Multiple definitions of rural populations have been formulated to describe the characteristics of low-population-density areas. Previous definitions have simply included either those towns with a population of less than 2500 or towns located in open country as rural. This definition has often been further differentiated into subcategories of farm and rural nonfarm. A second classification of interest used the term rural for populations with fewer than forty-five persons per square mile, and the term frontier for geographic areas with fewer than six people per square mile (Rural Health Assistance Center, 2010). Many counties of the Great Plains, Intermountain West, and Alaska are designated frontier.

The rural-urban continuum distinguishes counties by population and adjacency to metropolitan areas. Residences can range from small towns to large metropolitan areas. Statistical reporting has been in use since 1990. Census maps and statistical reports in use since the 1990s used the term Metropolitan Statistical Areas (MSAs) to differentiate nonmetropolitan and metropolitan areas. In June 2003, however, the Office of Management and Budget (OMB) released a new classification scheme, developed in 2000, to better reflect trends in population distribution across the nation (OMB, 2008). The MSA designation has been replaced by county-level Core Based Statistical Areas (CBSAs), which make up a new classification scheme to simplify the multilevel designations in use since 1990. The new CBSA system includes two categories of counties: metropolitan areas and micropolitan areas. Counties that are neither metropolitan nor micropolitan are called “outside CBSAs,” also known as noncare areas. Within CBSAs, metropolitan areas are those counties that contain at least one urbanized area of 50,000 or more people. A micropolitan area contains a cluster of 10,000 to 50,000 persons. Because the MSA classification is used extensively for congressional policymaking and funding decisions, the change could have serious ramifications for health care financing within rural market areas.

The health profiles discussed below are shared by rural areas in general and may be contrasted with overall patterns of health, health habits, and health care in urban settings. However, the reader should note that it is difficult to interpret differences between urban and rural health. First, statistically significant differences between urban and rural health indicators may seem small when data are aggregated to “rural areas” in general. The differences tend to become larger when data are available for particular rural areas (e.g., certain counties), particular rural subgroups (e.g., minorities), or specific characteristics (e.g., percentage of uninsured children). Second, heterogeneity of race, age, economic status, regional distribution, and cultural groupings makes health data for rural populations useful only as estimates of individual health. For example, there were 37.3 million people in poverty in 2007, up from 36.5 million in 2006. The family poverty rate was 9.8%, unchanged from 2006. Furthermore, the poverty rate and the number in poverty showed no statistical change between 2006 and 2007 for the different types of families (U.S. Census Bureau, 2008b).

Infant mortality, a major health status indicator, varies greatly by geographic area, even within rural areas, and dramatizes the importance of both contextual and compositional data. For non-Hispanic whites, the rates of infant deaths per 1000 live births continued a downward trend. For black Americans, the rate of infant deaths is 2.5 times that of whites and Hispanics. In both the South and West, rural counties experienced the highest rates (24% and 30% higher than fringe areas of large metro areas) (Hoyert, Kung, and Smith, 2005). Infant mortality rates ranged from 10.32 per 1000 live births for Mississippi to 4.68 per 1000 live births for Vermont. The highest rate noted (11.42) was for the District of Columbia. Overall, the infant mortality rate declined 10% from 1995 until 2004 (7.57); however, the rate has not declined much since 2000. From 2000 until 2005, small declines were observed for all races and ethnic groups. Significant decreases were noted for infants of Central and South American (4.68), Asian or Pacific Islander (8.06), and Mexican (5.53)(Centers for Disease Control and Prevention [CDC], 2008).

Mortality for white infants in rural areas adjacent to a population center with fewer than 2500 people varied from a high of 9.85 per 1000 in the South, to 6.46 per 1000 in the West. Although the infant mortality rates have changed since 1993, infant mortality data provide insight into the heterogeneity of rural populations and show why national or even regional data may or may not reflect the status quo for a particular county or local population.

