“Rural” is a term that elicits a variety of meanings and images such as farms, expansive landscapes, or small towns. For some, it is a state of mind or a feeling. Others contend its definition is quantifiable by population density or other measures. Although there are many definitions, all attempt to describe something socially and geographically different from urban areas.

The number of Americans living in rural areas has been declining; however, their numbers are substantial. The 2010 US census reported 19% of the population lives in rural areas and 75% of the US landmass is nonmetropolitan.¹ Globally, 3.4 billion people, or just under half of the world’s population, live in rural areas.² Within rural populations, there are many who struggle with health and health care. This chapter identifies and discusses some of the vulnerabilities and health challenges specific to rural populations, the context of rural health systems, and key issues for health-care providers in rural communities.

The social fabric of rural communities is complex and can vary greatly. The smaller scale of rural towns can frequently facilitate an interconnectedness and reciprocity among its inhabitants. People living in small towns tend to know their neighbors and interact with them in multiple settings. This interconnectedness lends itself to grassroots responses to local issues. Community action is frequently organized through churches, civic groups, and local government. These institutions and their leadership can often set the agenda for civic priorities.^3,4 It is no surprise that community-oriented primary care, with its focus on broad community needs that are fundamental to health, has its roots in rural health.

Although there are pockets of prosperity and economic growth in rural communities, many rural economies are on the decline. In recent decades, particularly in developing countries, people are migrating from rural areas to urban centers. This rural flight is spurred by the lack of economic opportunities in rural areas and the perception that larger cities hold the promise of better jobs and more educational opportunities.⁵

Concentrated poverty, low education levels, and hazardous occupations have been major contributing factors in the health inequalities found in rural places compared to urban cities. In line with global trends, rural Americans experience a significantly higher mortality rate than those living in urban areas.⁶ Although activities such as mining, agriculture, and farming are on the decline, they are exclusively rural industries, and they are among the most hazardous occupations. Each year, for example, approximately 10% of farmers are injured while working; their injuries are often multiple and severe, resulting in death or substantial disability.

Obesity is another challenge for rural Americans. Rural populations are 20% more likely to be obese compared with those living in urban areas.⁷ Some studies have indicated that rural people have a diet that is higher in fat and consume fewer fruits and vegetables. Ironically, rural communities, often the producers of fruits and vegetables, have less access to healthy foods than urban areas.⁸ Rural people have to travel farther to grocery stores, where there is frequently less of a selection of fresh foods compared with urban areas.

The lack of physical activity is another contributing factor to rural obesity in the United States. Rural people tend to exercise less than urbanites.⁹ Some researchers believe physical isolation is one barrier to regular exercise. Rural areas often have sprawling settlement patterns, encouraging people to walk less and drive more. Rural school children, for example, are more likely to ride the bus than walk to school. Sidewalks and trails also tend to be less prevalent in rural areas, reducing the opportunity to walk safely to local destinations; exercise facilities and sports teams may also be less accessible.⁹

Suicide represents another significant health disparity for rural America. Since the 1970s, rural counties have experienced a significantly higher suicide rate compared with urban areas. Risk factors for suicide such as depression, isolation, economic worries, and alcohol are exacerbated by the relative dearth of mental health care. Rural gun culture is also widely believed to contribute to the suicide disparity: three out of four suicides in rural America involve firearms.¹⁰

Similar to urban areas, rural America is a dynamic and constantly evolving social and economic landscape. Creating accessible and equitable health systems has been a major challenge for rural counties that have experienced this recent and dramatic demographic trend.

Although each rural community represents a unique social amalgamation of waves of migration, there are some distinguishable national trends. Hispanic migration to rural areas has dramatically changed the cultural composition of many rural communities, and since 1980 the number of Hispanics living in rural America has more than doubled.¹¹ Migrants from Mexico, Central America, and the Caribbean provide a much needed labor force for agricultural industries and contribute to small town economies. While this migration began in the southwest, it now encompasses all continental states and Alaska.

Many Hispanics, particularly those working as migrant agricultural laborers, face significant barriers to health and health care. Language barriers may prevent them from effectively navigating social or clinical institutions. They often live in poverty, have substandard housing, and may be further marginalized if they are undocumented immigrants. Educational opportunities for the children of migrant workers are also limited and few obtain higher educational degrees.¹² The health consequences of these upstream factors cannot be understated.

