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Running head: HEALTH DISPARITIES IN RURAL POPULATIONS

Health Disparities in Rural Populations

Lindsay Scholten
Ferris State University
NURS 340

HEALTH DISPARITIES IN RURAL POPULATIONS

Abstract
Rural populations are underserved and vulnerable to health disparities. Rural residents are
typically poorer, less educated, and more likely to live unhealthy lifestyles (Rural Health
Information Hub [RHI], 2016). Rural areas have fewer health care facilities and physicians, and
many residents lack transportation to get to appointments (Harkness & DeMarco, 2016).
Morbidity and mortality rates from disease are higher among rural populations (RHI Hub, 2016).
Residents are less likely to have employer provided health insurance, and many of those on
Medicaid and Medicare are not getting the care they need (Douthit, Kiv, Dwolatzky, & Biswas,
2015). Community and public health nurses are in an optimal position to deliver health care
services to rural populations.

HEALTH DISPARITIES IN RURAL POPULATIONS

Health Disparities in Rural Populations
One of Healthy People 2020s overarching goals is to achieve health equity, eliminate
disparities, and improve the health of all groups (U.S. Department of Health and Human
Services [USDHHS], 2016, para 5). Underserved and vulnerable populations face a number of
health disparities. Rural populations are especially vulnerable due to social determinants
including socioeconomic status, education level, and access to care and resources (UDDHHS,
2016). There is no agreed upon definition of the term rural, but most definitions refer to the
sparseness of population (Douthit et al., 2015, p. 612). Demographically, rural residents are
poorer, less educated, and have limited job opportunities (Rural Health Information [RHI] Hub,
2016). Rural populations have a higher incidence of morbidity and mortality from disease
compared to urban areas (RHI Hub, 2016). Cardiovascular disease has a higher prevalence
among rural residents, and is listed as one of Healthy People 2020s Rural Health Priorities
(Harkness & DeMarco, 2016). Community health nurses are vital in reaching underserved
populations by collaborating with and empowering residents to take control of their health.
Nurses are in a unique position to impact policy to improve the health of vulnerable populations
(Harkness & DeMarco, 2016).
Population at Risk
Rural populations face health disparities irrespective of race, gender or sexual
orientation (Douthit et al., 2015, p. 612). There are many barriers to getting health care in rural
areas. Rural communities lack access to health care services, have fewer primary care
physicians, lack public transportation, and have less comprehensive insurance coverage
compared to urban areas (Douthit et al., 2015). According to Douthit et al. (2015), patients in
rural areas fear being discriminated against and stigmatized because of their medical history.
Rural communities are often close knit, and residents worry their health information may not be

HEALTH DISPARITIES IN RURAL POPULATIONS

kept confidential (Douthit et al., 2015). Biases and stereotypes regarding intelligence and
socioeconomic class may also prevent rural residents from seeking care. In one study, patients
reported feeling like victims of the prejudice of their health care providers (Douthit et al.,
2015, p. 614). When nurses in the hospital setting were surveyed, they were more likely to agree
with stigmatizing statements as to why people lived in poverty, rather than statements relating
poverty to lack of education, fewer job opportunities, lower wages, and structural factors
(Wittenauer, Ludwick, Baughman, & Fishbein, 2015).
Rural areas have fewer medical facilities and residents are less likely to see a primary
care physician (Douthit et al., 2015). When primary care is available, the number of emergency
department visits for routine primary care problems is significantly lower (Douthit et al., 2015,
p. 615). Getting to appointments is also difficult for some living in rural areas. Residents rely
more on public transportation, yet only 60% of their communities have transportation available
(RHI Hub, 2016). Insurance coverage is less comprehensive for many rural residents. This
population depends on Medicaid and Marketplace coverage from the Affordable Care Act
(Douthit et al., 2015). Due to the lack of insurance coverage and the high numbers of patients on
Medicaid and Medicare, physicians struggle to stay afloat in rural practices (Douthit et al., 2015).
RHI Hub (2016) reports less than 10% of physicians choose to practice in rural settings. There is
an overall shortage of health care personnel in rural areas (Harkness & DeMarco, 2016). The
lack of access to care, logistics, and financial struggles are just a few of the factors that put rural
populations at a higher risk for experiencing health disparities.
Demographics
Residents of rural communities tend to be poorer and less educated (RHI Hub, 2016).
There is a direct relationship between health, income, and education; those with the lowest
income and education often have the poorest health outcomes (Ottawa County Community
Health [OCCH], 2015, p. 4). Douthit et al. (2015) write that 16.1% of those in rural populations