One might also consider the health disparities that exist among rural racial and ethnic minorities. Although limited because the phenomenon has only recently been studied, research findings support the conclusion that rural racial and ethnic minorities—Native Americans, Alaska Natives, Hispanics/Latinos, and African Americans—concentrated in the South and West are more disadvantaged, not only relative to rural majority members, but also relative to urban racial and ethnic minorities. The disparities include employment, income, education, health insurance, mortality, morbidity, and access to care (Probst, Moore, Glover et al., 2004).

Because population numbers are small, national rural data, limited as the data are, can only suggest the health needs of a particular area, racial or ethnic mix, or age distribution, for example. Program planners will still need to determine whether certain health or health care delivery problems apply to their specific service area. Useful data sources include state, county, and census tract level data on health and demographics available from state and federal government agencies, such as those cited in the reference section of this chapter. In planning for health-related programs, nurses can also gather community-level data from health care providers, local records, focus groups, and older residents who know the area’s history.

Healthy People 2020 is based on the premise that the health of the individual is almost “inseparable from the health of the larger community and that the health of every community in every State and territory determines the overall health status of the Nation” (USDHHS, 2000, p. 2). The new 10-year plan takes a bold step forward by presenting only one set of standards for the health of all racial, ethnic, income, gender, and age-groups. The new goal is to eliminate health disparities, achieve access to preventive health services, and add years of life for all groups. The challenges are great, but public health professionals and planners in every state have, or soon will have, a plan patterned on Healthy People 2020 goals to direct their efforts. A three-volume companion document to Healthy People 2010, entitled Rural Public Health 2010, has been published. These reports are designed to “better inform readers on current rural health conditions, provide insights into possible points of attack, and offer examples of models that might be employed in practice to improve health conditions” (Gamm and Hutchison, 2004, p. vi).

To better understand the health of populations and health disparities, there is also a growing emphasis on the distinction between context, which is defined by the characteristics of places of residence, and composition, which are the collective health effects that result from a concentration of persons with certain characteristics (Probst et al., 2004). Most public health problems include elements of both context and composition, though they may be predominately one or the other (Phillips, 2004; Probst et al., 2004).

Health issues in rural areas are contextual when they derive from characteristics of place. Characteristics of place include not only natural features of geography and environment, but also the political, social, and economic institutions that build and support communities within given geographic areas. For example, limited economic opportunities, low wages, or agricultural accidents might be considered to have contextual effects on the health of populations. Problems in rural areas are compositional when they derive from individual characteristics of groups of people residing in rural settings. Examples of compositional sources of health disparities include such characteristics as age, education, income, ethnicity, and health behaviors.

Consideration of both context and composition enables us to take a more deliberate and refined approach to study, plan programs, and deliver health care services to rural populations. Although the overall health of rural Americans is worse when compared with that of urban Americans, the relationship between rurality and health is not necessarily linear. Many differences exist between rural areas in both the nature and extent of health problems. Furthermore, some rural populations share more in common with people in urban core areas than with other rural areas. Effective planning depends on understanding and documenting needs that take into account context, composition, and their interaction (Eberhardt and Pamuk, 2004). The next section presents data for problems of both contextual and compositional sources of health disparities in rural America.

Regardless of their diverse demographic and geographic attributes, rural groups share certain health patterns, difficulties, and delays in obtaining health care (Ethical Insights box). Many of the contextual issues that contribute to rural health disparities are described in the introduction to the chapter (Rural United States). Many rural regions that are already sparsely populated are losing residents, which often triggers a downward spiral. People leave and services are lost; the local drugstore closes; the tax base will not support an ambulance service; most seriously ill persons must be transported long distances to get health care; jobs become scarce and younger people leave the area. Retirees may be attracted to the lower costs, but they need public health and other services provided by counties without the tax base to support them. Racial and ethnic minorities are migrating to rural areas to find employment opportunities. Structural, financial, and personal barriers to accessing health care services exist in all environments, but rural residents are unique in how they experience structural barriers.

