Approximately 60 million Americans reside in rural areas of the United States. Although this represents only 20% of the US population, rural Americans have a lower life expectancy than their metropolitan counterparts.1,2 The higher rate of premature death can be traced to a higher incidence of heart disease, cancer, unintentional injury, respiratory disease, and stroke. In addition, infant mortality, alcohol and drug abuse, obesity, diabetes, and HIV infection affect a higher percentage of rural Americans compared with urban residents.3,4

These poorer health outcomes in rural America have been linked to a growing older population, higher rates of poverty, lack of health insurance, and poor access to health care (lack of primary care and specialist healthcare providers and closure of local hospitals).5,6

Rural America has also seen a change in demographics. Similar to their urban counterparts, these communities have also become increasingly diverse: black, Hispanic, Asian American, Native Alaskan, American Indian, and Non-Hawaiian/other Pacific Islander community members now outnumber white individuals within rural America.7 An overarching goal of Healthy People 2020 is to achieve health equity and eliminate health disparities.8 To reach this goal, healthcare providers have to fully comprehend the specific healthcare needs of the rural population: improvement in availability, accessibility, and affordability.9

Lack of Primary Care Providers
Although 20% of the US population lives in rural America, only one-tenth of the physician workforce practices within these regions (Figure 1).10 The lack of primary care providers (PCPs) has led to a lack of screening and preventive health care for the common causes of morbidity and mortality: cardiovascular disease, diabetes, cancer, stroke, and mental illness.4 For example, as a result of the lack of cancer screening, residents of rural, poor regions have a higher risk of being diagnosed with later-stage cancer compared with urban residents.11,12

Figure 1. Shortage of primary care professionals in rural counties of US10

In addition to diagnosing and treating disease, PCPs are integral to patient education, behavioral counseling, social interventions, and implementing public health measures. Rural Americans are less likely to observe healthy behaviors such as weight management, not smoking, physical exercise, and moderate alcohol use.5 There is also a stigma surrounding mental illness in rural America and a scarcity of mental health care services.6There is a direct correlation between the lack of PCPs and greater mortality rate in the rural population.4,13-15

PCPs in rural areas serve large geographic areas and patients across the life span, from pediatrics to geriatrics. In many rural communities, PCPs are integral to maternity and prenatal care, home health care patients, long-term care residents, and patients with mental health issues, further stretching resources.16-19

Health Issues of Rural America

Cardiovascular Disease
There is a higher prevalence of risk factors for cardiovascular disease in persons living in rural areas compared with in those living in urban and suburban regions of the United States. There are high rates of cardiometabolic disease resulting from the prevalence of obesity, hypertension, and diabetes in underserved rural populations. These disparities are driven by complex factors such as socioeconomic disadvantage, social and cultural issues, and limited access to health care, healthy food, and opportunities for physical activity.20-22

Closer examination of cardiovascular disease risk in rural populations finds that women fare worse than men, and racial minorities fare worse than white individuals. Women living in rural areas tend to be uninsured, older, poorer, less educated, and have higher rates of chronic health conditions and disabilities than their urban counterparts.21 Also, the prevalence of stroke, coronary artery disease, and myocardial infarction is significantly higher in the rural South compared to the rest of the country. The prevalence of congestive heart failure in rural Southern regions is almost twice that in metropolitan regions in the rest of the country.23

There is a 17% higher prevalence of diabetes among rural Americans.24 Public health studies show a geographically distinct area known as the Diabetes Belt, which is a region of 644 counties in 15 states in the southern United States that is characterized by a 17% higher rates of diabetes among the adult population compared with urban residents.25 The Diabetes Belt has a significant rural population with risk factors for diabetes including obesity, sedentary lifestyle, extreme poverty, food insecurity, and significant unemployment rates.26,27

The racial minority groups most affected by diabetes include people of African and Hispanic descent, Alaskan Natives, and American Indians living in rural areas. American Indians and Alaska Natives served by the Indian Health Service have a higher rate of diabetes than any other racial group. Further, American Indians are 3 times more likely to die from diabetes than white individuals.27

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Diabetes self-management education and support programs provide patients with the knowledge and skills they need to manage their diabetes, prevent or delay complications, lower blood sugar levels, and improve health outcomes. However, 62% of rural counties in the United States do not have these programs.28