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Chronic Disease in Rural America

Chronic disease is a concern to the rural healthcare system and rural residents due to its impact on quality of life, mortality, and healthcare costs. The Centers for Disease Control and Prevention's Chronic Disease Overview provides a review of the impact that chronic diseases and conditions have in the United States as a whole. Rural communities have fewer resources to prevent and treat chronic diseases and conditions, and they face higher rates of multiple chronic conditions, which are difficult and expensive to treat.

This guide will discuss the impact of chronic disease on rural America, how providers and communities can help patients with chronic diseases, and where to look for funding to establish programs to address chronic conditions. Specific chronic diseases highlighted include:

  • Heart disease and stroke
  • Cancer
  • Diabetes
  • Chronic respiratory conditions
  • Arthritis
  • HIV/AIDS

For a more in-depth look at differences in health status for rural residents and contributing rural risk factors, see the Rural Health Disparities topic guide.

Frequently Asked Questions


How do rural areas compare to urban areas in terms of chronic disease prevalence and mortality?

Rural areas face higher rates of chronic disease and higher related mortality rates. In some rural regions of the country and for some rural population groups, the disparity is even worse.

According to the National Center for Health Statistics report Health, United States, 2016 (Table 39), nonmetropolitan (rural) residents report higher rates of multiple chronic conditions:

Multiple Chronic Conditions, 2015
Nonmetropolitan % Metropolitan %
2-3 chronic conditions 22.2 5.8
4 or more chronic conditions 18.2 4.3
Source: Health, United States, 2016. Table 39

Rural areas tend to have higher rates for many of the most prevalent chronic diseases:

Chronic Disease and Condition Prevalence, 2013
Chronic Disease Nonmetropolitan % Metropolitan %
High cholesterol 42.4 38.8
Hypertension 38.1 32.6
Arthritis 31.1 25.1
Depressive disorder 20.1 17.5
Asthma 13.9 14.0
Diabetes 12.0 10.4
Chronic obstructive pulmonary disease 8.7 6.3
Heart disease 8.6 6.5
Source: Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013, Preventing Chronic Disease, September 2016

A 2017 Morbidity and Mortality Weekly Report article, Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, reports that rural residents have higher age-adjusted death rates than urban residents:

Age-adjusted Death Rates per 100,000 Population, 2014
Cause of Death Nonmetropolitan Metropolitan
Heart disease 193.5 161.7
Cancer 176.2 158.3
Chronic lower respiratory disease 54.3 38.0
Stroke 51.3 35.4
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, Supplemental Tables, Morbidity and Mortality Weekly Report, 66(1), 1-8, January 2017

What contributes to higher rates of chronic diseases and conditions in rural areas?

Some of the factors that contribute to the disparity in rural chronic disease include:

An aging population
As people age, their risk of having multiple chronic conditions goes up, and rural areas have more older people, as a percent of the population. The 2011-2015 American Community Survey Table 0103 shows 18.6% of the non-core (small rural) and 16.3% of the micropolitan (large rural) population is over age 65, compared to 14.1% for the nation as a whole. For information and resources focused on the rural elderly, see RHIhub's Rural Aging topic guide.

Health-related behaviors related to chronic disease
A 2017 Morbidity and Mortality Weekly Report article, Health-Related Behaviors by Urban-Rural County Classification — United States, 2013, reports that people living in rural areas were worse off on several factors that can contribute to chronic disease. Rural residents were less likely to be nonsmokers, maintain a normal body weight, and meet physical activity recommendations, with rates of these behaviors decreasing as rurality increased:

Prevalence of Health-Related Behaviors, 2013
Health-Related Behavior Non­metropolitan Counties
(Small Rural) %
Micro­politan Counties
(Large Rural) %
Nation as a Whole %
Nonsmoker 74.9 76.5 81.0
Normal body weight 28.9 30.6 34.2
Meets aerobic physical activity recommendations 46.7 49.2 50.7
Source: Health-Related Behaviors by Urban-Rural County Classification – United States, 2013, Morbidity and Mortality Weekly Report, 66(5), 1-8, February 2017

Environmental and occupational factors
Many industries in rural areas increase the potential for chronic disease, such as respiratory illness for miners and prolonged exposure to chemicals and sun leading to cancer and other illnesses for farm workers. See What types of environmental hazards do rural communities face that endanger the health of their residents? on RHIhub's Social Determinants of Health for Rural People topic guide for additional information on environmental hazards.

