area and used the Money Generation Model (MGM2) to determine the economic impact of visitor spending.

MGM2 was developed for the National Park Service. For this analysis, MGM2 was used to estimate the economic impact of heritage area visitors on the local economy in terms of their contribution to sales, income and jobs.

First-Time and Returning Visitors
Thirty-nine percent of respondents were first-time visitors to the heritage areas and 61 percent were returning visitors.

Forty-eight percent of first-time visitors were day visitors and 52 percent were overnight visitors.

Most first-time visitors were not from Pennsylvania (44 percent), 43 percent were from a Pennsylvania county outside of the heritage area, and 13 percent were from the same county as the heritage area.

Return visitors were predominately day visitors (68 percent). Forty-four percent of return visitors lived in the same county as the heritage area, 35 percent were from another county within Pennsylvania and 21 percent were from outside the state.

Both first-time and return visitors were in similarly sized travel parties. First-time visitors were in a traveling party of 3.5 persons and return visitors were in a party of 3.4 persons. About 32 percent of both types of visitors had children in their travel party (persons under 18 years old).

First-time visitors saw or planned to see fewer heritage attractions than return visitors (2.5 and 3.5 attractions, respectively).

Number of Hours Spent in Heritage Area
The typical day visitor spent an average of 5.1 hours at the heritage area.

Day visitors accounted for 60 percent of all heritage area visitors.

The typical overnight visitor spent an average of 2.6 nights in the heritage area. Forty-seven percent stayed in a motel/hotel, 22 percent stayed at a campground, 22 percent stayed with friends or relatives, and 9 percent stayed outside the area.

Overnight visitors accounted for 40 percent of all heritage area visitors.

Number of Facilities/Attractions Visited
The typical visitor to the heritage area visited or planned to visit an average of 3.1 facilities/attractions.

There was a significant difference in the number of facilities/attractions visited and the following variables:

First-time visitors went to fewer (2.5) facilities/attractions than returning visitors (3.5).

Day visitors went to an average of 3.4 facilities/attractions compared to overnight visitors, who went to an average of 2.8.

Visitors without children went to an average of 2.8 facilities/attractions compared to visitors with children, who went to 3.2.

Total Visitor Spending
According to the MGM2 model, visitors to the eight heritage areas spent a total of about $301 million in 2008.

About $168 million (56 percent) came from overnight visitors staying in motels, hotels, bed-and-breakfasts, and other lodging.

About $88 million (29 percent) came from persons staying at campgrounds, or with family and friends.

About $45 million (15 percent) came from out-of-town day visitors. (Note: Spending by day visitors who were local residents was not included in the calculation since their spending represents a recirculation of money already in the heritage area.)

Direct Economic Effects
According to the MGM2 model, 85 percent of total visitor spending will remain in these local areas. Therefore, visitor spending at Pennsylvania’s eight heritage areas ($301 million) generated an estimated $256 million in direct sales.

Among the heritage areas, a combination of a large number of visitors and a high percentage of overnight visitors produced higher direct sales. These sales supported 4,372 jobs, which generated about $96 million in salary and wages.

On average, every $58,500 spent by visitors supported one job in the heritage area.

The total value added for all visitor spending, or the personal income plus rent and profits and indirect business taxes, was $146 million.

Heritage areas positively affect the economies of their regions.

Visitors to the eight heritage areas participating in the survey had a direct economic impact of about $256 million in sales.

These sales had a ripple effect throughout the local economy, supporting more than 4,000 jobs and generating about $96 million in salary and wages.

Although 2008 was a difficult economic period for the nation, Pennsylvania’s eight heritage areas hosted more than 18 million visitors. Thirty-two percent of these visitors were from outside Pennsylvania.

Pennsylvania’s heritage areas have the potential to make an even greater economic impact if the number of overnight visitors increased.

For example, a 1 percentage point increase in overnight visitors staying in motels would generate an additional $6 million in sales, which in turn could support 113 new jobs.


Pennsylvania Poverty Rate Lower than National Rate
Across the United States, poverty rates have been increasing. In fact, national poverty rates have increased by about 17 percent, on average, from 2000 to 2008, according to data from the United States Census Bureau’s Small Area Income and Poverty Estimates (SAIPE).

Since poverty rates tend to increase during and after recessions, the increase in poverty rates from 2000 to 2008 may not be surprising since this time period included two recessions.

In Pennsylvania, poverty rates were lower than the national rates as a whole. Bucks County had the lowest overall poverty rate at about 5 percent, while Forest County had the highest at about 24 percent.

However, poverty rates in Pennsylvania have been increasing at a faster rate than the national average. This could be because median household incomes in Pennsylvania are decreasing more rapidly than the national average.

Median household incomes and poverty rates share a statistically significant negative relationship, which means poverty rates tend to increase when median household incomes decrease.

Nationwide, median household incomes decreased about 1 percent, on average, from 2000 to 2008. Median household incomes decreased by about 4 percent, on average, in rural Pennsylvania and by about 2 percent, on average, in urban Pennsylvania from 2000 to 2008.

According to the Census Bureau, some groups of individuals are more likely to live in poverty than others. Historically, these groups have included the 18 year old and younger population, the foreign born population, households headed by a single female, and households headed by minorities, particularly Hispanics.


Just the Facts: Marriage and Divorce Rates
Less people are tying the knot in rural Pennsylvania and more people are untying it, according to data from the Pennsylvania Department of Health.

From 1989 to 2008, the number of marriages per 1,000 residents decreased 24 percent in rural counties and the number of divorces per 1,000 residents increased 28 percent.

In urban counties, the number of marriages per 1,000 residents decreased 24 percent and the number of divorces per 1,000 residents decreased 34 percent.

In 2008, Northampton and Delaware counties had the fewest marriages per capita and Pike and Dauphin counties had the most.

Delaware and Philadelphia counties had the fewest divorces per capita and Cameron and Potter counties had the most in 2008.

Though the difference in the rural and urban divorce rates is not statistically significant, Cameron and Potter counties are clear outliers with divorce rates of 466 and 321 per 1,000 residents, respectively.

Removing these two counties from the analysis produces some different results.

Excluding Cameron and Potter counties, rural Pennsylvania had a 23 percent decrease in the divorce rate.
In rural Pennsylvania, there were an estimated three divorces for every 1,000 residents.

The estimates showed two divorces for every 1,000 residents in urban Pennsylvania.

Statewide, the marriage rate was six marriages for every 1,000 residents.

According to 2007 data from the National Vital Statistics System (NVSS), Nevada and Hawaii had the highest number of marriages for every 1,000 residents while the District of Columbia, Mississippi and New Jersey had the lowest (Mississippi and New Jersey had the same rate).

Nevada and Arkansas had the highest number of divorces per 1,000 residents while the District of Columbia and Massachusetts had the lowest.

Nationwide, the NVSS estimated that there were seven marriages for every 1,000 residents and about four divorces. Like those in Pennsylvania, marriage and divorce rates across the nation have been decreasing.