RURAL PUBLIC HEALTH

There are two common methods used to determine if an area may be properly defined as "rural." The first is based on population density and defines a community of under 2,500 people as rural. The other approach involves the designation of counties as being either "metropolitan" or "nonmetropolitan." The principal criterion for considering a county metropolitan is the presence of a city with 50,000 or more inhabitants within the county. Using this definition, which is more popular with organizational and planning groups due to a greater availability of data, nearly one-fourth of the residents of the United States live in nonmetropolitan counties, and the number of nonmetropolitan counties is much greater than the number of metropolitan counties. In 1998, this translated to approximately 54 million people living in rural America.

Rural communities may be at greater public health risk because of certain geographic and demographic characteristics. Compared to urban and suburban areas, residents of rural communities have lower average total incomes, higher unemployment rates, lower educational levels, poorer housing, increased levels of poverty, and a greater proportion of elderly in their midst. Rural economies are more likely to be dependent upon a single industry. The lack of other industry to take up the slack when the singular principal economic activity is stressed can lead to abrupt shifts in economic well-being and to population migration away from the area.

The lower population density in rural areas plays a prime role in the breadth and scope of health systems that are developed there. Access to health care is often problematic. The relative paucity of health professionals in these areas makes it difficult for residents to reach health care providers, particularly medical and dental specialists, physical therapists, and a variety of other practitioners. There are few health care facilities that can manage acute or chronic health conditions, and at times even primary care is difficult to access. The loss of a physician or a health care facility may cause a major disruption in a rural community's health care system.

A number of financial factors can create barriers to health care in rural settings. Medicaid eligibility is often more restricted by rural states; the percentage of uninsured individuals in rural areas is growing; and income for rural family physicians is 15 percent lower than for their urban counterparts, though they tend to see more patients and work longer hours.

Rural minorities lag behind rural whites and urban minorities on many crucial economic and social measures. These disparities, in addition to inadequate community organizational and network resources supportive of minorities, are formidable barriers to rural minorities seeking to access and utilize the already limited health system.

RURAL HEALTH RISKS, NEEDS, AND ISSUES

Rural areas often have a distinct set of health problems. These may be more complex or need to be addressed in a different way, than health problems in metropolitan areas. Farming, mining, and lumbering accidents; environmental hazards; migratory populations; managed-care barriers; and health screening underutilization—these all add complications to rural health practice. In addition, certain problems are unique to certain areas. Farming communities may have greater encounters with zoonotic diseases, insecticide and pesticide contamination, farm machinery accidents, and farmers' lung disease, while rural areas in West Virginia have health problems such as black lung disease, that are unique to coal miners.

Injury is of particular concern in rural areas, not only because of its higher incidence but also because of the higher per capita trauma death rate and the limited resources available to treat injury. Delayed discovery of injury, long transportation times, rudimentary training of prehospital personnel, fewer available physicians, and less experience with trauma patients all result in a poorer prognosis for rural injury patients than those injured in urban settings. Many rural areas rely on volunteer emergency medical technicians with limited equipment and training to provide prehospital care. As a result, trauma patients may be less likely to receive potentially lifesaving interventions such as intravenous fluids or an artificial airway. Volunteer personnel may also be delayed in responding to emergencies.

Environmental hazards of concern in rural areas include pesticides, toxic waste products from factories and chemical plants, and the growing disposal of nuclear waste in these areas. Although regulations have been developed to cope with many environmental hazards, there are many gaps in oversight and monitoring mechanisms. In addition, the potential health hazards of many environmental agents are not fully understood.

The underutilization of common health screening procedures is a serious problem in rural areas. Women in rural parts of the United States are less likely to use breast cancer, cervical cancer, and osteoporosis screening than other major population groups, and higher rates of breast cancer and late-stage disease have been found in some surveys. Migrant populations, principally minority migrant farm workers, tend to lack any form of regular health care. While they are the targets of a variety of federal and state public health programs, their disproportionately increased disease burden persists.

