Extending Work on Rural Health Disparities: A Commentary on Matthews and Colleagues’ Report

We are writing The Journal of Rural Health to draw readers’ attention to the recent study by Matthews and colleagues that appeared in Morbidity and Mortality Weekly Report1 and offer suggestions to extend their work. We applaud the authors for their focus on rural health—a disparities dimension that is often overlooked—and concur with their assessment that US health surveillance data are rarely disaggregated by meaningful geographic location. Indeed, the authors’ use of 6 detailed geographic categorizations is a marked advance over the commonly used urban-rural dichotomy. Further, Matthews and associates examined 4 health-related behaviors (smoking, physical activity, alcohol consumption, and amount of sleep) and 1 key health status (overweight) that are not only antecedent to multiple health outcomes, but are also the targets of several Healthy People 2020 objectives.2 In short, their report provides better data about the geographic distribution of key determinants, which is a necessary foundation for efforts to improve population health generally and to address rural health disparities specifically. We reiterate Matthew and colleagues’ key findings. Compared to metropolitan counties (ie, urban, suburban, and periurban), noncore (ie, rural) counties had higher levels of current smoking, excessive drinking, and overweight, but lower levels of physical activity. There was no difference by geographic area in prevalence of adequate sleep, which fell short of target levels in all geographic areas. Approximately one-third of rural county residents reported multiple health risks, with higher levels of multiple risks among rural women, people age 65 and older, and those with higher educational attainment. Although the study's focus was largely on the distribution of health-risk behaviors, Matthews and colleagues also noted the role of social context in shaping rural health. In the interest of developing a more rigorous evidence base, particularly one that fosters a holistic understanding of rural health risks, we offer several recommendations to build upon Matthews and colleagues’ work. First, we note that at present, no Healthy People 2020 objectives focus specifically on rural health, and we recognize that many current objectives would benefit from consideration of geographic variation. For example, it is well documented that nonmetropolitan areas suffer from constrained economic opportunity leading to higher levels of poverty,3-6 a key social determinant of health. Thus, objective SDOH-3.2, which seeks to monitor the proportion of children living in poverty, would benefit from analysis by geographic unit, such as the 6-level categorization used by Matthews and associates. We encourage the development of new rural health objectives as well as ongoing monitoring of current objectives for rural-urban differences. Second, given that health-related behaviors take place within distinct rural contexts, we remind the public health community of several established factors that warrant further attention, particularly related to structural barriers to better health. Foremost, as noted by the authors, rural communities are often at a disadvantage when seeking health care as residents must often contend with limited local services, which may include lack of medical clinics and pharmacists in small towns or no easily available specialty provider, such as an oncologist or psychiatrist.7-11 Similarly, healthy food is less affordable, and distances to obtain healthy food are farther, in rural areas.12-14 Rural residents often travel far to metropolitan areas to access food, take advantage of lower prices, or because the local area lacks a store or lacks quality produce.15 As a result, large numbers of low-income families with children in rural areas remain food insecure.16 However, structural barriers extend beyond access to health care and wholesome food. Related to the environmental context, there is a dearth of evidence-based interventions specifically for rural areas. Notably, it remains unclear how traditional efforts to increase physical activity by promoting active transport (eg, walking), physical activity at work, or alternatives to sedentary leisure activity may be adapted to rural areas. For example, many rural residents live along roads with no sidewalks, have less access to fitness facilities and parks, and reside in areas where stores are too distant to walk to.17 We applaud the efforts of those who are addressing this gap18-21 and urge further work, as individual efforts at behavior change are less likely to be successful when they are nested within constrained environments. Third, related to structural barriers, we highlight the importance of the social context, notably the rapidly changing demographic profile of many rural areas. Many young adults have left rural areas to pursue career opportunities in metropolitan areas, which has resulted in an aging rural population.22-24 This shifts the health profile and needs of rural communities and may undermine the economic base necessary to provide essential services. Concurrently, many rural areas have seen population growth through immigration, particularly through Latino migration to nontraditional settlement areas.25-27 Such new arrivals often provide much needed labor; however, there are attendant challenges, such as bridging language and cultural barriers to ensure full integration.28-30 If new arrivals are marginalized, they may suffer poorer health, which further contributes to rural health disparities. Thus, there is an urgent need to better understand the social forces that shape differential rural health so that we may minimize risk and promote resiliency. Finally, we encourage all researchers to pursue a more nuanced approach to health. As Krieger has argued regarding race and socioeconomic position,31 our science is better when we recognize multiple dimensions of disparities. In other words, rural health risk may not be an “either-or” proposition but a case of “both-and.” The central question is whether the pathway to poorer rural health is through a single dimension (eg, geographic location and its structural or social features), another dimension (eg, individual characteristics, such as gender, age, or educational level), 2 concurrent dimensions (eg, female gender in a rural location), or something else. In sum, we commend Matthews and colleagues’ report as an example of a more rigorous approach to rural health research. We urge continued work to gain a better understanding of the demographic, cultural, and economic heterogeneity of America's rural communities and the ways that these forces shape health status and needs.