To review, health problems in rural areas are compositional when they result from a concentration of persons with certain characteristics (Probst et al., 2004). Examples of compositional sources of health disparities include such characteristics as income, health behaviors, education, occupation, gender, and ethnicity. In the Rural Healthy People 2010 survey cited previously, 73% of respondents listed access to health care as the top rural health priority (Bolin and Gamm, 2003). An additional thirteen priorities listed by respondents as leading health problems are largely compositional but may also have a contextual dimension. For example, such problems as obesity, chronic pulmonary disease, and higher levels of infant mortality have a strong compositional component because their variation is related to the health behaviors and educational, socioeconomic, racial, and ethnic characteristics of the rural groups. The variation may also be contextual, because the groups have fewer educational opportunities, have low-wage jobs, lack insurance, or have genetic propensities for certain health problems.

Income and Poverty

Income, education, and type of employment help determine socioeconomic status, and in the aggregate, rural dwellers have lower educational levels, higher unemployment rates, higher poverty rates, and lower income levels than urban aggregates (Probst et al., 2004). The poverty rate is one of the most important indicators of the health and well-being of all Americans, regardless of where they live (see Ethical Insights box p. 450). The USDA’s Economic Research Service (ERS) tracks economic trends and demographic characteristics of rural dwellers to help develop policies and services. In the most recent report, the ERS contrasted the economic growth and downward trend in poverty rates during the 1990s with those of the current decade. In the previous 10 years, rural poverty declined on average from a decade high of 17% (1993) to a low of 11% (2000). Since 2000, the rate of rural poverty has been climbing. In 2003, 14% of the general rural population lived in poverty (compared with 12% of urban dwellers) (USDHHS, 2005). Poverty rates for rural people have always been higher than those of urban dwellers (Figure 23-1). As noted earlier in this section, however, data averaged across all rural counties in the United States do not give planners and providers much information about their own counties, or even regions. On the following pages are examples of data that are available to make an analysis of local and regional conditions and characteristics.

Rural poverty: regional differences

Consistent with the idea that there are many rural Americas in rural America, rural poverty varies by rural region (Box 23-1). For example, rural counties make up 340 of 386 (88%) counties with persistent poverty rates in the United States (persistent poverty is defined as counties in which 20% of the population has been in poverty over the last 30 years). Of the 340 rural counties with persistent poverty, 280 (82%) are in the South and 60 (18%) in the West and Midwest (USDA, 2004b). Poverty is also highest in the most rural areas. In completely rural counties (i.e., not adjacent to any metropolitan counties) the poverty rate is 16.8%.

BOX 23-1

The 2009 Health and Human Services Poverty Guidelines

In concept, the poverty guidelines are determined by estimating the minimum income level needed by a family or individual to just meet the basic needs of food, shelter, clothing, and other essential goods and services. Official poverty guidelines adjusted for family size and composition are set by the Department of Health and Human Services (DHHS) for use by all federal agencies to determine financial eligibility for certain federal programs (e.g., Medicaid). Some programs (e.g., State Children’s Health Insurance Program) also use multiples of the guidelines to determine eligibility of participants. For example, participants may be eligible for programs if they are classified as being at or near poverty, where poverty is defined as 100%, and near poverty as 125% or 150% of the poverty level. Poverty guidelines are adjusted periodically by DHHS to reflect price changes, and are published in the Federal Register. The 2009 guidelines reflect just the size of the “family unit” rather than the family composition. The poverty level for a family unit of one, for example, was $2,460; it was $5,360 for a family unit of four, and $2,560 for a family of eight. Each household’s cash income (including pretax income and cash welfare assistance, but excluding in-kind welfare assistance, such as food stamps and Medicare) is compared to the poverty line for the household.

From U.S. Department of Health and Human Services: The 2009 HHS poverty guidelines: one version of the [U.S.] federal poverty measure, 2009: http://aspe.hhs.gov/poverty/09poverty.shtml.

Rural poverty: racial and ethnic minorities

When poverty rates among rural dwellers are analyzed by race, ethnicity, age, and family structure, the statistics on poverty are even more dramatic than for residence or region. Racial and ethnic minorities (mainly nonwhite Hispanics, blacks, and Native Americans) constituted 17% of the rural population, according to the 2000 Census (USDA, 2004b). This segment of the rural population has grown 30% in the last decade, largely due to the dramatic increase in nonwhite Hispanics (up 70.4% from 1990 to 2000) (IOM, 2005). In 2002, according to the ERS, poverty rates among rural and racial minorities were two to three times higher than poverty rates for rural whites (11%) (USDA, ERS, 2004).

