Introduction

According to a W.K. Kellogg Foundation (2001) survey of rural, urban, and suburban residents, 85% of Americans hold a strongly positive view of rural life. They characterize rural life as involving a strong sense of family, exhibiting a commitment to the community, being hardworking, possessing deeply held religious beliefs, and being self-sufficient. Rural life is seen as emblematic of the individualism and self-sufficiency that has often defined America. At the same time, these positive views are moderated by the serious economic and social challenges that are also ascribed to rural localities: low wages, poverty, decreased job opportunities, resistance to change, and a reluctance to accept outsiders.

Mention the word rural and the picture most people describe is that of an agricultural community. However, fewer than 10% of rural Americans live on farms, and only 2% earn their living from farming. Moreover, total agricultural employment—including farm workers, suppliers, processors, and marketers—account for less than 12% of rural employment (W.K. Kellogg Foundation, 2001). More than half of rural jobs are in the service industry, and manufacturing jobs also outnumber farming jobs. Because perception helps determine policy, the stereotypes held of rural America may be detrimental. For a further discussion of stereotypes, see the chapters on diversity (Chapter 14) and vulnerable populations (Chapter 19).

When rural health is mentioned, actions related to agricultural hazards are often proposed. Although these are needed, actions related to securing accessible health care services and increasing the availability of insurance are much higher priorities for rural residents. Understanding the most important rural needs can help policymakers develop the most effective health strategies and help rural residents identify lifestyle changes that can improve health. For example, many people, both urban and rural, perceive rural localities as being much “safer” than other areas. Although the crime rate is lower in most rural areas, the rate of death from accidents is much higher. Similarly, preconceptions of rural life may include visions of fresh vegetables and much physical labor. Although fresh vegetables may be more available in rural localities, rural residents now report some of the highest obesity rates.

Rural health care presents both challenges and opportunities. Many indicators of health status are less favorable than in other areas of the country. However, nurses have the potential to bring about change in a meaningful way because they are received with respect in rural areas. Nurses have opportunities to develop policies at the local level and influence health and fitness patterns in communities. The positive perceptions of rural communities can provide the foundation for building strategies to support and enhance rural health.

What Is Rural?

A number of different classification systems exist for defining how rural a locality is. Some systems focus on actual population numbers, whereas others define rural areas by population density or distance from an urban center. People’s perceptions of the definition of rural are relative; the term is often thought to mean “smaller than where I’m from.” Someone from a large city may think of a town of 20,000 as rural, whereas residents of a remote farming community may consider the town of 20,000 to be a city. Depending on the criteria chosen, rural areas account for 17% to 25% of the American population.

The U.S. Census Bureau (2008) and the Office of Management and Budget (OMB, 2004) have established two of the most frequently used classification systems for determining what is rural and what areas qualify for rural federal programs. The classification system used by the OMB was significantly revised in June 2003, resulting in a decrease of the percentage of the population defined as rural. Previously, metropolitan statistical areas (MSAs) were designated as counties encompassing a central city or urbanized area of at least 50,000, whereas all other areas were designated as nonmetropolitan areas. Counties were included in MSAs if they were both economically tied to the central city by daily commuting and displayed a “metropolitan character” based on population density. The revised guidelines placed more emphasis on daily commuting. If 25% of a community’s population commuted to a central city, then it was redesignated as metropolitan, no matter what its population density. The net effect of this change decreased the actual enumeration of nonmetropolitan (rural) population from 55 million to 49 million persons and the percentage of the U.S. population characterized as nonmetropolitan from 20% to 17%. The OMB also introduced the new category of micropolitan, an area with a small city of 10,000 (Cromartie & Bucholtz, 2008).

At approximately the same time, the Census Bureau, which classified rural areas as localities of fewer than 2500 residents, started to include the population of the areas immediately surrounding these localities in their population totals. For instance, in 1990 a small town of 2200 people with an adjacent suburb of 500 would have been designated as rural. Under the 2008 guidelines, the population of the two areas would be combined for a total of 2700 and designated as an urban cluster. The net effect of this definition change decreased the number of rural residents in the United States by 3 million by reclassifying them as urban. If these criteria had not been changed, the U.S. rural population would have actually increased by approximately 2 million from the 1990 to the 2000 census. The population in rural areas rose 0.4% per year from 2000 to 2006, primarily as a result of increased numbers of Hispanics moving there. Since then, the rural population has started to decline, partly because of rising energy prices and a slowing economy (National Advisory Committee on Rural Health and Human Services [NACRHHS], 2008; U.S. Department of Agriculture [USDA], 2008).

A third popular classification system uses population density as its determining characteristic. In this system, urban is defined as any area containing at least 99 persons per square mile, rural as containing 7 to 98 persons per square mile, and frontier as areas containing fewer than 6 persons per square mile (National Center for Frontier Communities, 2007). This system is particularly helpful in delineating the unique needs of sparsely populated, geographically isolated localities. Other definitions describe rural areas by their distance to urban centers (e.g., 30 miles, 60 minutes). Communities that are only 30 miles from an urban area have different health issues than communities whose residents must travel 2 hours to reach the nearest city (Frontier Education Center, 2004).

