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Rural Health Disparities

Rural Americans are a population group that experiences significant health disparities. Health disparities are differences in health status when compared to the general population, often characterized by indicators such as higher incidence of disease and disability, increased mortality rates, lower life expectancies, and higher rates of pain and suffering.

Rural risk factors for health disparities include geographic isolation, lower socio-economic status, higher rates of health risk behaviors, and limited job opportunities. Higher rates of chronic illness and poor overall health are found in rural communities when compared to urban populations.

Several studies have shown that rural residents are older, poorer, and have fewer physicians to care for them. This inequality is intensified as rural residents are less likely to have employer-provided healthcare coverage, and if they are poor, often are not covered by Medicaid.

Federal and state agencies and membership organizations are working to reduce these disparities and improve the health and overall well-being of rural America. Some provide funding, information, and technical assistance to be used at the state, regional, and local level, while others inform state and federal legislators to help them understand the issues affecting population health and healthcare in rural America.

For an in-depth look at rural health disparities, the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report Rural Health Series examines rural mortality and preventable deaths, health-related behaviors, chronic disease, and related topics.

Additional insights and data are available in the Rural Health Reform Policy Research Center's 2014 Update of the Rural-Urban Chartbook and Exploring Rural and Urban Mortality Differences.

Frequently Asked Questions

How do rural mortality rates compare to urban?

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
Source: Rural Health Reform Policy Research Center. The 2014 Update of the Rural-Urban Chartbook. (2008–2011 data.)

Another way to examine rural-urban mortality differences is by examining excess deaths. Across U.S. counties, the proportion of deaths that occur before age 80 varies; the lowest rate is used as a benchmark. Excess deaths are deaths in each county that might not have been expected if the county matched the lowest U.S. county rate (the benchmark rate). Recent CDC National Vital Statistics System data for the 5 leading causes of death in the U.S. continues to demonstrate higher rates of excess deaths for populations in nonmetropolitan areas than in metropolitan areas by identifying the percentages of potentially excess deaths.

Percentage of Excess (or Potentially Preventable) Deaths for Leading Causes of Death
Cause of Death Nonmetro Counties Metro Counties
Heart Disease 42.6% 27.6%
Cancer 24.2% 13.5%
Unintentional injury 57.5% 39.2%
Chronic lower respiratory disease 54.3% 30.9%
Stroke 37.8% 26.1%
Source: CDC Stacks, Supplemental tables for Leading Causes of Death in Nonmetropolitan and Metropolitan Areas – United States, 1999–2014: Figures 2-5

Four of the five leading causes of death in rural areas are associated with chronic disease. RHIhub’s Chronic Disease in Rural America topic guide provides additional information and resources on the impact of chronic disease in rural areas and funding opportunities for programs to address chronic conditions.

How does rural life expectancy compare to urban?

Rural Life Expectancy Compared to Urban, 2005-2009, in Years of Age
Life Expectancy Nonmetro Counties Metro Counties
All 76.8 78.8
Male 74.1 76.2
Female 79.7 81.3
White 77.2 79.2
Black 72.8 74.2
American Indian and Alaska Native 74.8 85.8
Asian and Pacific Islander 84.9 86.9
Hispanic 82.2 83.1
Source: Singh, G.K., Siahpush, M. 2014. Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009. American Journal of Preventive Medicine, 46(2), 19-29. Article Abstract

What regions of the country experience high levels of rural health disparities?

High levels of rural health disparities are found in several regions in the U.S. although not all of these regions exhibit the same high levels in all identified disparities.