Rural poverty: family composition

Families with two or more adults are less likely to be poor, whether in rural or urban areas, because they are more likely to have multiple sources of income. Families with more than one adult have lower out-of-pocket child care costs and are less likely to have to limit their working hours. More than 75% of rural families are headed by a married couple, and these constitute only 7% of families living in poverty. On the other hand, people living in female-headed families (15%) have the highest poverty rates (37%), which is 10 percentage points greater than in female-headed families in metropolitan areas. The ERS attributes the high rate of poverty for female-headed families to “lower labor force participation rates, shorter average work weeks, and lower earnings” (USDA, 2004b).

Rural poverty: children

Children are particularly vulnerable to outcomes of poverty and are among the poorest citizens in rural America, constituting 36% of the overall population of rural poor in 2003. The heaviest concentrations of child poverty are in the South and West. Understanding how poverty is distributed in rural populations is important for planning and delivering programs that ameliorate the impact of poverty, such as food stamps, school lunch programs, school health nursing interventions, and health insurance coverage (USDA, 2005).

When race and ethnicity are taken into account, the poverty profile of children worsens dramatically. Racial and ethnic minorities fare far worse than the general rural population of children from birth to 18 years of age. When family composition is taken into account, we find that almost half of non-Hispanic black children, 34% of Native American children, and 18% of rural children who live in a female-headed household are poor (USDA, 2005).

Although the discussion of agricultural issues has focused primarily on farmers and farm families, it is important to understand the role of migrant (i.e., migrate to find work) and seasonal (i.e., reside permanently in one place and work locally when farm labor is needed) farmworkers in U.S. agricultural production and the health risks to this population. Older references to farmworkers often referred to three “migrant streams,” in which workers entered the country through Mexico and migrated north. The present reality is that migrant workers enter the country through a variety of access points and follow any route necessary to obtain work. Seasonal workers permanently reside in agricultural areas and take various farm jobs during harvesting times. For example, a seasonal worker may be employed in restaurant work during the winter and may spend the summer months picking apples or working in a local apple shed or cannery (Branas et al., 2005).

MSFWs comprise a vulnerable population in regard to health risks because they have low income and migratory status. In many rural areas, community health nurses form the central link between farmworkers and health services. Through standing or mobile clinic sites, nurses have established a leadership role in the provision of episodic and preventive services for workers and their families. Lacking access to many types of preventive services, farmworkers often visit a migrant clinic with any number of health problems including severe dental problems, unresolved communicable diseases, and untreated injuries. In addition to the direct provision of care, nurses in many communities have served as important advocates on behalf of farmworkers and have worked to ensure health care access to those traveling through their areas.

Cultural, linguistic, economic, and mobility barriers all contribute to the nature and magnitude of health problems observed in farmworkers. Cultural and linguistic barriers are the most overt because many of the communities where farmworkers work consider them outsiders. In many settings, migrant workers live isolated from the agricultural communities they serve. Although some workers travel in extended family groups and have the support that comes with being together, other workers leave their families at home. Often these are male workers who work and live together. A common misconception among U.S. health care providers is that these farmworkers are from Mexico and Spanish is their primary language. Farmworkers originate from many communities in Mexico, the Caribbean, and Central and South America, and they may speak English, the language of their home country, or several languages.

There are consistent differences between the ways rural and nonrural residents perceive health. The primary one may be the relative importance of “work” and “being able to work” in self-reported definitions of health (Weinert and Long, 1987). Rural attitudes generally emphasize the “doing” aspects of health by functioning and performing the daily activities fundamentally important in their daily lives. The high value placed on “being able to do” can provide astute nurses with intervention opportunities for both families and communities. Examples of nursing intervention strategies that capitalize on this include accident prevention programs for children, exercise and nutrition programs for seniors, and local industry participation in risk reduction programs for workers. Active involvement of the target population in all phases of program planning and implementation is key to the success of these programs.