The 2004 Omnibus Appropriations Act simplified the definition of rural to include any incorporated city or town of 20,000 or fewer to broaden eligibility for many rural federal programs (Institute of Medicine [IOM], 2005). In general, the literature uses the term rural to describe localities of fewer than 20,000 to 50,000 inhabitants and fewer than 99 persons per square mile. No matter which definition is used, being rural and having fewer people in geographically extended areas affects both transportation and interactions with other people, as well as the availability and accessibility of health care services.

Health Status of Rural Residents

The Department of Health and Human Services (Gamm, 2007) identified health insurance as a top-10 “health indicator” and a reliable predictor of overall health status. Rural residents are more often self-employed or employed in smaller, often family-run, businesses that are less likely to offer health insurance to their employees. However, the gap between urban and rural insurance coverage has decreased over the last 10 years, primarily as a result of increased utilization of government-sponsored insurance programs (IOM, 2005; NACRHHS, 2008). Most of the uninsured are full-time workers; businesses with fewer than 25 employees account for 38% of the uninsured workers in the United States (National Coalition on Health Care, 2009). Rural children are less likely to have insurance than children in urban areas, especially children of Hispanic or African descent (Martin, Probst, Moore, Patterson, & Elder, 2005). Migrant seasonal rural workers are unlikely to receive health benefits or even minimum wage. Seasonal migrant workers have the additional obstacle of establishing any level of continuity of care.

Conducted every 10 years, the Rural Healthy People (RHP) 2010 project identified access to quality health services as the overwhelming top priority in rural areas (Bolin & Gamm, 2003). Residents of rural communities seem to have higher rates of chronic illness such as diabetes, hypertension, cardiovascular disease, cancer, and arthritis. However, when these disease rates are adjusted for age and the higher proportion of older residents in rural areas, the difference is erased (IOM, 2005; NACRHHS, 2008; Ricketts, 2000). Although living in a rural area does not increase the risk for developing chronic disease, a higher percentage of the rural population does cope with chronic illnesses. The resulting need for increased health services for these chronic diseases is coupled with the fact that fewer than 10% of physicians practice in rural communities even though 17% to 25% of the population lives there (Cromartie & Bucholtz, 2008; National Rural Health Association [NRHA], 2008; Ricketts, 2000). This disparity is likely to increase in the future as the proportion of female physicians in America increases. Female physicians are less likely to practice in rural areas than urban areas (Ballance, Kornegay, & Evans, 2009; Fordyce, Chen, Doescher, & Hart, 2007). However, nonphysician primary care providers such as nurse practitioners and nurse midwives are starting to fill the positions and serve the needs of rural communities (Lindsay, 2007) (Figure 17-1). In 2006, 27% of all employed nurse practitioners practiced in rural areas (Newland, 2006; Ricketts, 2005).

Although rates of coronary heart disease and stroke have fallen 50% during the past 30 years, these conditions were still the leading causes of death in 2000 and a top priority of rural health care providers (Zuniga, Anderson, & Alexander, 2003). Rural populations are particularly vulnerable to cardiac conditions because of their higher rate of smoking (unadjusted for age) and high-fat diets, as well as their greater distance from comprehensive cardiac rehabilitation facilities. Buczko (2001) found heart failure and stroke to be the most common discharge diagnoses for hospitalized rural Medicare beneficiaries.

According to the Rural Healthy People 2010 survey, diabetes is the third-highest ranking health problem among rural residents, behind access to care and heart disease (cited in Gamm, 2007). The prevalence of diabetes seems to be somewhat higher in rural areas, but ethnic, socioeconomic, and lifestyle factors are greater risk factors than geographical environment (Dabney & Gosschalk, 2003). For example, rates of diabetes are two to five times more common in certain minority groups; rural communities with high African American, Hispanic, or American Indian populations are particularly at risk. Limited resources for the management of diabetes and specialized care such as ophthalmological examinations compound the problem. The rate of hospital admissions due to diabetes increased 85% in recent years, and patients with diabetes from poor communities are 80% more likely to be hospitalized for diabetes (Agency for Healthcare Research and Quality [AHRQ], 2007).

Rural health leaders identify mental health and mental disorders as the fourth most important priority in rural health care (Gamm, 2007). Although both rural and urban areas report that approximately 20% of their residents are affected by mental disorders each year, suicide and severe psychological distress rates are higher in rural areas (Strong et al., 2005). Rural communities are far less likely to have sufficient mental health services. Almost 90% of the federally designated Mental Health Professional Shortage Areas in the United States are in nonmetropolitan counties, including 20% of nonmetropolitan counties that have no mental health services. Lengthy travel to mental health outpatient services is common and associated with fewer visits. Many insurance plans limit the number of visits to mental health professionals. However, rural residents report that they prefer discussing their psychological concerns with their primary care provider more than a psychiatrist. Frequently, specialized mental health services programs are only economically viable with grant funding and cease when the funding ends. Consequently, rural primary care physicians and nurse practitioners play a greater role in mental health care than do their metropolitan counterparts. Some studies have found that the treatment of rural residents with depression is more likely to be improved by enhancing the mental health education of primary care providers than by increasing the supply of specialty mental health providers in rural areas (Gale & Lambert, 2006; Sawyer, Gale, & Lambert, 2006). Hanrahan and Hartley (2008) propose a model of using advanced practice psychiatric nurses to ease the rural mental health workforce shortage.