HEALTH DISPARITIES IN RURAL POPULATIONS

live in poverty compared to a national average of 14.5%. Incomes are lower for rural adults and
24% of children live in poverty (Harkness & DeMarco, 2016). Michigans rural population has
a poverty rate of 17.4% compared to 16.8% in urban areas (RHI Hub, 2016). According to the
USDA Economic Research Service, the average per-capita income for Michiganians in 2014 was
$40,740, although rural per-capita income lagged at $34,268 (RHI Hub, 2016, Michigan, para
3).
Job opportunities are limited in rural areas and residents work in industries with lower
levels of employer sponsored health care insurance coverage (Douthit et al., 2015, p. 616).
Working conditions also contribute to health risks. Rural residents who work in factories,
agriculture, mining, and forestry occupations are exposed to environmental hazards (Melvin et
al., 2013). Michigans rural unemployment rate is 7.6%, compared to 7.3% in urban areas (RHI
Hub, 2016). Fewer rural residents are college educated and they are more likely to drop out of
high school (Harkness & DeMarco, 2016). RHI Hub (2016) writes that 10.9% of Michigans
rural residents have not completed high school, compared to 10.7% in urban areas.
Health Concerns
Rural populations are more likely to be overweight and physically inactive. They are also
more likely to smoke, abuse alcohol, and eat less healthy foods (RHI Hub, 2016). Lack of
primary care means less preventative care, such as routine screening and immunizations (Douthit
et al., 2015). Rural areas are less diverse made up of mostly Caucasians (Harkness & DeMarco,
2016). Minorities including blacks, Hispanics, and American Indians face even more disparities
(RHI Hub, 2016). Mortality rates are higher for COPD, ischemic heart disease, unintentional
injuries, motor vehicle accidents and suicide among rural residents (see appendix for complete
data) (RHI Hub, 2016). Rates for diabetes, childhood obesity, teen pregnancy and preventable
hospital stays are also higher (RHI Hub, 2016). In Ottawa County, one in three residents in

HEALTH DISPARITIES IN RURAL POPULATIONS

underserved populations report their health is fair to poor, compared to one in ten in the general
population (OCCH, 2015, p. 4).
At the federal level there are several programs in place addressing the needs of rural
populations including Healthy People 2020, Centers for Disease Controls Office of Minority
Health and Health Equity, and The National Partnership for Action (RHI Hub, 2016). Michigan
also has state and local programs. The Michigan Center for Rural Health (MCRH) was
implemented as part of a nation-wide, federal and state initiative to recognize the importance of
rural health care and to create a mechanism for resources to flow to rural areas (Michigan State
University [MSU], Michigan Center for Rural Health [MCRH], 2016, p. 1). Locally, Ottawa
County Community Health (2015) is striving to reduce barriers to accessing health care,
especially for low-income and underserved populations.
Community and public health nurses are a great resource for rural areas. Nurses can
collaborate with volunteers to provide rides for those needing transportation to appointments
(Harkness & DeMarco, 2016). Mobile clinics and telehealth can be used to reach residents
(Douthit et al., 2015). Many living in rural areas do not have internet access, so education
programs should also be offered in the community (Harkness & DeMarco, 2016). While nursing
intervention within the community is a start, policy must be changed at the state level to
represent the needs of rural communities (Douthit et al., 2015). Despite the passing of The
Patient Protection and Affordable Care Act, health care is not being equally provided (Douthit,
2015). Newkirk and Damico (2014) write that two-thirds of uninsured rural residents live in
states not currently implementing the Medicaid expansion (as cited in Douthit et al., 2015, p.
615), which means less affordable coverage options for this vulnerable population. Medicaid
and Medicare programs must be reviewed to maximize the benefits for the underserved
populations (RHI Hub, 2016).
Prevalent Disease