The Bureau of Health Professions (2003) states that the size and characteristics of the future health workforce are determined by the interaction of various forces acting on the health environment, including economic factors, technology, regulatory and legislative actions, epidemiological factors, the health care education system, and demographics. Current shortages of health care professionals in rural areas are likely to become worse with increased demand caused by population aging and increasing racial and ethnic diversity. In actual numbers, the shortage has been growing since 1990. Although approximately 25% of the U.S. population lives in nonmetropolitan counties, only 18% of registered nurses (RNs) practice there. In addition, the supply of physicians has not equaled service need in rural areas (Ferrer, 2007). For nonphysician primary care professionals, such as nurse practitioners (NP), physician assistants (PAs), and certified nurse-midwives (CNMs), trends are similar to those for physicians except for PAs. Hanrahan and Hartley (2008) report that 22% of NPs and 23% of PAs practice in urban areas. This pattern distribution has begun to resemble the distribution of physicians and other clinicians with heavy concentrations in urban areas and a growing shortage in rural and underserved areas.

Clearly, the growing nursing shortage will affect all of America. This is both a supply and a demand shortage. Declining school enrollments, retirement of current nurses, and the increased need for care of an aging population make the situation especially critical (Sigma Theta Tau International, 2006). A survey by the American Organization of Nurse Executives found that in small hospitals, usually located in rural areas, it takes significantly longer to fill vacancies than in larger urban facilities (Thrall, 2007). Rural nurses earn less than their urban counterparts, which compounds recruitment difficulties. Nurses with baccalaureate and master’s degrees, other than master’s-prepared NPs, are compensated less for this additional education (Thrall, 2007).

A solution proposed for the shortage of health care providers is for rural communities to “grow their own.” A rural community, a group of small communities, or a county could support local students attending college and recruit students currently attending professional schools. The students make a commitment to work in the community in return for monetary support for their educations (Thrall, 2007). Tuition reimbursement and access to distance learning programs can assist practicing nurses. Continuing education and baccalaureate and master’s degrees are available through e-mail, Internet-based courses, interactive video classes, and by-mail videos. Some programs are provided exclusively via the Internet. Nebraska rural communities are enthusiastic about the University of Nebraska College of Nursing Internet courses. The program is helping them grow their own nurses. Research shows that nurses educated in rural communities are more apt to stay and work there than those who move away to attend school (Pullen, 1998; Thrall, 2007).

Managed care has recently changed health care delivery in the United States. In rural areas, health care delivery networks with managed-care elements are being developed. Potential benefits and risks of managed care to rural areas have been identified, recognizing the difficulty for rural providers to deliver the cost-effective, complex health care needed from solo or small group practices. Possible benefits to managed care include lowering primary care costs, improving the quality of care, and stabilizing the local rural health care system. Risks are also apparent, including probable high start-up and administrative costs, and the volatile effect of large, urban-based for-profit managed-care companies (Allender, Rector, and Warner, 2010; Ricketts and Heaphy, 1999).

Outside of Medicaid, managed care has yet to become a major presence in much of rural America because of small dispersed populations, few visits per individual, and large numbers of elderly on Medicare with low-level reimbursements that do not make the aggregate financially attractive to a managed-care organization (MCO). In fact, despite the existence of federally qualified health centers that provide care to underserved populations through Medicare, Medicaid, or sliding fee scales, the reality is that there were few rural people enrolled in sponsored health plans (Allender et al., 2010). Providers in rural markets face severe financial constraints as HMOs increasingly cope with smaller numbers of enrollees and continue to decrease provider reimbursement (IOM, 2005). Communities that make the most progress toward partnerships or integration are those whose local leaders and providers have strong incentives to work together and are motivated to bring about change to the health care system. Authorities in rural health and managed care report that it is too soon to know whether managed care will become a significant way of delivering health care in rural areas, as it has become in urban America (Allender et al., 2010; IOM, 2005).