Healthcare access barriers
Access to Quality Health Services in Rural Areas – Primary Care: A Literature Review, a section of the 2015 report Rural Healthy People 2020: A Companion Document to Healthy People 2020, Volume 1, connects limited primary care access to poor health outcomes for chronic conditions such as cancer, diabetes, and heart disease. One of the important roles primary care plays is in screening for conditions so that needed treatment can be provided.

Screening rates in rural areas often lag. For example, Health, United States, 2016 (Table 72) reports that, 63.2% of metropolitan residents had a colorectal test or procedure in 2015, compared to 58.5% of nonmetro residents, and 59.8% of metro residents had a colonoscopy, compared to 56.5% of nonmetro residents.

An August 2016 American Journal of Public Health article, Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States, reports that rural residents had lower rates of screening for cholesterol (80.3% rural, 87.2% urban) and cervical cancer (81.3% rural, 87.3% urban).

For more information on barriers to accessing healthcare, see RHIhub's Healthcare Access in Rural Communities topic guide.


How can wellness and self-management programs help to prevent and address chronic diseases?

Wellness Programs
Wellness programs promote healthy habits through change in lifestyle, disease management practices, healthy eating, and regular physical activity. These programs may be offered by schools, workplaces, healthcare facilities, and community organizations.

Wellness programs may target a particular age group, population, or chronic disease. For example, Fit & Strong! focuses on osteoarthritis in older adults. Another example, the Steps to Wellness/Pasos a Salud, offers community-wide outreach and educational opportunities focused on diabetes reduction and weight management. Courses and activities are geared specifically toward the region's Hispanic migrant workers and their families.

Some wellness programs not only focus on the physical aspect of managing disease, but also the mental involvement. Trinity Hospital Twin City's Fit for Life program educates participants on ways to counter obesity and diabetes through body, mind, and soul. The curriculum was developed and is taught by one of hospital's family practice doctors, lending more credibility to the program and interest from the community.


For additional program examples, see Wellness, health promotion, and disease prevention in RHIhub's Rural Health Models & Innovations.

Self-Management Programs
Self-management programs can help patients manage different aspects related to their chronic diseases. A 2012 Journal of Nursing Scholarship article, Processes of Self-Management in Chronic Illness, identifies the following self-management processes for patients with a chronic illness:

  • Learning about their condition and related health needs
  • Taking ownership of their needs by monitoring and managing symptoms, taking medications, keeping appointments, and other activities
  • Engaging in activities that promote health and minimize the impact of the condition, such as eating healthy and being physically active
  • Activating healthcare, psychological, spiritual, social, and community resources
  • Adjusting to living with their illness

Stanford's Chronic Disease Self-Management Program (CDSMP) is an evidence-based approach that has been widely implemented, including programs in many rural areas. The model is centered around online and in-person workshops led by people who have at least one chronic disease. CDSMP includes action planning, problem-solving, decision making, interactive learning, behavioral modeling, and social support. Training and materials are geared toward specific diseases and are offered in over 19 languages.

Dissemination of Chronic Disease Self-Management Education (CDSME) Programs in the United States: Intervention Delivery by Rurality, a 2017 article in the International Journal of Environmental Research and Public Health, looked at the availability and types of chronic disease self-management programs available in rural areas. The article identifies gaps in the CDSMP offerings and discusses challenges rural areas face in delivering programming, including travel distance and cost.

A 2014 Rural and Remote Health article, Qualitative Exploration of Rural Focus Group Members' Participation in the Chronic Disease Self-Management Program, USA, examined the experiences of rural participants in a CDSMP. Participants in the program reported prioritizing health behavior change as a result of the program. They increased their physical activity, primarily through walking, and also improved their eating habits. Participants found their CDSMP group to be a supportive environment for discussing their condition, an important factor in rural communities where those with a chronic condition may feel socially isolated.

