Metropolitanstatistical areas are defined as geographical areas with a core urban area of 50,000 or more population. NonMetropolitanstatistical areas include geographical areas with a core urban area of less than 50,000 or no core urban area. Micropolitanstatistical areas are defined as geographical areas with a core urban area of at least 10,000 but no more than 50,000. Noncore-based statistical areas include geographical areas with a core urban area under 10,000 or no core urban area. Of the total U.S. rural population, approximately 5% live in towns of fewer than 2,500 residents. (Coburn et al., 2007; Office of Rural Health Policy [ORHP], 2002; U.S. Bureau of the Census, 2000;USDA, 2006) (Figure 32-1).

Another classification distinguishes between farm and nonfarm residency. Less than 2% of the total U.S. population has a farm residence. Generally, farm residents are involved in some type of agricultural production. Another set of definitions classifies regions as urban (99 or more persons per square mile), rural (less than 99 persons per square mile, and frontier (six or fewer persons per square mile). In some ways, these terms better illustrate the challenges encountered by a few people living in a very large geographical region.

Another set of definitions for rural takes into consideration the distance and/or time to commute to an urban area to access health care services (e.g., more than 30 minutes or more than 20 miles). However, the factors of time and distance to access services also may be applicable to residents who live in the inner city or, perhaps, a suburban area. For research purposes, the rural-urban continuum offers a classification scheme that distinguishes metro counties by the population size and nonmetro counties by the degree of urbanization associated with adjacency to a metro area. This classification helps to address overlapping and inconsistent definitions of rural versus urban (Centers for Medicare and Medicaid Services [CMS], 2011; USDA, 2007b; U.S. Department of Health and Human Services [USDHHS], 2010c).

Furthermore, the various terms used to describe and understand rural residency are relative. For instance, small communities with 10,000 people have some features that one expects to find in a large city; whereas residents living in a community of fewer than 2000 perceive a town with 5000 people as a city. Or, residents in geographically remote areas may not feel isolated because they perceive having urban services within easy reach, either through telecommunication or dependable transportation (Bushy, 2010).

Another classification of rural areas created by the federal government provides greater specificity concerning a rural area’s economic climate based on the principal industries in that area. The seven categories of nonMetropolitan counties, based on economic dependencies, are farming dependent, manufacturing dependent, mining dependent, specialized government, persistent poverty, federal lands, and recreational-retirement (USDA, 2005, 2007c, 2007d).

For example, manufacturing-dependent counties are characterized by a larger and denser population, a higher proportion of households with a female head, and a greater proportion of African American residents. In contrast, farming-dependent counties are characterized by a smaller population, fewer persons per square mile, fewer households with female heads, and a higher proportion of older adults. This categorization, based on demographic characteristics, may also lend some insight into a particular community’s health problems (e.g., older adults with chronic illness, younger-than-average population with higher fertility rates, and specific types of occupational hazards and environmental risks, such as farming and ranching with an increase in skin cancer). This approach, however, can falsely lead to a perceived homogeneity of the community, because little consideration is given to subpopulations (underrepresented groups) that also live there (USDA, 2005, 2007c).

Recent census trends indicate some nonMetropolitan areas have experienced a substantial influx of new residents, especially in recreational and retirement counties (USDA, 2007a, 2007c, 2007d, 2007e). Counties experiencing the most rapid rural growth are found in states located in the intermountain west extending from Canada to Mexico, as well as in regions of the Ozarks, the lake country of the upper Midwest, Florida, the Blue Ridge Mountains, and along the outskirts of some thriving Metropolitan suburbs. Population estimates reveal that some rural communities are rapidly expanding with relocated urban residents. Existing local infrastructures and public services are unable to keep pace with the growth. For instance, aging water, sewage, and communication systems; housing units; and schools are inadequate to handle the increased demands associated with the influx of local residents. However, approximately 25% of all nonMetropolitan counties continue to have a declining population. Disproportionately, communities with declining populations are located in the Great Plains, the Corn Belt, and the Mississippi delta and scattered among mining districts across the 50 states. Few data exist that describe either the short- or long-range impact on the health of rural communities caused by the rapid in-migration of formerly urban residents. More is known about the impact on a community experiencing a declining population. One can anticipate, however, that traditional community dynamics will play a role in how long-time rural residents integrate new residents into their communities (McGranahan et al., 2010; USDA, 2007e).

