Health Care in Rural Areas: What's Different?

This blog will detour from writing specifically about cancer patients to highlight health care in rural areas. I’ll begin with general information, such as the definition of “rural,” and how health care differs in rural areas.The next portion of this blog will discuss different conceptualizations of “health,” challenges to mental health, and will then focus on the psychosocial wellbeing of rural cancer patients and rural breast cancer patients.

First, two important points:

• If you live in a highly populated area, you may think this topic does not apply to your practice. But what about patients from rural areas that come to your hospital for a second opinion? Or patients who have recently moved to a more populated area? Or patients who live with a relative for the duration of their treatment?
• Please keep in mind that when I’m describing people living in rural areas, my comments are a generalization. To quote a co-worker who teaches medical interpretation and how to care for patients from different cultures, “There’s a difference between a stereotype and a generalization. A stereotype is where the discussion ends. A generalization is where it begins.”

HOW DO YOU DEFINE “RURAL?”

There are a variety of definitions for “rural,” and definitions of rurality may be based on population density, distance from urban areas, or degree of urbanization. Although the terms urban and rural represent a dichotomy, in fact, rural and urban areas exist in a continuum. Also, rural (or for that matter, urban) areas which fall in the same classification may in fact vary dramatically in nature. For our purposes, we will use the US Census Bureau definition of rurality, which is based on population density. When using this definition, approximately 61 million people, or 20% of the US population, live in rural areas¹.

HOW IS RURAL HEALTH DIFFERENT?

• Population demographics: It is a myth that rural areas are homogenous, and in fact, the population in rural areas can be quite diverse. I live in Kansas, which is generally thought of as being inhabited by solely Caucasian residents. However, Kansas is made up of significant numbers of Hispanic/Latinos and Black/African Americans, as well as Asian Americans and American Indian/Alaska Natives. Just as important is the fact that each of these groups can and should be broken down further: Hispanic/Latino can refer to people of whose origins are based in a multitude of cultures, and the specific origins of the patient may be important when considering treatment.
• Why are these distinctions important? Different groups may vary in their healthcare needs: American Indians have high rates of diabetes and some Latin American countries have a high prevalence of cleft palate. Cultural origins may result in differences in beliefs regarding health and illness. A patient from Mexico may view cancer as resulting from natural causes, while the patient from Columbia may view her cancer as a punishment for misdeeds.²
• Demographics in rural areas vary in other ways as well: Compared to folks living in urban areas, rural people are poorer: they have a lower per capita income, more often live below the poverty level, and are more likely to use food stamps. Rural residents are more often under- or uninsured and are less likely to have employer-provided healthcare coverage or prescription drug coverage¹. One example of how these factors may combine to impact health care is that due in part to financial barriers, older cancer survivors living in rural areas are more likely than urban survivors to be non-adherent to follow-up care³.
• Individuals in rural areas tend to be in poorer health: Mortality rates are higher in rural areas and rural residents have shorter lives. Rates of mortality increase with increased rurality and the gap is widening as time progresses. Rates of many diseases are higher in rural areas, including heart disease, hypertension, stroke, diabetes, COPD, lung cancer, unintentional injuries, pneumonia and influenza, and Alzheimer’s disease⁴.
• Rural culture is different: Compared to urban populations, rural folks tend “to be more religious, conservative, work-oriented, intolerant, fatalistic, familial”⁵. Also, rural communities are small and closely-knit and a high value is placed on independence and self-reliance. Many of these traits may result in barriers to health care. Social stigma may prevent rural individuals from seeking health care, as illness may be viewed as a weakness, and seeking help can be seen as not being strong or self-reliant.
• Rural health behaviors are different: Rates of obesity and obesity-related diseases are higher in rural areas, due in part to differences in diet, with rural folks consuming on average more calories and fat, and fewer fruits and vegetables than people in urban areas. Prevalence of smoking is higher in rural areas, and health screening guidelines are not as well adhered to, even when the services are free¹.
• Geographic barriers to healthcare: Access to health care is often difficult, with transportation and distance being major concerns. Another major barrier to care is a lack of facilities and providers. There are 2,157 rural areas that have been designated as Health Professional Shortage Areas. About 10% of physicians practice in rural areas, despite the fact that 20-25% of the population lives in rural areas. There is also a shortage of specialists in rural areas. For example, there are only 40 dentists per 100,000 people in rural areas, compared to 60 per 100,000 in urban areas, and 20% percent of nonmetropolitan counties lack mental health services⁶. Due to a paucity of healthcare workers and therefore a limited choice of practitioners, it is not unusual for health care providers to treat people they know personally.
• Emergency services are an area of critical concern, especially because rural areas have an increased rate of accident-related morbidity and mortality. There are time delays due to distance and lower density of personnel, and 57-90% of First Responders in rural areas are volunteers. Not surprisingly, the rural death rate from unintentional injuries is twice the rate in urban communities¹.

REFERENCES:

• Crosby RA, Wendel ML, Vanderpool RC, Casey BR. eds: Rural Populations and Health: Determinants, Disparities, and Solutions. San Francisco, CA: Jossey-Bass, 2012.
• Galanti G-A. Caring for Patients from Different Cultures. 5th edition. Philadelpha, PA: University of Pennsylvania Press; 2015.
• Cavallo J. Older cancer survivors in rural areas forgo health care due to cost. www.ascopost.com/ViewNews.aspx?nid=8623. Accessed February 4, 2015.
• Singh GK, Siahpush M: Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2014;91(2):272-292.
• Melton GB. Ruralness as a Psychological Construct. In: Rural Psychology. AW Childs, GB Melton, eds. New York: Plenum Press; 1983.
• Rural Healthy People 2010—Healthy People 2010: A companion document for rural areas. http://srph.tamhsc.edu/centers/rhp2010/Volume1.pdf​. Accessed February 4, 2015.