Peer Support for People with Chronic Conditions in Rural Areas: A Scoping Review, a 2016 Rural and Remote Health article, provides an overview of rural peer support programs, which offer support to those with chronic conditions provided by someone with the same condition or otherwise in similar circumstances. These types of programs offer social support and skill development to participants, helping patients learn the skills needed for chronic disease self-management. The article concludes with recommendations for rural communities developing a peer support program.

For guidance on starting a rural self-management program, see the National Council on Aging's Offering Chronic Disease Self-Management Education In Rural Areas: Tips, Success Stories, Innovative Approaches, and Resources.


What are strategies to ensure access to necessary care for rural residents with chronic disease? How can rural providers work with other healthcare facilities and healthcare professionals to address chronic diseases?

There are many ways that rural communities and healthcare facilities can support the health of people with chronic conditions:

  • Care Coordination
    Care Coordination in Rural Communities: Supporting the High Performance Rural Health System, a 2014 RUPRI Health Panel report, identifies care coordination models, such as the Patient-Centered Medical Home (PCMH), that have been successful in supporting rural residents with chronic conditions.

    The Centers for Medicare & Medicaid Services offers Connected Care: The Chronic Care Management Resource to highlight the benefits of Chronic Care Management (CCM) and assist healthcare professionals in implementing CCM. RHIhub's Care Management Medicare Reimbursement Strategies for Rural Providers also includes information for rural providers on billing for CCM services.

    For specific information on rural care coordination, see RHIhub's Rural Care Coordination topic guide and Rural Care Coordination Toolkit.
  • Integrated Service Delivery
    Integrating behavioral health services with primary care can be an effective way to ensure that rural residents with chronic depression or other chronic behavioral health conditions have better access to care. For example, Cross-Walk is a program in rural Michigan that provides access to counseling and treatment to address depression and substance abuse issues in a primary care setting.
  • Transportation Services
    Rural healthcare providers and communities can provide transportation to help patients with chronic conditions get to healthcare appointments and supportive services, such as wellness programs. Transportation may help patients access care within their rural community or reach specialty care available outside the community. For more on this approach, see the Transportation to Support Rural Healthcare topic guide.
  • Traveling Specialists
    Programs that bring specialists to rural facilities can help rural patients with chronic conditions get the care they need without leaving their community. For example, a 2016 article in the Journal of the American Heart Association, Providing Cardiology Care in Rural Areas Through Visiting Consultant Clinics, describes a program that has improved access to cardiologists in rural Iowa.
  • Telehealth
    Telehealth can provide access to specialty care, as well as training for rural primary care providers on the specific needs of their patients with chronic conditions. Project ECHO – Extension for Community Healthcare Outcomes is a well-known and evidence-based program that connects primary care providers and academic specialists in a team to meet patient needs. More information about using telehealth in rural areas can be found on RHIhub's Telehealth Use in Rural Healthcare topic guide.
  • Networking with Larger Systems
    Rural facilities and providers may seek out relationships with larger healthcare systems as a way to help their patients access needed care. This type of relationship, whether formal or informal, may facilitate and support access to traveling specialists, telehealth, and many of the other strategies listed above.

How can rural communities and healthcare facilities work together to prevent the increase of chronic diseases?

Rural communities and healthcare facilities can work together to address the risk factors that are common to many chronic conditions. Here are some approaches to create an environment where it is easier to stay healthy:

  • Support for Physical Activity
    Walking trails, sidewalks, and parks are all aspects of the built environment that can encourage residents to be active. Rural communities may also develop programs to get people moving, such as Walk with a Doc, a national program that has been implemented in rural Oregon, and the Albert Lea Blue Zones Project, which includes walking and biking initiatives in rural Minnesota.
  • Access to Healthy Foods
    Community gardens, healthy cooking classes, and exposure to healthy foods are all ways to support healthy eating among rural residents at risk for chronic disease. Some rural programs offering up healthy food include the Rural Restaurant Healthy Options Program in rural Iowa, the Farm Fresh Rhode Island Food Hub, and Putting Healthy Food on the Table in Appalachian Ohio.
  • Tobacco Cessation
    Encouraging rural residents to stop smoking and using tobacco products is a valuable investment in preventing chronic conditions such as cancer and COPD. RHIhub's Rural Tobacco Control and Prevention Toolkit offers step-by-step guidance for communities interested in developing programs to help their residents stay healthy.