Consistent with national trends, there has been an increase in the proportion of racial minorities in rural areas, and they make up approximately 17% of the rural population (USDA, 2007c). Although not much is known about rural residents in general, even less is known about the subgroups and minorities who live there. Most health information about rural populations focuses on maternal, infant, and older adult populations; such information is easier to assess and monitor because of existing public services. There are regional differences as well as great variations in health status even within a given community. For example, some rural states in the upper Midwest and intermountain area report the best overall pregnancy outcomes. Within those same states, however, American Indians have the poorest outcomes, comparable with those of third world countries. Except for American Indians, many of whom receive care from the Indian Health Service (IHS) (2011a, 2011b, 2011c), adequate descriptions are lacking about the health status of rural minority populations. This is partially attributable to the very small numbers of rural minority group members, for whom data tend not to be extrapolated from large national data sets (Institute of Medicine [IOM], 2005) (Table 32-1).

Both out-migration and in-migration can create problems that, in many instances, a small town cannot solve because of the lack of resources. For example, population shifts disrupt long-established informal “helping networks,” creating a need for unusual kinds of human services for localities, such as support services for abused women, parenting classes, and crisis intervention teams. Despite the need, public health programs, community nursing, and mental health services often are not available, accessible, or acceptable to target groups in rural areas.

Rural Initiatives: Healthy People 2020.

In general, rural areas can be described as “bipolar”—that is, most residents are either younger than 17 years or older than 65 years. In turn, the demographics are reflected in the health status and health care needs of residents in a particular community (see the Healthy People 2020 box on the following page). Rural Healthy People 2010: A Companion Document to Healthy People 2010 (Gamm & Hutchison, 2004) was developed to correspond with Healthy People 2010. It remains to be seen if such a corresponding rural document will be developed for Healthy People 2020. (Bellamy et al., 2011; U.S. Department of Health and Human Services [USDHHS], 2010a). Rural Healthy People 2010 identified and prioritized the health care needs of at-risk populations; specifically migrant workers, blacks, American Indians and other American natives, Asians, and Pacific Islanders, as well as pregnant women, children, and older adults. (Refer to Chapters 10 and 21 for additional information.) In spite of the contributions offered by this rurally focused initiative, there continues to be a serious gap in data on the health status of vulnerable and at-risk rural populations, particularly minorities (Bennett et al., 2008; IOM, 2005; Mead et al., 2008; National Advisory Committee on Rural Health and Human Services [NACRHHS], 2011).

In general, the literature indicates that, compared with urban Americans, rural people:

Although many regional differences exist, generally there are higher rates of maternal and infant mortality and morbidity in rural areas than in urban areas, especially among racial minorities. This biostatistic reflects social, genetic, economic, and environmental factors that prevail in rural communities. For instance, social factors include a group’s religious belief system regarding the appropriate time for a pregnant woman to seek professional prenatal services. A genetic factor is exemplified by the predisposition of African Americans to sickle cell anemia. Environmental factors include contaminated water, air pollution, or pesticide to which a migrant worker who is young and pregnant may be exposed. Less-than-optimal pregnancy outcomes, however, can also be attributed to impaired access to and availability of obstetric and pediatric providers and services (Curtis et al., 2011; Hendricks & Hendricks, 2010; NCHS, 2010; USDHHS, 2010a).

In recent years, there has been a marked reduction in the number of family planning and maternal and child care providers and services in nonMetropolitan areas. Despite an overall increase in the number of obstetricians, pediatricians, and family/general practitioners in the United States, many children and pregnant women face a shortage of providers and services. This can be attributed partly to the high cost of malpractice insurance and partly to the fact that health care providers are not equitably distributed in rural geographical areas. This leaves some areas of the United States without any—or with an insufficient number of—health professionals (Bureau of Health Professions [BHPR], 2010; Centers for Medicare and Medicaid Services [CMS], 2011; National Health Service Corps [NHSC], 2011; National Rural Health Association [NRHA], 2011).