  • The South
    The rural South is consistently at the top of the list for high rates of mortality for nearly all leading causes of death. Average life expectancy at birth is lower in the South than the national average by a year and in some states by 3 – 4 years. CDC has identified the nonmetropolitan areas of the South as having the highest rates of potentially excess deaths related to heart disease, cancer, chronic lower respiratory disease, and stroke. In the Southeastern region, states with largely rural populations exhibit a diabetes prevalence rate higher than 10.6% and in some areas almost double the national rate. Other health concerns with high mortality rates include septicemia, liver disease and suicide.
  • Appalachia
    Many areas of Appalachia overlap with the rural South and exhibit many of the same health disparities. A recent study identified infant mortality as 16% higher in Appalachia than in the U.S. as a whole over the period from 2009-2013, and the deficit in life expectancy has widened by 2.4 years since 1990-1992. Research has shown mortality rates for cancer, heart disease, diabetes, chronic lower respiratory disease, unintentional injury, and stroke in Appalachia are higher than the rest of the nation. Other diseases and health concerns causing death which are prevalent in the region include septicemia, chronic liver disease, suicide, prescription drug and illegal drug overdose. Additional information can be found in Health Disparities in Appalachia and Appalachian Diseases of Despair.
  • The Delta Region
    The Delta Region, also located in the South but limited to rural geographic areas along the Mississippi River, exhibits many of the same disparities found in the South and in Appalachia. Life expectancy for counties located in the Delta Region are some of the lowest in the country, as low as 70.93 years at birth compared to 79.08 for the U.S. as a whole. Mortality rates for cancer, suicide, diabetes, lower respiratory, stroke, and septicemia are higher than the rest of the nation. Heart disease is of special concern as it is higher than the national average for all age groups including children. Other health issues prevalent in the Delta Region include high mortality rates due to pregnancy, childbirth, and sudden infant death syndrome. See Exploring Rural and Urban Mortality Differences in the Delta Region for specific data.
  • U.S. – Mexico Border While life expectancy in many counties of the border region exceeds the national rate, there continue to be persistent health issues confronting the border region including obesity, diabetes, unintentional injuries, and tuberculosis according to Healthy Border 2020. Nearly 60% of adults residing in the border region are overweight or obese. Border areas also have some of the highest rates of diabetes in the U.S. In Texas several border counties exhibit a diabetes prevalence rate greater than 20%. Mortality rates due to unintentional injuries from traffic fatalities and infectious disease such as tuberculosis continue to be a concern; however, in recent years these mortality rates have decreased, particularly on the U.S. side of the border. Another important health issue in the border region is the prevalence of asthma affecting adults and children, which is often caused by poor air quality due to emissions from industry, electrical generation, unpaved roads, and vehicles on the road.
  • American Indian/Alaska Native (AI/AN) Tribal Communities
    American Indian/Alaska Native populations live 4.4 years less than the U.S. population for all races. The leading causes of death among AI/AN populations are heart disease, unintentional injuries, cancer, and diabetes. The Indian Health Service's Disparities Fact Sheet notes that AI/AN populations experience mortality for several causes at over double the rate of the U.S. population. Additional information regarding health disparities of AI/AN are further detailed in Trends in Indian Health: 2014 Edition.

For additional information, the Institute for Health Metrics and Evaluation (IHME) at the University of Washington developed the U.S. Health Map, an interactive map providing county-level data for the U.S. on life expectancy, mortality rates, and risk factors. Health trend data by county is available for major causes of death, including several types of cancer, cardiovascular diseases, stroke, obesity, diabetes, hypertension, unintentional injury, and mental and substance use disorder. IHME also publishes data and maps on major causes of death by county: US County Profiles – Institute for Health Metrics and Evaluation.

What is the difference between health disparities and health inequities?

Healthy People 2020 defines health disparities as:

"a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion."

Health equity is defined by the National Partnership for Action to End Health Disparities as the:

"Attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities."

Lastly, health inequity is defined in CDC’s Social Determinants of Health Definitions as the:

"difference or disparity in health outcomes that is systematic, avoidable, and unjust."

What are the causes of rural health disparities?

Causes of health disparities in rural America are many and vary by region. Some frequently cited factors that underlie rural disparities include healthcare access, socioeconomic status, unhealthy behaviors, and chronic conditions.

Access to Healthcare

Rural people experience many barriers to healthcare access which can contribute to health disparities. The following factors create access difficulties for rural Americans:

  • The uninsured rate is higher in the rural counties (nonmetropolitan) than in the urban (metropolitan) counties as reported by CDC's National Center for Health Statistics.
  • Healthcare workforce shortages are prevalent with less than 8% of all physicians and surgeons choosing to practice in rural settings according to the National Center for Health Workforce Analysis.
  • Services available in rural areas are less likely to include specialized and highly sophisticated or high-intensity care. This exacerbates the problems with distance to care for people requiring higher levels of care. For some services, such as emergency medical services, the lower level of care available, when added to the increased time to services caused by distance, can be the difference in life or death.
  • Transportation to care can be a barrier due to long distances, poor road conditions, and the limited availability of public transportation options in rural areas. For additional information about the access to healthcare in rural areas, see RHIhub’s topic guide: Healthcare Access in Rural Communities.