Another aspect of prevention is early detection and treatment through health screening. Early warning signs, such as high blood pressure or cholesterol, can help identify rural residents who would benefit from wellness programs or other interventions to prevent or control a chronic condition:

  • Screening Fairs
    Communities and local healthcare providers can come together to sponsor screening fairs. Taking advantage of events that already bring residents together can be an effective way to reach people who might otherwise not get screened.
  • Mobile Screening Vans
    Mobile vans are a popular method of getting health screening to rural residents where they live. Some examples include The Health Wagon in rural Virginia, the Great Plains Area Indian Health Service Mobile Women's Health Unit, and the New Mexico Mobile Screening Program for Miners.

What are community health workers, home health, and school nurses' roles in helping a patient manage chronic diseases?

Community Health Workers
Chronic diseases require follow-up care, accountability, education, and preventive measures in order to better manage the diseases. Community Health Workers (CHWs) fill gaps that are often left untouched by medical professionals due to lack of time. The roles that CHWs play in helping chronic disease patients in rural communities include:

  • Providing wellness programming and education on chronic conditions and guidance on altering their diet, lifestyle, and daily habits to improve health.
  • Serving as patient navigators to help patients access their healthcare facility's services and to ensure the most appropriate care for their chronic disease is provided.
  • Offering counsel and support to patients and families.
  • Providing screenings and other basic services to patients.

For more information on the role of CHWs for patients suffering from chronic diseases, see the 2015 CDC report Addressing Chronic Disease through Community Health Workers. RHIhub's Community Health Workers Toolkit offers step-by-step guidance for rural communities interested in using CHWs to improve health in their community. Additional information and resources are available on RHIhub's Community Health Workers in Rural Settings topic guide.

Home Health
Home health providers offer a wide range of services to chronic disease patients in the comfort of their own homes. Many home health programs use telemonitoring to manage patients with chronic diseases, many of whom would otherwise require a hospital stay. The Telehealth Monitoring in Home Health project summary outlines an example of home health using telehealth monitoring of remote rural patients. Home health professionals also serve as an extra support to patients between clinic visits.

School Nurses
One purpose of school nurses is to help students with chronic conditions manage their health while in school. Nurses serve as a liaison between the students, their parents, and healthcare providers. Since schools are a consistent place for children, partnerships between schools and local healthcare facilities provide a method to help children manage their chronic diseases on a regular basis. School nurses also educate youth on healthy habits and chronic disease prevention. Michigan's Munson Healthcare Charlevoix Hospital School Nurse Program, for example, offers wellness programming to all students, as well as care planning to help students with chronic conditions. Similarly, Illinois' Visiting School Nurse Program helps rural students with chronic disease management and health education. For more information, see RHIhub's Rural Schools and Health topic guide.


How can policymakers support rural communities' efforts in fighting chronic diseases?

Robert Wood Johnson Foundation's Realizing Rural Care Coordination Considerations and Action Steps for State Policy-Makers outlines steps state policymakers can take to improve rural care coordination and features several state programs that address rural chronic disease. The National Conference of State Legislatures' Chronic Disease Prevention and Management Health Care Safety-Net Toolkit for Legislators, while not focused on rural needs, does offer guidance on what can be done at the state level to address chronic disease.

For an overview of policymaking to support rural health, see RHIhub's Rural Health Policy topic guide.


How prevalent are specific chronic diseases in rural America and what is being done to treat and prevent them?

Heart Disease and Stroke

Heart disease and stroke are more common in rural areas, and rural residents have higher death rates from these diseases.