In some regions of the United States, for example, some pregnant women must travel more than 150 miles one way to obtain care from an obstetrician. Traveling long distances for care also may be required for children with disabilities because specialists usually practice in urban areas. Consequently, pregnant women living in rural areas, especially minorities, are less likely to initiate care during the first trimester, and their children with special needs are less likely to receive rehabilitative and restorative care (Gamm & Hutchison, 2004; Swaim & Stanley, 2011).

Closure of rural hospitals and their obstetric units has had an adverse effect not only on access to services but also on pregnancy outcomes. Hospital closures in rural areas often are associated with depressed local economies and inequitable third-party reimbursement policies. More recently, the development and expansion of large health care systems have also led to closures of small and rural hospitals, buying out small hospitals and physician practices. When these health care systems enter the community, local residents are told that outreach health care services will be provided. Because the numbers of rural residents are small and because the overall health of rural residents is poor, services to these communities are not as profitable as initially projected. To cut costs and improve profits, outreach services to rural communities may be reduced or eliminated, leavings already underserved communities with even fewer providers. The impact of health care systems on rural communities poses many unresolved and serious concerns. Data are currently being collected to assess the effects of this particular phenomenon on the health of rural communities (CMS, 2011; NHSC, 2011; Ortiz & Bushy, 2011).

Women who live in communities with relatively few obstetric providers, for example, are less likely to deliver in their local community hospitals than are those who live in communities with a higher ratio of providers. Moreover, women who must leave “high-outflow” communities to deliver have been found to have a higher rate of complicated and premature births, which has been attributed to delays in seeking prenatal care early in pregnancy and inadequate health education (Gamm & Hutchison, 2004).

Mothers and infants living in professionally underserved areas remain in the hospital longer after delivery because of the distance of the hospital from their home and the potential need for emergency services. For example, a new mother who lives more than 100 miles from the hospital and must contend with ice and snow on a county road to reach her home is less likely to be discharged with her new infant after 24 hours than one who lives in the town in which the hospital is located.

Higher rates of maternal and perinatal mortality and morbidity among rural individuals cannot be attributed entirely to geographical distances and delays in securing health care. As mentioned earlier, rural areas suffer from higher rates of poverty and lower percentages of families with health insurance. Rural states historically have had more restrictive qualification criteria for public assistance. Likewise, welfare reform that limits the time one can receive benefits has had mixed results in rural areas. Particular rural concerns include fewer educational and employment opportunities and limited child care services for those trying to get off public assistance (Gamm & Hutchison, 2004; Mead et al., 2008; NCHS, 2010).

There are regional differences in the predominant health problems in rural communities, depending on environmental, genetic, industrial, and socioeconomic factors. Compared with urban areas, there are wider variations in rural areas in the rates of accidents, trauma, chronic illness, suicide, homicide, and use of alcohol and drugs, especially among some minority groups (Bellamy et al., 2011; Curtis et al., 2011; Fan et al., 2011; National Association for Rural Mental Health [NARMH], 2011).

Policy makers are attempting to identify ways to equitably allocate acute and primary preventive services among all Americans, especially those living in HPSAs located in both rural counties and the inner city. Community health nurses and those who provide outreach services to rural communities should be aware of concerns regarding the availability, accessibility, and acceptability of services. These interrelated delivery issues have serious implications for planning, implementing, managing, and evaluating community nursing services that target rural clients (Bushy, 2009; Winters & Lee, 2009).

Box 32-1 highlights some of the major legislation that has affected rural health care delivery. In rural communities, the issues of accessibility, availability, and acceptability of services and providers must always be considered when legislation is implemented. A program that is highly effective in a more populated area rarely can be lifted and transplanted as-is to a rural environment. In some cases, legislated programs have resulted in highly innovative approaches that serve the population well. In other cases, mandated programs simply create other barriers that deter rural populations from using a much-needed service.

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