Socioeconomic Status

According to the Kaiser Commission on Medicaid and the Uninsured, rural populations have a higher rate of low to moderate income, are less likely to have employer-sponsored insurance coverage, and are more likely to have Medicaid or another form of public health insurance. Rural residents are more likely to be unemployed, have lower rates of post-secondary education, and have lower median household incomes than urban residents. Research has shown that these and other social determinants of health have a significant effect on health status.

Health Behaviors

Whether populations adopt positive health behaviors impacts rates of disparities in health status and mortality. A 2017 Morbidity and Mortality Weekly Report article examined the prevalence of 5 key health-related behaviors by urban-rural status. Urban residents were more likely to report 4 or 5 of the behaviors.

Prevalence of Health-Related Behaviors Among Adults, 2013
Behavior Large metro center Large fringe metro Medium metro Small metro Micro-politan Non-core
Current nonsmoking 83.9% 82.3% 80.5% 77.5% 76.5% 74.9%
Non- or moderate drinking 61.1% 59.9% 63.3% 64.3% 67.3% 68.6%
Maintaining normal body weight 36.5% 35.3% 33.3% 32.9% 30.6% 28.9%
Meeting aerobic activity recommendations 51.4% 51.4% 51.1% 50.7% 49.2% 46.7%
Sufficient sleep 62.4% 61.7% 62.4% 62.1% 61.1% 61.5%
Reported 4 or 5 of these health-related behaviors 31.7% 30.2% 30.5% 29.5% 28.8% 27.0%
Source: Health-Related Behaviors by Urban-Rural County Classification — United States, 2013, CDC Morbidity and Mortality Weekly Report

The 2014 Update of the Rural-Urban Chartbook reports a striking difference in the rates of adolescent smoking among urban-rural classifications, with youth in rural noncore counties being more than twice as likely to smoke as their peers in large central metropolitan counties (11% vs. 5%). This raises concerns of worsening rural health disparities in the future.

For additional information about the causes of health disparities in rural areas, see RHIhub's topic guide: Social Determinants of Health for Rural People.

Where can I find supporting documents and statistics on rural health disparities?

Several publications identify and describe the rural/urban disparities.

Exploring Rural and Urban Mortality Differences
Provides data tables and online tools displaying mortality rates for the 10 leading causes of death by rurality, age, region, and sex.

The 2014 Update of the Rural-Urban Chartbook
Highlights current trends and disparities across different levels of metro- and nonmetropolitan counties. Includes population characteristics, health-related behaviors and risk factors, mortality rates, and healthcare access and use. Individual data tables are available in an Excel file.

National Healthcare Disparities Report
Produced annually by the Agency for Healthcare Research and Quality (AHRQ), provides a comprehensive national overview of disparities in healthcare among racial, ethnic, and socioeconomic groups in the general U.S. population and rural areas. Tracks the success of activities to reduce disparities.

Health Disparities: A Rural-Urban Chartbook
Presents data on health disparities experienced by people living in rural America. Some disparities identified are poorer health status, higher prevalence of obesity, lesser options for activity and higher mortality rates.

Health, United States, 2017: Health, United States, 2017: With Special Feature on Mortality
Presents an annual overview of national trends in health statistics. Covers health status and determinants, healthcare utilization, access and expenditures. To view rural data in the metro and nonmetro charts and tables, select metropolitan and nonmetropolitan in the population subgroup filter.

Rural Healthy People 2020
Texas A&M’s Health Science Center School of Rural Public Health’s Southwest Rural Health Research Center published Rural Healthy People 2020 to provide a resource that documents the successes, challenges, and relevant information for planning.

Rural Health Research Gateway: Health Disparities and Health Equity Topic
Provides publications and projects on the topic of rural health disparities developed by rural health research centers that are funded by the Federal Office of Rural Health Policy (FORHP).

For additional information on rural/urban disparities see What sources cover health behaviors and health status for rural areas or by county? on RHIhub's Finding Statistics and Data Related to Rural Health topic guide.

What agencies and organizations are working to seek solutions to these disparities?