Prevalence, 2014-2015
Rural % Urban %
Heart disease 13.1 10.3
Stroke 2.9 2.3
Source: Health, United States, 2016. Table 38: Respondent-reported prevalence of heart disease, cancer, and stroke among adults aged 18 and over, by selected characteristics: United States, average annual, selected years 1997–1998 through 2014–2015
Chronic Disease and Condition Prevalence, 2013
Nonmetropolitan % Metropolitan %
Hypertension 38.1 32.6
High cholesterol 42.4 38.8
Source: Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013, Preventing Chronic Disease, September 2016
Age-adjusted Death Rates Per 100,000 Population, 2014
Nonmetropolitan Metropolitan
Heart disease 193.5 161.7
Stroke 51.5 35.4
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, Supplemental Tables, Morbidity and Mortality Weekly Report, 66(1), 1-8, January 2017
Heart Disease and Stroke Age-adjusted Death Rates
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, MMWR Surveillance Summaries, 66(1), 1-8

In particular, rural African Americans face higher heart disease mortality than rural whites, as reported in a 2014 Public Health Reports article, Urban-Rural Differences in Coronary Heart Disease Mortality in the United States: 1999–2009. This disparity may be related to high rates of high blood pressure, diabetes, and obesity in African Americans, which contribute to heart disease risk, as reported by the American Heart Association's African-Americans and Heart Disease, Stroke.

Prevention and Treatment of Heart Disease and Stroke in Rural Areas

A 2017 MMWR Surveillance Summaries report, Reducing Potentially Excess Deaths from the Five Leading Causes of Death in the Rural United States, identifies rural tobacco use, lack of physical activity, poor nutrition, and obesity as contributors to high blood pressure and diabetes, which in turn contribute to heart disease and stroke deaths.

Rural community health programs that focus on nutrition, weight control, tobacco cessation, physical activity and limiting alcohol use can help prevent heart disease and prevent stroke. Targeting high blood pressure and high cholesterol are also strategies to consider, with a focus on screening and intervention to help prevent or control cardiovascular disease.

Rural Heart Disease and Stroke Program Examples

RHIhub Resources on Heart Disease and Stroke

Diabetes

Diabetes rates are higher in rural areas, and the related factors of obesity and physical inactivity also tend to be higher.

Chronic Disease and Condition Prevalence, 2013
Nonmetropolitan % Metropolitan %
Diabetes 12.0 10.4
Source: Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013, Preventing Chronic Disease, September 2016

The National Diabetes Statistics Report, 2017 identifies American Indians and Alaska Natives as having the highest rates of diagnosed diabetes. The condition is also more common among non-Hispanic African Americans and Hispanics than it is among whites and Asians.

Prevention and Treatment in Rural Areas

Rural programs that support access to healthy food and opportunities for physical activity are helpful in diabetes prevention efforts. Programs that focus on weight control and healthy living may also reduce obesity, a risk factor for diabetes.

Screening programs can help rural residents find out if they are at risk for diabetes, allowing them to make lifestyle changes and receive medical care to help prevent the disease from developing. Screening programs are also helpful in targeting diabetes self-management education (DSME) programs to those who could benefit. A 2017 MMWR Surveillance Summary, Diabetes Self-Management Education Programs in Nonmetropolitan Counties — United States, 2016, provides an overview of DSME programs in rural areas. It reports that in 2016, 62% of nonmetro counties did not have a DSME program. The counties lacking a DSME program tended to be poorer, with more minorities, and higher rates of diabetes.

The Centers for Disease Control and Prevention's National Diabetes Prevention Program, which works to prevent or delay type 2 diabetes, offers a lifestyle change program that can be implemented by rural organizations.

Telehealth can be used to help rural residents with diabetes access specialty care and learn how to manage their condition.

Rural Program Examples

RHIhub Resources

Cancer

Cancer, unlike other chronic conditions, is unique in scope because of the many types of the disease and the multiple treatment options for each. Rates of cancer and stage of diagnosis can also vary widely in rural areas depending on environmental impacts, population demographics, availability of screening, and access to culturally informed treatment options. In general, cancer rates are higher in rural areas, as is mortality.