American Indian (AI) and Alaska Natives (AN) are other populations with unique histories and special health needs in rural America: many AI/ANs are committed or constrained to living in rural areas, almost all reservations are located in rural areas, and most of the tribal governments own rural land. The percentage of AI/AN adults living in poverty is among the highest compared with other racial/ethnic groups, and housing conditions for many Native Americans are substandard.¹³ Native Americans have lower life expectancies and worse health statistics than any other ethnic group in the United States. AI/AN have higher mortality rates from tuberculosis, chronic liver disease and cirrhosis, accidents, diabetes, pneumonia, suicide, and homicide compared with other racial and ethnic groups.¹⁴ These trends date back to the historical trauma experienced when contact was made with European settlers, subsequent inequitable treaties, and dislocation to reservations. Additionally, cultural barriers and geographic isolation have added further obstacles for AI/AN populations to receiving adequate health care.

Rural communities are aging. The proportion of US residents over 65 years old is 14.6% in rural areas compared with 11.9% in urban areas.¹⁵ The rural elderly are largely nonminority, less educated, poorer, and more likely to live in substandard housing compared with metropolitan elderly. Rural communities lack specialized transportation and geriatric services, resulting in special health challenges for the elderly and the providers that care for them.

CORE ELEMENTS OF RURAL HEALTH DELIVERY

At least three core elements provide the basis for a stable rural health-care system: strategically placed and stable hospitals, clinics, and support services; adequate health professions workforce; and sufficient health-care financing. Political commitment and policy interventions targeting these elements are essential to maintaining viable rural health-care systems in the United States and globally.¹⁶

Hospitals, Clinics, and Ancillary Services

The economic and community value of hospitals, clinics, and other health-care services are critical factors in linking together the various components of the rural health-care system. In addition, rural hospitals are often the largest employer in the community and play a substantial role in recruiting and retaining physicians and other health-care professionals. Communities that have stable and adequate health-care services also become magnets for other new businesses, recreation, retirement, and referrals to ancillary health services.

The vitality of hospitals to rural communities became apparent in the 1980s in the United States, when reduction in Medicare payments, coupled with a slowing economy and population movement away from rural areas, contributed to the collapse of 160 small and rural hospitals.¹⁷ The effect on these communities was so devastating that Congress responded by providing grants to develop rural health networks, to regionalize services, sustain local emergency medical system (EMS), and increase quality of care. The Critical Access Hospital (CAH) program was one of the initiatives that sought to stabilize the financial impacts on rural hospitals and reverse some closures that had left communities without adequate access to hospital-based services.^18,19 To be designated a CAH and eligible for enhanced reimbursements, hospitals had to be located in a defined (federal or state) rural areas; be 35 miles distant to the next closest acute care hospital (or 15 miles if the roads were through mountains or poorly maintained); have 25 acute beds maximum; and maintain an average annual 96-hour length of stay for admissions.⁶

CAHs have played a significant role in consolidating services in rural communities. Physicians have increasingly merged their practices with hospitals to lessen the administrative burden of federal and insurance compliance and reimbursement policies, and to allow them to focus more on patient care. In addition, the hospital-associated clinics have applied for designation as federally supported Community Health Clinics (CHC) or Rural Health Clinics (RHC) in order to receive supplemental federal payments for clinical services provided in rural locations.

These federally supported clinic systems have also been vital for improving access to health care in all underserved areas, especially rural ones. CHC, Migrant Health Clinics, Health Care for the Homeless Clinics, and Public Housing Clinics, all also known as Federally Qualified Health Centers (FQHC), are one system that provides much of the care to rural communities. About one-half of FQHCs are located in rural areas. They serve one out of every seven US rural residents, about 10 million people.

RHCs, like FQHCs, were created by Congress to enhance access to medical care. RHCs differ from FQHCs in that they do not target specific underserved populations, but rather increase access to rural areas that are identified as health professions shortage areas (HPSA). RHCs can be either independent (free standing) or provider based (as part of a hospital or nursing home) and are reimbursed for Medicare and Medicaid services through an all-inclusive rate rather than fee-for-service or prospective payment.⁸ Key elements for certification as an RHC include being in a nonurban area, being located in a federal/state designated HPSA, and employing physician assistants (PA), nurse practitioners (NP), certified nurse midwives (CNM), or licensed psychologists for at least 50% of the time the clinic is open for services.⁹ Indeed, RHCs provided the first federal initiative to recognize PAs, NPs, and CNMs and to encourage their use in expanding access to health care.

