Elizabeth Crouch

Breakthrough Star: Elizabeth Crouch

Researcher seeks to identify, remedy health disparities

Health disparities between rural and urban children can have long term consequences. Elizabeth Crouch and her colleagues at the Rural and Minority Health Research Center don’t just study those disparities; they want to address them head on.

An assistant professor of health services policy and management at the Arnold School of Public Health and deputy director of the RMHRC, Crouch studies the effectiveness of home visits, the incidence of adverse childhood experiences (or ACEs) and the experiences of both the families receiving home visits and the caregivers providing them.

Crouch joined the RMHRC team in 2015 and was appointed deputy director in 2018, by Dr Jan Eberth, an associate professor of epidemiology and director of the RMHRC. Her first study after joining the center was  on end-of-life care in rural communities, which remains one of her other chief research focuses.

There are barriers in the South that don’t exist in other parts of the country.

Elizabeth Crouch

“It was stark, the disparities that existed between rural and urban, and the disparities were even greater among ethnic minorities,” she says. “For example, African Americans were much less likely to have access to hospice care than their urban counterparts. That was the beginning for me of looking at race and residence.”

In 2016, Crouch began work on a grant-funded project working with the Children’s Trust of South Carolina to evaluate the Maternal Infant and Early Childhood Home Visiting Program (MIECHV)  Through collaborations with the Children’s Trust of South Carolina, she began to examine the incidence of adverse childhood experiences (ACEs). Using data collected through the Center for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System — a nationwide telephone health survey — the team quantified the incidence of ACEs in South Carolina, which can affect an individual’s long-term mental and physical health outcomes throughout their life.

“You’re asking adults about their childhood,” Crouch explains. “For example, did they experience household violence?” But as she became more deeply invested in the study, she found herself on a new path, increasingly interested in the plight of rural children, particularly minorities, compared to their urban counterparts.

While rural children enjoy some advantages overall — “We know, for example, that rural areas have been demonstrated to have pretty high social network and social support versus urban areas, where maybe it’s a little bit more disconnected,” she says — those same children also face significant disadvantages, including access issues and a higher incidence of poverty.

The landscape is further complicated by differences in rural areas around the country, some of which haven’t been adequately studied, all of which bear their own distinct hallmarks when it comes to access, racial and economic demographics, education, etcetera.

“Rural in the deep South is very different from where I grew up in rural Kentucky,” says Crouch. “Farms in Kentucky look very different from farms in South Carolina, which look very different from farms in the Midwest or the West. I think that’s why this work is so important, especially here. There are barriers in the South that don’t exist in other parts of the country.”

And how those barriers are addressed is critical. Adverse childhood experiences among rural children are wide-ranging and can include factors such as household dysfunction, substance abuse and caregiver depression, among other variables. A decrease in the number of rural hospitals and a decline in rural health services overall exacerbates the problems.

“The home visiting program is actually getting into the intervention part. How do we prevent these experiences happening in South Carolina, the ‘real world’ impact? We can measure that with our surveys and then write papers, and we do, but what we really want to know is how do we prevent, moderate and mitigate these ACES?”

But the center’s work isn’t all grim, and the center’s research doesn’t focus strictly on the negative.  “We’re now looking at positive childhood experiences as well,” says Crouch. “How comfortable are you talking to your caregiver? Do you get to share ideas? Can you participate in afterschool activities? There’s a number of positive aspects we can also look for among children.”

The work has been a positive experience for Crouch as well. Although still very early in her career, since 2015 she has published more than 60 peer-reviewed articles, brought in millions of dollars in grants, received national fellowships and been named to the editorial board of the Journal of Rural Health, the preeminent peer-reviewed research publication.

And studying the rural-urban divide is a good fit for the Louisville, Ky., native, whose brother is a physician in Appalachia, and whose grandfather, a veterinarian, used to take her along on house calls to farms in the summers. “I know some of the issues that rural people face,” she says. “So, it’s partially personal background that got me interested in this work.”

It’s also the people she works with, she says — on the RMHRC team, at the Arnold School of Public Health, among the greater university research community and in the larger field of rural health disparities.

“It’s really a pretty small group of people who do this kind of work,” she says. “There are nine research centers across the country, but everyone is working on the same issues and everyone is encouraging and collaborative— nationally as well as at our center. Everyone wants to improve health status in rural America, and everyone is collaborative. I can’t emphasize that enough.”

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