Prevalence, 2014-2015
Rural % Urban %
Cancer 6.3 5.8
Source: Health, United States, 2016. Table 38: Respondent-reported prevalence of heart disease, cancer, and stroke among adults aged 18 and over, by selected characteristics: United States, average annual, selected years 1997–1998 through 2014–2015
Age-adjusted Death Rates per 100,000 Population, 2014
Nonmetropolitan Metropolitan
Cancer 176.2 158.3
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, Supplemental Tables, Morbidity and Mortality Weekly Report, 66(1), 1-8, January 2017
Age-adjusted Death Rate for Cancer
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, MMWR Surveillance Summaries, 66(1), 1-8

A 2017 MMWR Surveillance Summary, Invasive Cancer Incidence, 2004–2013, and Deaths, 2006–2015, in Nonmetropolitan and Metropolitan Counties — United States, looked at specific types of cancer and found that rural areas had higher rates of tobacco-related cancers and cancers where screening is an effective prevention approach. Rural areas also had higher death rates than metro areas for all cancer sites combined, yet lower age-adjusted incidence of cancer.

Prevention and Treatment in Rural Areas

Rural programs that improve cancer screening are an effective approach to address the disparity in cancer mortality in rural areas. A 2017 Rural Monitor article, “Doing Something Exceptional”: Rural Communities and Colorectal Cancer Screening, describes the impact that screening can have on outcomes for this particular type of cancer and highlights two rural programs that have developed successful colorectal cancer screening programs.

Given that tobacco use is higher in rural areas and tobacco-related cancer is more common, tobacco cessation and prevention programs are also an effective way to help reduce cancer in rural areas. The MMWR Surveillance Summary on cancer also identifies physical inactivity and obesity as cancer risk factors in rural areas. Programs that support physical activity and healthy eating are also effective approaches to help prevent cancer.

Access to specialist care for cancer treatment is a challenge in rural areas, particularly when a course of treatment may require frequent trips or an extended stay in a place that offers oncology care. Telehealth can help rural providers work with specialists in other locations to help patients stay in their own communities as much as possible.

Programs that help improve rural access to palliative care are also helpful to rural patients and their caregivers.

Rural Program Examples

RHIhub Resources

Chronic Respiratory Diseases

Chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), make it difficult to breathe due to problems with the airways and other lung structures. Death rates for chronic lower respiratory disease, which includes asthma, COPD, and other lung conditions, are higher in rural areas. COPD is more prevalent in rural areas. For the population as a whole, rural asthma rates are similar to rates in urban. Among the American Indian and Alaska Native (AI/AN) population, however, the Office of Minority Health reports that AI/AN children are 60% more likely to have asthma than non-Hispanic white children, most likely due to the exposure to secondhand tobacco smoke.

Chronic Disease and Condition Prevalence, 2013
Nonmetropolitan % Metropolitan %
Asthma 13.9 14.0
Chronic obstructive pulmonary disease 8.7 6.3
Source: Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013, Preventing Chronic Disease, September 2016
Age-adjusted Death Rates per 100,000 Population, 2014
Nonmetropolitan Metropolitan
Chronic lower respiratory disease 54.3 38.0
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, Supplemental Tables, Morbidity and Mortality Weekly Report, 66(1), 1-8, January 2017
Age-adjusted Death Rates for Chronic Lower Respiratory Disease
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014, MMWR Surveillance Summaries, 66(1), 1-8

Prevention and Treatment in Rural Areas

The Centers for Disease Control and Prevention identifies ways to prevent chronic respiratory disease by avoiding:

  • Smoking and exposure to tobacco smoke
  • Air pollutants, both at home and in the workplace

Health-Related Behaviors by Urban-Rural County Classification — United States, 2013, a 2017 MMWR Surveillance Summary, reports that smoking increases with level of rurality. Only 74.9% of the noncore (small rural) and 76.5% of micropolitan (large rural) residents are nonsmokers, compared to 81% for the nation as a whole. Rural programs that target tobacco use prevention and cessation are useful in addressing both direct exposure through smoking and exposure to secondhand smoke.

Environmental and occupational exposures are also a risk factor. Bringing Change for Rural COPD Patients: Possibilities with the COPD National Action Plan, a 2017 Rural Monitor feature article, provides an overview of COPD in rural areas and describes the types of exposures, in addition to tobacco smoke, that can result in COPD. In rural communities, one such factor is coal workers' pneumoconiosis (CWP), more commonly known as Black Lung, caused by exposure to coal dust. Another 2017 Rural Monitor article, Pulmonary Health in Rural America: Cause and Impact of Work-Related Lung Diseases, offers an in-depth look at how occupational lung diseases impact rural areas and discusses prevention strategies.