Home health and hospice programs vary in structure. In a national study on Medicare hospice use, only one third of rural counties have a hospice based within the county, but nearly two thirds of urban counties do (Virnig et al., 2004). Urban hospices are more likely to be freestanding, whereas rural hospices tend to be hospital based. Larger communities may support a hospital-based home care agency with hospice service, a freestanding, full-service agency, or both. In sparsely populated rural locations, home health and hospice services may be contracted from a larger regional agency, with a local nurse hired to provide services.

Virnig et al. (2004) found that the more remote the rural environment, the less likely hospice services were used. Nurse case management and development of local resources, using the county extension services as a bridge for outreach services, can improve home care for these patients and provide support for their families. A partnership between the public health nurse and county extension service could provide support and information groups and caregiving classes for the important informal provider network. Chapter 33 discusses home health and hospice in greater detail.

Rural residents are perceived as having strong traditional values. At the heart of these values is a strong sense of community, family life, and religious faith (W. K. Kellogg Foundation, 2001).

Since the conceptualization of parish nursing in the early 1980s, RNs have developed and expanded the role. Parish nurses integrate nursing expertise and faith-based knowledge to provide holistic care to members of congregations. More than 7000 nurses have completed formal training programs in parish nursing. The exact number of parish nurses working as paid and unpaid staff in both urban and rural faith communities is not known, because many nurses have not been formally prepared for the role (International Parish Nurse Resource Center, nd). Both professional nursing and parish nursing are based on health and healing (American Nurses Association, 2005).

In a comparison of experiences of rural and urban parish nurses, Chase-Ziolek and Striepe (1999) found rural nurses more likely to be involved in case management and coordination of services than their urban counterparts. In urban settings, contact with parishioners was primarily at the church, whereas contacts in rural settings were most often in the home, on the phone, or in other community-based settings. Collaboration between faith communities and other organizations can help extend limited rural community health resources. Such partnerships have been promoted by federal and state governments to enhance the public health efforts (Zahner and Corrado, 2004). Chapter 32 provides an in-depth discussion of faith community nursing.

Limited availability and accessibility of formal health care resources in rural areas combined with self-reliance and self-help traits of rural residents have resulted in the development of strong rural community informal care and social support networks. Rural residents are more apt to entrust care to established informal networks than to new formal care systems (Weinert and Long, 1987, 1990). One study reported that rural residents sustain a higher level of social health than urban residents. They attributed this social health to their higher level of family and community involvement (Eggebeen and Lichter, 1993), which may contribute to the formation and use of informal systems.

Informal care systems or networks include people who have assumed the role of caregiver based on their individual qualities, life situations, or social roles. People who participate in these networks may provide direct help, advice, or information. Rural residents identify spouses, adult children, other family members, friends, and neighbors as informal providers of care (Buckwalter et al., 2002).

Informal caregivers often find themselves in stressful circumstances. Rural residents who are in need of assistance are usually elderly, have chronic illness, have few resources, and must travel long distances for health care. Rasheed and Rasheed (2004) suggest that by 2050, 21% of all Americans will be members of a minority group. Existing disparities in the physical and mental health status, service availability, service access, and socioeconomics impact Americans in rural communities. Coupled with the “helping tradition” in the black community, there has been a great reliance on community-based informal care systems for the elderly black population.

Van Exel, de Graaf, and Brouwer (2008) studied caregiver attitudes toward respite care and found those who could potentially benefit were reluctant to seek it for various reasons. This has enormous implications for nursing practice. Because informal health care is an important, cost-effective component of the health care systems, different forms of respite care have been implemented to support caregivers. Not only do many patients have a preference for receiving care from someone familiar in their home environment, but in many cases it will help them to avoid long-term-care placement. Nurses have a role in discussing the potential benefits of support for both the family and the care recipient.

There are more than 2800 local health departments in the United States. Many of these serve populations of fewer than 50,000 people (Rosenblatt, Casey, and Richardson, 2002). The purpose of Healthy People 2020 objective 23-11 is to increase the proportion of state and local public health departments that meet national performance standards for public health services (USDHHS, 2000). The standards are based on the core public functions of assessment, policy development, and assurance. Data from 2004 indicate that only 11% of 2315 local public health agencies used the national standards, with only 3% fully or substantially meeting the model national standards (USDHHS, 2004).