  • Federal Office of Rural Health Policy (FORHP)
    FORHP, part of the Health Resources and Services Administration under the U.S. Department of Health and Human Services, promotes better healthcare service in rural America. FORHP focuses on matters affecting rural hospitals and healthcare, coordinating activities within the department that relate to rural healthcare, maintaining a national information clearinghouse, and providing rural-specific grant programs to address many of the disparities affecting rural health. Several Rural Health Research Centers are funded by FORHP to help policymakers understand the problems rural communities face in regards to health disparities and in assuring access to healthcare. Their research findings inform a wide audience of national, state, and local decision-makers concerned with rural health.
  • Agency for Healthcare Research and Quality (AHRQ)
    Sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. AHRQ publishes an annual National Healthcare Disparities Report that summarizes healthcare quality and access in the United States among priority populations including people with disabilities, rural populations and racial, ethnic, and socioeconomic groups.
  • National Institute on Minority Health and Health Disparities
    Leads scientific research to improve minority health and eliminate health disparities through research, training of a diverse workforce, research capacity and infrastructure development, public education and information dissemination programs.
  • National Rural Health Association (NRHA)
    Promotes leadership, ideas, information, communication, education, research, advocacy, and methods to improve rural health and reduce health disparities. The organization is composed of individual and organizational members who share a common interest in rural health.
  • Robert Wood Johnson Foundation (RWJF)
    Supports research and programs devoted to health and healthcare. Engages policymakers, business leaders, and community groups to establish a national agenda for improving population health, well-being, health equity, and to achieve better health, and track progress.

For additional information on rural health research see the Conducting Rural Health Research, Assessments and Evaluation topic guide.

Where can I find programs that illustrate best practices to meet the challenges of providing health services in areas characterized by disparities?

The Rural Health Information Hub's Rural Health Models and Innovations features examples of programs and interventions that have shown to be successful in providing health services in rural areas experiencing health disparities.

Some examples of successful programs include:

  • Hidalgo Medical Services – Family Support Program – Community based chronic disease intervention program to help individuals with diabetes or who are at risk for diabetes. Community health workers (CHWs) provide education and support to diabetic and pre-diabetic patients.
  • Kentucky Homeplace – Another community health worker (CHW) initiative focused on reducing health disparities in the rural areas of Kentucky with an emphasis on coordinating care and health coaching. Many health services are provided at no cost to the patient.

The Robert Wood Johnson Foundation awards an annual Culture of Health Prize to communities that are working to improve health, well-being and health equity. A browsable database allows you to explore prize winners' stories by community type including rural and tribal as well as by topic.

What are the health disparities that affect rural minority populations?

Rural minority populations often experience health disparities related to their health status, rates of chronic disease, life expectancy, and rates of unintentional injury. Racial/Ethnic Health Disparities Among Rural Adults – United States, 2012 – 2015 shows health disparities for adult rural minority populations as compared to other racial or ethnic groups, including:

  • Adult rural American Indians/Alaskan Natives, non-Hispanic blacks, and Hispanics self-reported higher rates of fair or poor health
  • Rural non-Hispanic blacks and American Indian/Alaskan Native adults were more likely to report having multiple chronic health conditions than non-Hispanic whites
  • Adult rural non-Hispanic blacks were most at risk for obesity and severe obesity
  • American Indian/Alaskan Native rural adults reported the most limitations in their activities due to physical, mental, and emotional problems

In the article All-Cause and Cause-Specific Mortality Among US Youth: Socioeconomic and Rural-Urban Disparities and International Patterns, the authors found that rural American Indian and Alaska Native (AI/AN) youth have a higher mortality rate than their urban counterparts. Additionally, the rate of substance abuse admissions was higher for rural AI/AN than for those residing in urban areas according to a SAMHSA report.

Rural minorities face a myriad of issues that can affect their health ranging from chronic poverty, to a lack of stable medical care for migrant workers, and to language barriers experienced by newcomers to this country. According to the HHS Action Plan to Reduce Racial and Ethnic Health Disparities the two major factors contributing to their disproportionate health problems are inadequate access to care and substandard quality of care. Several federal government agencies within the Department of Health & Human Services work to eliminate the health disparities experienced by minority populations:

  • HHS Office of Minority Health
    Dedicated to improving the health status of racial and ethnic minorities, eliminating health disparities, and achieving health equity in the United States
  • National Partnership for Action (NPA)
    Works to mobilize and connect individuals and organizations across the country to create a nation free of health disparities, with quality health outcomes for all people
  • Federal Office of Rural Health Policy (FORHP)
    Has had a longstanding concern with the diverse health needs of rural minority populations and provides information, expertise and grant opportunities to address the inequities found in rural minority health populations
  • CDC's Office of Minority Health & Health Equity (OMHHE)
    Aims to accelerate CDC’s health impact in the U.S population and to eliminate health disparities for vulnerable populations as defined by race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status related to sex and gender, and among other populations identified to be at-risk for health disparities.

Also, each state has a state office of minority health or health equity office designated to reduce health disparities within their state that provides state-level health information and resources targeted toward minority populations.

Last Reviewed: 11/14/2017