Rural patients with a chronic respiratory condition may find it more difficult to access the treatment and specialty care to manage their condition. As with other chronic conditions, telehealth may help with both access to specialists and increased knowledge for rural providers.

Rural Program Examples

RHIhub Resources

HIV and AIDS

A 2014 National Rural Health Association policy brief, HIV/AIDS in Rural America: Disproportionate Impact on Minority and Multicultural Populations, states that:

“HIV is of particular concern to rural America because lack of resources can lead to gaps in detection of the infection and in treatment maintenance. ”

A 2017 Centers for Disease Control and Prevention document, HIV Surveillance in Urban and Nonurban Areas through 2016, provides detailed statistics on HIV and AIDS in rural areas. In general, the rate of HIV infection is lower in nonmetropolitan areas than metropolitan areas across racial and ethnic groups. African Americans are most affected by HIV in rural areas, just as they are nationwide. The other groups most affected in rural areas – people of multiple races and Hispanics – are again similarly high in metro areas. Regionally, the South is the region most impacted by HIV for rural areas, with the Northeast second.

Rate of Diagnosed HIV for Adults and Adolescents per 100,000 Population, 2015
Population Size Rate
Metropolitan Statistical Area (MSA), population over 500,000 423.5
MSA of 50,000 – 499,999 200.8
Nonmetropolitan 138.7
Source: HIV Surveillance in Urban and Nonurban Areas through 2016

This map from the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) shows county-level data on HIV prevalence in 2014:

HIV Prevalence, 2014
Source: NCHHSTP AtlasPlus, Centers for Disease Control and Prevention (CDC)

For additional county-level data on HIV and AIDS, as well as location information for testing and treatment centers, see AIDSVu.

Prevention and Treatment in Rural Areas

Just as they are in urban areas, rural HIV diagnoses are connected to sexual contact and injection drug use. Programs to prevent HIV infection may focus on abstinence, the use of condoms, safe sex, and needle exchanges to prevent sharing of needles, which can spread infections. Offering pre-exposure and post-exposure prophylaxis (PrEP and PEP), medications that help prevent the spread of HIV, can also be effective. Those with an HIV infection can take antiretroviral therapy to help prevent passing the infection to others.

Screening for HIV infection is an important step in both prevention and treatment. Stigma and privacy concerns are problematic in rural areas where there is less anonymity, so programs that offer screening treatment in a setting where other health services are also provided can help patients more readily access treatment.

Rural patients with a diagnosed HIV infection may face challenges getting access to specialty care. The use of telehealth is one promising method for both providing access to AIDS specialists and helping rural providers gain greater expertise. The National HIV Curriculum, a free educational resource for healthcare providers, is also available to help rural providers learn more about HIV prevention, screening, diagnosis, and ongoing treatment.

Rural Program Examples

RHIhub Resources

Arthritis

A 2017 Morbidity and Mortality Weekly Report article, Prevalence of Arthritis and Arthritis-Attributable Activity Limitation by Urban-Rural County Classification — United States, 2015, provides an in-depth look at the impact of arthritis in rural areas. Arthritis rates increase with rurality, with 31.8% of people in the most rural areas reporting physician-diagnosed arthritis, compared to 20.5% of those in the most urban areas. One contributing factor to arthritis is age, but even age-adjusted rates show the burden of arthritis is greater in more rural areas:

Age-adjusted Arthritis Prevalence
Source: Prevalence of Arthritis and Arthritis-Attributable Activity Limitation by Urban-Rural County Classification — United States, 2015, Morbidity and Mortality Weekly Report, 66(20), 527–532

The groups most affected by arthritis in rural areas are the same as those most affected nationwide: older adults, women, people who smoke, people who are overweight, those who are physically inactive, and those with less education.

The same study reports that rural adults with arthritis report higher rates of arthritis-attributable activity limitation, and this is true across different demographic and health behavior groups.