In 2002, approximately 3.3% of all money spent on health care in the United States was spent on public health services. Public health expenditures have steadily decreased since 1960. This trend is unlikely to improve given limited public resources, the aging of the population with the subsequent need for acute illness care, and changing Medicaid from public to private providers (NIOSH, 2004).

In a study of 99 local health departments in three rural states, Rosenblatt et al. (2002) found that public health nurses were the core provider of public health services. Many smaller local health departments do not have the economic base to employ other professional public health providers, such as physicians, epidemiologists, sanitarians, and nutritionists at the local level. Frequently, these services are provided at the state level or collaboratively between groups of local health departments. A local physician may serve as a part-time, unpaid health officer. The lack of additional on-site public health providers poses two problems. First, the ability to collaborate with others about potential or actual public health problems is decreased or nonexistent. Second, the ranges of services provided are less comprehensive. Often, these small facilities can only offer federally funded programs with few locally funded services. Environmental health, maternal and child health, and communicable disease control are the three highest priority programs of rural local health departments (Berkowitz, 2004).

The economic crisis that affected much of the rural population in the 1980s contributed to mental health problems (American Psychological Association, 1995). Natural disasters, such as drought and flood, and economic downturns in the late 1990s have contributed to continuing chronic stress. Those affected are most apt to work in the traditional ranching, farming, mining, forestry, and fishing industries. They have not enjoyed the good economic times generated by the information and technology age (NRHA, 2007, IOM, 2005). Although mental health disorders widely affect rural and urban residents across the life span, factors such as poverty, race, age, and rural dwelling lower the prospect of accessing mental health services (Gamm, Stone, and Pittman, 2003). Clearly, large sections of at-risk rural populations are without mental health care (NRHA, 2007).

There are three key factors that have been identified as contributing to mental illness in rural areas (Gamm et al., 2003). First, there is a lack of specialized mental health providers in rural areas. The most recent figures show that 75% of rural counties with populations between 2500 and 20,000 do not have a psychiatrist, and 95% do not have a child psychiatrist. Next, because of the lack of qualified mental health care providers, rural residents often receive services from primary care providers. McCabe and Macnee (2002) found that many rural primary care providers are ill equipped to provide mental health services. Both specialized mental health care and primary health care providers are confronted with barriers related to rural practice. These include a more diverse practice, fewer opportunities for ongoing education, and fewer professionals to consult than their colleagues in urban practice.

Last, rural residents often do not seek mental health services because of perceived stigma. They do not always recognize a need for mental health services (Gamm et al., 2003).

Access to emergency medical services (EMS) has been identified as one of the most significant health care issues for rural residents (Rawlinson and Crews, 2003). EMS include prehospital care, hospital or health center–based emergency care, and trauma systems.

Rural residents depend on EMS because of their high risk for unintentional injury. Low population density has been shown to be a strong predictor of increased injury-related morbidity and mortality rates in rural areas (Peek-Asa et al., 2004). In medically underserved areas, EMS systems play an increasingly important role in decreasing the morbidity and mortality of individuals needing emergency care. Getting patients from the place of injury to the trauma center within the “golden hour” is frequently not possible in rural areas because distance, terrain, climatic conditions, and communication methods produce barriers. Some rural facilities are more than 1 hour away by air from the nearest trauma center or tertiary care hospital, and, according to Branas et al. (2005), of the 46.7 million Americans who have no access within an hour, most live in rural areas. For those rural residents the death rate remains twice that of urban residents.

Challenges faced by rural EMS systems include a shortage of volunteers, a lower level of training than among urban providers, training curricula that often do not reflect rural hazards (e.g., farm equipment trauma), lack of guidance from physicians, and lack of physician training and orientation to the EMS system (Rawlinson and Crews, 2003). Low population density; large, isolated, or inaccessible areas; severe weather; poor roads; and lower density of telephones or other communication methods also contribute to difficult public access for emergency care. These problems make the challenges of developing EMS in rural areas substantial (Branas et al., 2005).