A variety of diseases and health problems are newly emerging or reemerging in rural communities. While HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) infection has been slowing in homosexual populations, its relative frequency is increasing significantly among minorities, women, drug abusers, and rural residents. In contrast to the early 1980s, the twenty-five U.S. counties with the highest rates of increase in HIV infection during the 1990s were mostly rural counties with an average population of 73,000. One of the reasons for this may be due to the increased migration of AIDS patients to rural settings. A higher frequency of heterosexual activity is also noted among rural patients with HIV infections. This expansion of the AIDS epidemic to rural areas is worrisome because rural communities have fewer adequate health care facilities and services than urban areas, particularly for the care of such a complex and multifaceted disease as AIDS. Rural areas have also experienced an increase in other sexually transmitted diseases.

Drug abuse continues to be a significant health problem in rural communities. Rural adolescents and adults have an equal or higher prevalence of alcohol, marijuana, and tobacco use (lifetime and current use) in comparison with national samples. A 1999 report by the National Center on Addiction and Substance Abuse at Columbia University indicated that the increased use of illegal drugs in students may be increasing at an appreciably greater rate in rural youth than urban youth. Adult drug usage was found to be about equal across communities of all sizes. Another study in a grade school population in New Hampshire showed that for all grades and both genders, alcohol is the preferred drug, followed by cigarettes. Marijuana is the third choice for female children while chewing tobacco is third for male children. The use of inhalants, cocaine, downers, uppers, psychedelics, quaaludes, tranquilizers, and heroin was comparatively low.

The prevalence of mental health disorders, particularly mild disorders or early phases of more serious disorders, is not adequately delineated in rural populations. However, the scarcity of mental health professionals and mental health services in rural areas is clear—fewer than one in five rural hospitals has treatment service for these conditions.

Drug-resistant tuberculosis is increasingly affecting rural populations. This is due in large part to infected migrant populations that have received erratic treatment, leading to the growth of drug-resistance within these populations. Resistant strains from HIV/AIDS patients in rural areas may also be playing a role in this increase.

Evidence suggests that rural residents also suffer from more chronic illness—including visual and hearing impairments; ulcers; thyroid, kidney, and heart disease; hypertension; emphysema; and arthritis—than do urban residents. Rural residents also report more activity restrictions from these health conditions.

There is growing information that homelessness is a significant problem in rural areas. Homeless families, in particular, are a growing segment of the homeless population, including the subsector of the rural homeless. This group has a high prevalence of single family heads, unimmunized and developmentally delayed children, and behavioral problems among children and mothers.

Other health problems, such as domestic violence, exist in rural areas, but the significance is difficult to determine, however, because of insufficient data.

HEALTH SYSTEMS IN RURAL SETTINGS

Rural health care is characterized by a relative paucity of available health services, facilities, and health professionals. This is particularly true for health problems that require specialized and tertiary care. Many small rural hospitals closed during the 1990s, and many health care facilities are in serious financial straits. Transportation problems further aggravate other barriers to accessing the health systems in rural settings.

The Balanced Budget Act of 1997 had a serious adverse consequence on the ability of many rural health care providers and facilities to maintain the services they provided to rural Medicare and Medicaid beneficiaries. The mandated Medicare prospective payments systems and other Medicare payment changes caused some rural hospitals, already struggling financially, to reduce their services or close completely. The more recent Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 addressed many issues that resulted from the implementation of the Balanced Budget Act of 1997. It is estimated that the net impact of the 1999 act was to restore approximately $17 billion, over five years, of the reduction anticipated from the 1997 act. However, these budgets still create a variety of responses to meet the health care needs of rural populations, rather than promoting a policy that strengthens a more integrated and coordinated rural health system. It is quite apparent that more comprehensive financial incentives that can support system integration through reduced duplication of services and increased health care efficiencies remain elusive.

During the last decade of the twentieth century, the private sector in urban areas moved to embrace managed care as a way to decrease costs while attempting to maintain, or even improve, access and quality of care. Managed care structures have developed much more slowly in rural areas because of the relative scarcity of health professionals and a lower population density—with the attendant deficiency in dependable transportation. To gain the same efficiencies that were anticipated in the private sector, the use of waivers has been used to bring managed care to the Medicaid environment in metropolitan areas, including some contiguous rural areas. The transition to Medicaid managed care has been fraught with difficulties in client enrollment, access to services, and provider reimbursement. Because of the uncertainties in providing managed care to rural Medicaid populations, coupled with the potential of decreased profits or even financial losses, managed care organizations are not eager to expand Medicaid waivers into rural areas. The failure to expand managed care in rural areas may not necessarily be a negative phenomenon, however, because of the variable success that managed care systems have had in urban settings.