Prevention and Treatment in Rural Areas

The Centers for Disease Control and Prevention identifies risk factors for arthritis, including some that cannot be prevented, such as aging and genetics, and others that can, such as excess weight. Given that obesity rates tend to be higher in rural areas, programs that help rural residents achieve a healthy weight are well-suited for preventing arthritis in rural areas. Physical exercise is also helpful in addressing arthritis, though it can be more difficult in rural areas to find places to walk or engage in a formal exercise program. The 2017 MMWR article mentioned above discusses the role that self-management programs can offer, and points out that rural healthcare providers may want to encourage patients to enroll in such a program. The same article also discusses how rural communities and organizations can deliver effective self-management programs and support physical activity to help manage arthritis.

Rural Program Examples

  • Fit & Strong! – community-based physical activity and education classes to help promote self-management of arthritis symptoms
  • Chronic Disease Self-Management Program – a well-established program that has been implemented in rural areas to address many conditions, including arthritis

RHIhub Resources


Are particular parts of the country more prone to certain chronic diseases?

Due to the diverse landscape and demographics in the U.S., certain chronic diseases are more common in particular regions of the country. Health disparities are closely tied to socioeconomic status, race/ethnicity, education level, and access to healthcare facilities. The following largely rural regions have well-documented health disparities for a range of chronic conditions:

Appalachian Region

The Appalachian Region follows the Appalachian Mountains, stretching from Mississippi to New York. A 2017 report, Health Disparities in Appalachia, looks at both mortality disparities related to chronic disease and risk factors contributing to chronic disease on the region. Mortality is higher in Appalachia for all chronic conditions included in the report and, in rural Appalachian counties, even higher:

Appalachia Mortality Rates per 100,000 population (2008-2014)
Non­metro, not adjacent to a metro Non­metro, adjacent to small metro Non­metro, adjacent to large metro Nation as a whole
Heart disease 234 219 218 175
Cancer 202 190 189 168
COPD 68.9 58.3 58.5 42.0
Stroke 46.0 45.9 44.6 38.4
Diabetes 27.7 26.4 24.7 21.5
Source: Health Disparities in Appalachia, August 2017

In terms of risk factors, rural Appalachian counties fare worse in terms of physical activity and smoking. Rural counties in the region also face more challenges for a range of social determinants of health, including poverty and education levels.

Delta Region

The Delta Region includes 252 counties and parishes across eight states from Illinois to Louisiana. A 2015 report, Exploring Rural and Urban Mortality Differences in the Delta Region, looks at leading causes of death for the region. The rural Delta fares worse for all the chronic conditions included in the report, compared to rural areas nationwide:

Mortality Rates per 100,000 population (2011-2013)
Rural Delta Region Rural, National Nation as a Whole
Heart disease 248.4 195 171.3
Cancer 202.3 180.4 166.2
Lower respiratory disease 60 53.3 42.1
Cerebrovascular diseases 51.5 42.7 37.0
Alzheimer's 34.4 27.3 24.0
Diabetes 31.1 25.3 21.3
Kidney disease 24.1 15.7 13.3
Source: Excel Workbook Tables: Mortality Rates among Persons by Cause of Death, Age, Region, and Rural-Urban Status: United States, 2011-2013, based on data from National Vital Statistics System (NVSS) via CDC WONDER. Part of the Exploring Rural and Urban Mortality Differences project, Rural Health Reform Policy Research Center.

While not rural-specific, the 2016 Delta Regional Authority report, Today's Delta: A Research Tool for the Region, identifies a number of potential contributing factors to chronic disease, including higher rates of obesity, physical inactivity, poverty, and unemployment.


Where can I find grants to help start a chronic disease management program?

The Rural Health Information Hub has an ongoing list of funding opportunities for chronic disease programs. Note that the inactive records listed may become active again in the future. RHIhub staff reviews funding and opportunities that are added to the database, making certain that all of the funders either expressly state they will fund in rural areas, or have been known to fund in rural areas in the past.

RHIhub can also conduct a free, customized funding search on your behalf, which will identify funders who may be interested in your project or program. Contact us at 800.270.1898 or info@ruralhealthinfo.org to request a custom search. Please include your city, state, county and the purpose of your project in your request.

To stay up-to-date on the latest funding opportunity announcements, subscribe to the RHIhub This Week newsletter or to one of our RSS feeds.

For more general information about finding and developing grants in your rural area, see the Grant Writing for Rural Healthcare Projects topic guide.