Dental health is the fifth most identified health need in rural areas, according to the Rural Healthy People 2010 survey. Dental caries are more prevalent in rural areas. Fewer than 20% of children covered by Medicaid receive preventive dental care each year. Tooth loss among senior citizens and lack of dental visits within the last year are much more common occurrences in rural areas. Shortages of dentists, lack of community-fluoridated water because of individual wells, decreased access to dental insurance, and increased rates of poverty in rural areas are all factors in the dental health status of rural communities (Martin, Wang, Probst, Hale, & Johnson, 2008; NACRHHS, 2008).

Substance abuse is recognized as a health problem in both rural and urban areas, with slightly higher rates of alcohol use among rural residents and slightly higher rates of illicit drug use among urban residents. However, the consequences may be greater in rural areas because of the lack of substance abuse treatment services, regional isolation, and the stigma associated with treatment in small localities (NACRHHS, 2007). Rates of driving under the influence of alcohol are greater in rural areas, possibly because of the greater distances traveled and greater reliance on automobile travel. Tobacco use is also significantly greater in rural areas, especially among adolescents. More recently, methamphetamine use has been recognized as a significant problem in rural America, where “meth labs” are easier to set up and escape detection (Gfroerer, Larson, & Colliver, 2007; NACRHHS, 2007). Prescription drug abuse, especially of OxyContin, has been found to be a greater problem in rural areas, particularly among rural youth and in mining communities. Approximately one in seven rural Americans report abuse or dependence problems (Duncan, Salant, & Colocousis, 2006).

Statistics on domestic violence tend to be conflicting but show no overall differences between rural and urban communities (Alexander & Castillo, 2004; Breiding, Ziembroski, & Black, 2009). However, with homes far apart, there may be fewer opportunities for domestic violence to be noticed and reported. Moreover, such behaviors may also be less likely to be identified as inappropriate by residents, particularly when support services are lacking. Fewer resources exist in rural areas for preventing intimate partner violence (Breiding et al., 2009).

Childhood immunization rates are similar among rural and metropolitan areas (NACRHHS, 2008; NCHS, 2007). This may be attributable, in part, to the positive health finding that rural residents are more likely to be able to report having a “usual source of health care,” but they are less likely to report a health care visit within the previous 12 months (NCHS, 2007). Studies have found that rural residents are less likely to obtain some preventive health services such as mammograms (Casey, Call, & Klinger, 2001; Zhang, Tao, & Irwin, 2000), whereas other studies (Edwards & Tudiver, 2008; Pol, Rouse, Zyzanski, Rasmussen, & Crabtree, 2001) found that rural residents receive preventive services at rates as good as, or better than, their suburban and urban counterparts, as long as they visit a health care provider. Rural nurses have been noted to have a positive effect on the use of preventive health services (Butler, Kim-Godwin, & Fox, 2008).

Unintentional injuries or accidents are the fifth leading cause of death in the United States each year and are more prevalent in rural areas (NCHS, 2007; NRHA, 2008). Rates of motor vehicle–related injuries and death, in particular, are much higher. More than half of motor vehicle–related deaths occur in rural areas, and rural residents are 50% more likely to die from trauma than urban residents (Gonzalez, Cummings, Mulekar, & Rodning, 2006). Children in rural counties have a much higher rate of fatal injuries from all types of accidents.

Occupational injury rates are also much higher for workers employed in the agriculture, mining, and forestry industries. Most agricultural injuries involve tractors and farm machinery. Youth working in agriculture account for 40% of work-related fatalities, yet they make up only 8% of agricultural workers (Alexander & Castillo, 2004; Hill & Butterfield, 2006).

The problem of obesity and overweight has been described as our new national epidemic and a critical public health threat. The number of Americans who are overweight or obese has doubled in the last 20 years, and the number of overweight or obese children has tripled (Liu et al., 2007; Ogden et al., 2006; Trust for America’s Health, 2008). Diet and activity patterns rank second only to tobacco as the leading “actual cause of death.” The problem is particularly significant in rural areas because of higher self-reports of adult obesity than in urban areas. Numerous studies have also shown a considerably greater incidence of obesity and overweight in rural children and adolescents (Rogers, 2005; Trust for America’s Health, 2008). Cultural patterns of eating increased calories—developed when rural residents historically were more engaged in heavy physical activity—may play a role. Rural communities with high percentages of African Americans or American Indians are especially at risk because of the high prevalence of obesity in these populations. Seventy percent of rural African American adolescents are obese (26%) or overweight (44%), as are 80% of rural African American adults (Trust for America’s Health, 2008).