HEALTH DISPARITIES IN RURAL POPULATIONS

Cardiovascular disease (CVD) is the leading cause of death in the United States and it
affects those in rural communities disproportionately (Melvin et al., 2013, p.1011). Healthy
People 2020 lists heart disease second on their ranking of Rural Health Priorities (Harkness &
DeMarco, 2016). Rural areas have a CVD prevalence rate of 13.1%, compared to 11.2% in
urban areas (Melvin et al., 2013). Residents living in rural areas have more risk factors for CVD
including smoking, obesity, physical inactivity and less healthy diets (RHI Hub, 2016).
Hypertension and diabetes are two co-morbidities that are also higher among this population
(RHI Hub, 2016).
Melvin et al. (2013) write that community-based research and engagement are necessary
to implement effective programs. Engaging the community means meeting them where they live,
in schools, churches, and work-sites (Melvin et al., 2013). Programs should be specific to the
needs of the community. If poor diet and inactivity are identified as issues, education should be
focused in those areas. The community health nurse can implement educational programs and
blood pressure clinics to raise awareness of CVD in rural populations.
Conclusion
Barriers to accessing health care that rural residents face include limited services, fewer
physicians and lack of transportation. Rural populations socioeconomic status and limited
health insurance coverage also make affording treatment difficult. As a result, this vulnerable
population has higher morbidity and mortality rates than urban areas. Improving access to care
and eliminating disparities requires a nationwide effort at the federal, state and local levels.
Nurses make up one of the largest sectors of the healthcare industry (Harkness & DeMarco,
2016, p. 54) and are in a prime position to create policies and implement change in rural
communities. Collaboration with community members is necessary for identifying issues and
creating programs to eliminate disparities and improve the flow of resources to rural populations.

HEALTH DISPARITIES IN RURAL POPULATIONS

HEALTH DISPARITIES IN RURAL POPULATIONS

References
Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to
health care access in the rural USA. Public Health, 129, 611-620. doi
10.1016/j.puhe.2015.04.001
Harkness, G.A. & DeMarco, R.F. (2016). Community and public health nursing: Evidence for
practice. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins.
Melvin, C. L., Corbie-Smith, G., Kumanyika, S. K., Pratt, C. A., Nelson, C., Walker, E. R.,
The Workshop Working Group on CVD Prevention in High-Risk Rural Communities.
(2013). Developing a research agenda for cardiovascular disease prevention in high-risk
rural communities. American Journal of Public Health, 103(6), 10111021. doi /
10.2105/AJPH.2012.300984
Michigan State University, Michigan Center for Rural Health. (2016). Annual report [PDF File].
Retrieved from http://www.mcrh.msu.edu/documents/ annualreport/2014_ Annual_
Report.pdf.
Ottawa County Community Health. (2015). Ottawa county community health needs assessment.
Retrieved from http://www.miottawa.org/Health/OCHD/pdf/2014_2015_OCCHNA.
Rural Health Information Hub. (2016). Rural health disparities introduction. Retrieved from
https://www.ruralhealthinfo.org/topics/rural-health-disparities
U.S. Department of Health and Human Services. (2016, March 16). About healthy people.
Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People
Wittenauer, J., Ludwick, R., Baughman, K. & Fishbein, R. (2015), Surveying the hidden
attitudes of hospital nurses towards poverty. Journal of Clinical Nursing, 24: 21842191.
doi: 10.1111/jocn.12794
Appendix

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HEALTH DISPARITIES IN RURAL POPULATIONS

Rural Mortality Rates Compared to Urban Rates per 100,000
Population

Nonmetro counties

Metro counties

Measure

With a city
10,000
population

Without a
city
10,000
population

Large
central

Large
fringe

Small

Infant mortality

6.8

7.0

6.8

5.7

6.7

Chronic
obstructive
pulmonary
disease (COPD),
death rate among
persons 20 years
of age or older

79.9

81.9

56.2

60.6

70.9

Death rates for

ischemic heart
disease among
persons 20 years
of age and older

197.2

206.5

192.9

174.9

173.8

Death rates for all

unintentional
injuries

58.9

52.7

32.1

33.1

40.8

Death rates for all

motor vehicle
traffic-related
injuries

23.3

19.5

7.9

9.3

12.1

Suicide

18.2

20.0

12.8

13.7

16.1

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HEALTH DISPARITIES IN RURAL POPULATIONS

Rural Mortality Rates Compared to Urban Rates per 100,000
Population

Nonmetro counties

Measure

(RHI Hub, 2016)

With a city
10,000
population

Without a
city
10,000
population

Metro counties

Large
central

Large
fringe

Small