Health Workforce—Meeting the Needs of the Future

Doctors and health-care facilities are distributed unequally in all regions of the world, with rural areas suffering particularly from maldistribution issues. Seventy-seven percent of rural counties in the United States are designated as HPSAs and, conversely, 65% of all HPSAs are rural. Impending attrition in medicine, nursing, and dentistry as large blocks of providers reach retirement age in the next decade; declining interest in primary care disciplines; and inadequate teaching and clinical training resources are likely to compound this problem. Policymakers in the United States and globally have focused on multiple strategies to address the imbalance from providing grants and incentives to subsidize health-care systems and attract providers, to expanding the nonphysician health provider workforce.

A cornerstone to any rural health-care system is a solid base of primary care providers—primarily family practice physicians, supplemented with PAs and NPs. Details of the projected primary care shortfall are documented in multiple federal and professional association studies within the past several years, and although there may be differences in absolute numbers, there is no quarrel with the outcome—the United States^20,21 will be short between 20,400 and 124,000 primary care physician Full Time Employments (FTEs) by 2025. Rural areas are likely to be the hardest hit by this shortfall. Furthermore, the decline of interest in family medicine will have significant and disproportional impacts on rural communities since family physicians are the largest segment of primary care physicians practicing in rural areas.²²

PAs and NPs, health professions established in the early 1960s as a response to the shortage and maldistribution of physicians, particularly in rural and underserved urban areas, have since increased their training programs and graduates, and now serve in every medical discipline and health arena. Indeed, both professions are increasing the number of programs and graduates at a much faster rate than medical schools²⁰ and have projected growth rates of 58% and 30%, respectively, between 2010 and 2020. For example, in 2013, there were 181 accredited PA programs with approximately 5971 graduates. Sixty more programs are currently pending accreditation through 2020, and that number may yet increase as demand grows. There were 84,064 practicing PAs in 2013 and projections are for an increase²³ up to 125,847 by 2026.

PA and NP providers fill the gap created by the continuing shortage of primary care and rural physicians: 34% of primary care providers in rural areas are PAs and NPs, and they comprise 46% of the provider base in community health centers. Slightly more than one-third of PAs and a little more than half of NPs are in primary care with approximately 14% and 18%, respectively, practicing in rural locations. Osteopathic physicians and international medical graduates (IMG) also select rural practice more frequently than allopathic physicians (18% and 13%, respectively, versus 11%).²⁴

Since the “barefoot doctors” deployed in China over 50 years ago, use of community health workers (CHW) has been an important strategy to improving health-care access in rural areas. CHWs are typically lay people provided with some medical training who help implement specific health-care interventions. For example, CHWs have been shown to improve rates of immunization and breastfeeding, TB treatment outcomes, and reduce child morbidity and mortality.²⁵ Used extensively in lower- and middle-income countries, use of CHWs is now being adopted in the United States as well.

FUTURE STRATEGIES TO INCREASE THE RURAL HEALTH PROFESSIONS WORKFORCE

Studies of strategies to increase the rural health professions workforce in the United States and internationally have consistent recommendations: broaden the medical student applicant pool to include more rural students; increase the emphasis on primary care/family medicine; provide training opportunities with rural providers and practices through medical school and residency; and provide practice and financial incentives (such as loan repayment and enhanced reimbursement) to attract and retain health-care professionals.^22,26

An intervention used in many countries is to require medical students or graduates to complete national or rural service commitments as part of their educational or licensing requirements. In the United States, the National Health Service Corps (NHSC) was created to improve the distribution of health-care providers by offering financial support to physicians, PAs, NPs, pharmacists, nurses, and mental health providers who choose to work in rural and other underserved areas. Since 1972, more than 37,000 health professionals have served in the corps, with more than 7500 primary care providers currently in NHSC-supported positions. The NHSC is also creating a system to support its clinicians with training resources and a virtual community specifically designed for providers serving in isolated settings.

Other federal and state initiatives target increasing rural medical educational opportunities, recruiting people from rural communities into the health professionals and increasing the numbers of IMG who practice in rural areas. IMGs comprise about 25% of the primary care workforce in the United States and in some regions are more likely to practice in rural areas than US trained doctors.

Telemedicine

Telemedicine, defined by the Institute of Medicine in 1996, as “the use of electronic information and communications technologies to provide and support health care when distance separates participants,” is a rapidly evolving field.²⁷ It comprises a diversity of clinical practices and technologies that hold much promise for improving care, particularly specialty care, for rural patients. Currently, three broad categories of telemedicine are being used: (real time) interactive services, remote monitoring, and store-and-forward consultations.

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  Interactive telemedicine services provide real-time face-to-face interactions between patients or primary care providers and specialists and back-up physicians. Issues of responsibility, reimbursement, ethics, and effectiveness of these new technologies are just now being elucidated.

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