The public health infrastructure of rural areas is also being assaulted by financial problems and the lack of adequately trained personnel. In many areas, a single public health authority, often with no public health training of the personnel, is the operational unit for the community or county. However, dramatic changes are unfolding in local and county public health departments. In 1998, for example, the Texas Legislature approved a bill (HB 1444) for restructuring the state's local public health departments and aligning their responsibilities with the ten essential public health services. The Texas Department of Health; academic, public, and private health organizations; and community partnerships are all working together—with some support from tobacco lawsuit dollars—to bring this public health restructuring to fruition.

A number of efforts are also in place or being developed to improve rural health care services. Some regions have established ambulance or helicopter services for transporting serious, acute, or chronically ill residents to larger, more appropriate health facilities. In other instances, small clinics and secondary care installations (e.g., community health centers, rural health clinics) have been developed through sponsorship and collaboration by rural hospitals, private medical groups, and federal or state programs. These smaller clinics or care centers may be staffed by nurse practitioners or physician assistants, often with needed backup by rural physicians. In other models, specialists from urban areas or larger communities travel to rural areas on a regular basis, providing more specialized health services.

Home health care is reaching rural residents, although there are some differences compared to home care in urban settings. Rural residents are less likely to receive home health care than urban dwellers, and while urban patients typically have long-term illnesses and are physically dependent, rural patients are more likely to be recipients of post-acute care, often recovering from heart attacks.

An important model for addressing rural health systems is the consolidated or integrated system developed by the Marshfield Clinic in a rural region of central Wisconsin. This six-hundred-physician multispecialty group medical practice runs thirty-seven regional centers and provides all levels of care, both outpatient and inpatient, from primary care through highly specialized tertiary care. Computerized information systems are extensively used for patient care and administrative functions. This has provided opportunities for rural health research and public health surveillance.

Another ongoing collaborative model is that of an obstetrical service (supervised by Columbia University) woven into a system of fourteen satellite clinics providing primary health care in rural upstate New York and linked to a referral rural hospital, the Mary Imogene Bassett Hospital. A team of nurses, nurse-midwives, and obstetricians in this practice model have demonstrated the feasibility of providing effective care for women and their families living in rural communities.

Urban-based health maintenance organizations and hospitals have also organized private satellite rural group practices, and universities have sponsored rural medical practices, particularly as related to their resident and student training programs (some of these are related to the federally supported Area Health Education Centers).

Finally, rural residents, perhaps mainly through necessity, tend to exhibit greater reliance on self-care, with the principal role as caregiver usually occupied by rural women. With further health education and health promotion awareness, these women could be major forces in improving the health of their families and the communities.

HEALTH PROFESSIONALS

Obtaining a quality professional health care workforce has been a long-term, unresolved problem in many rural areas. Not only is the number of primary-care physicians practicing in rural areas often inadequate, but many such practitioners are also in older age brackets. In addition to physicians, shortages of health professionals include midlevel practitioners such as nurse practitioners, nurse-midwives, physician assistants, and nurse anesthetists. Dentists, social workers, allied health personnel, pharmacists, and mental health personnel, are also in short supply. In addition, health professionals, particularly medical specialists, are needed to manage the special needs of mothers and children, the elderly, those with complex and chronic illnesses such as AIDS, and minority populations. Midlevel health professionals or practitioners (e.g., nurse practitioners, certified nurse-midwives, physician assistants) are quite useful in providing needed primary care services to rural communities. Their role in rural health centers, in particular, as well as related governmental efforts to establish a more adequate reimbursement mechanism under Medicare and Medicaid for the services of midlevel practitioners (Rural Health Clinic Services Act), enhances their outreach to rural residents. The American Academy of Family Practitioners has released guidelines in the supervision of these practitioners to direct, coordinate, and review such care. A greater liberalization of health professions practice acts in individual states to expand the scope and autonomy of clinical practice by these midlevel professionals, a highly controversial issue, could potentially reduce even further the unmet primary health care needs of rural communities. Reform of payment systems to favor rural and primary care clinicians as a whole would be beneficial to counter the specialty and geographic differential in incomes among physicians and other health professionals.

Unfortunately, the principal factors (e.g., education and training, reimbursement, regulation) that influence the recruitment and retention of needed health professionals in rural America are not given sufficient attention by educational institutions, governmental programs, and policymakers. To adequately meet the needs of rural communities it is vital that effective interventions take place in the health profession education system, which is predominantly geared to urban areas in recruitment, orientation, and training.

On the positive side, there are a number of programs, such as the Area Health Education Centers, Interdisciplinary Rural Health Training Grants, and other rural initiatives sponsored by the Health Resources and Services Administration, that provide support for the education and training of health professionals for rural areas. The placement of, and increased access to, health professionals and facilities in rural areas is promoted by the National Health Service Corps, the Community and Migrant Health Center Program, and through telecommunications and health support efforts from the Office of Rural Health Policy. Likewise, there are educational institutions that promote efforts to improve the health workforce in rural communities. A study of these institutional efforts by the National Rural Health Association (1992) revealed some quite successful academic programs that feature specific characteristics such as targeted recruitment efforts, rural-oriented didactic and clinical instruction, effective preceptors at rural practice sites, and availability of sociocultural or ethnographic information about rural populations for students. Selected successful rural-oriented academic programs include the following characteristics:

• Recruitment efforts target students from nonmetropolitan areas.
• A specific program or tract is rural-oriented in both didactic and clinical instruction, with faculty that are knowledgeable of and committed to rural health.
• Preceptors at rural practices sites are fully qualified to teach/evaluate students and are integrated into the faculty.
• Students learn sociocultural and ethnographic information about the rural population.
• Academic programs tailored to allow students to remain in their own community are developed.
• Administrative support for the academic program, including technology maintenance, and faculty and student travel and lodging is provided.

In 1995, Texas A&M University opened the School of Rural Public Health, which is intended to provide a strong academic resource to educate students and future leaders, develop research on important issues, and provide service and out-reach to benefit the health of rural communities and residents. The school is also making a concerted effort to provide public health education to the large proportion (estimated at over 80%) of individuals assuming public health responsibilities who have had little formal education in public health. This effort is being made through a graduate education program, and it could be of special significance to rural communities and counties where no public health department exists and the only public health resource is a single health professional with minimal public health education.

In spite of these and other excellent programs and activities, the problem of an inadequate health professions workforce in rural areas persists. It is clear that additional innovative, effective measures and a more determined commitment to address this national problem are required.

RESEARCH ON RURAL HEALTH ISSUES

Research on rural health issues is also plagued by a research and institutional structure and bias that favors urban areas. Yet, there is a substantial need for research efforts to identify and analyze significant rural health problems. Research is needed on attitudes about family planning services among adolescents and young adults, access to health care for rural Medicaid populations, the health of rural homeless families, and incidence and management of domestic violence and mental health disorders.

It is also important to develop and monitor health policies that take consequences for rural communities into account. At the beginning of the twenty-first century, much health policy activity revolved around cost containment issues rather than access to services. Access is, of course, a crucial issue for rural communities and needs to be addressed. The policy implications of ongoing and future demographic changes—such as the increase in rural elderly residents and minority populations and the frequency of chronic diseases, which place significant stresses on rural health systems—also require attention. Policy development will need to address the emergence and increase of diseases such as HIV/AIDS, sexually transmitted diseases, drug-resistant tuberculosis, and substance abuse in rural populations. Effective environmental interventions in farms, including the allocation of more resources to farm safety programs and a revision of current farm safety legislation, is also necessary.

Ciro V. Sumaya

(see also: Economics of Health; Environmental Determinants of Health; Equity and Resource Allocation; Essential Public Health Services; Farm Injuries; Inequalities in Health; Migrant Workers; Regional Health Planning; Urban Health Planning; United States Department of Agriculture [USDA] )

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