Heart disease, cancer, stroke, unintentional injury — individuals living in rural communities are at greater risk than their urban counterparts for these leading causes of death, according to the Centers for Disease Control and Prevention (CDC). Why? Several issues contribute to such health disparities. However, limited access to rural health care services factors in considerably.
Today, an estimated 46 million to 63 million Americans live in rural areas, according to the U.S. Department of Agriculture (USDA) and the U.S. Census Bureau, respectively. These areas may be geographically isolated or have populations that are too small to support a hospital or clinic. They often also have shortages of health care professionals due to a number of factors, including lower pay. And telehealth isn’t as widely accessible because of poor broadband penetration.
Because well-trained nurses can provide key preventive services, staff mobile clinics, and reduce the impact of health care professional shortages in these areas, they can play a unique role in overcoming the challenges of rural health care. Thus, a key policy solution to the problem of rural health care disparities is to enhance the nursing pipeline. By earning an online post-master’s certificate in nursing, nurses can fill roles like these and help build health equity across rural communities.
Rural Health Care Disparities
Though the USDA has no standard definition for what they consider a “rural” community, typical rural communities have smaller, less dense populations than other communities. They also are in more geographically isolated locations.
While these characteristics themselves don’t negatively affect people’s health, data from the U.S. Bureau of Labor Statistics (BLS) and the USDA shows that, compared to urban communities, rural communities experience:
- Higher rates of poverty
- Lower rates of health insurance
- Higher rates of participation in unhealthy behaviors such as cigarette smoking
These variables inevitably have a negative impact on the health of people who live in rural communities. In general, the conditions and circumstances of people’s lives, including where they live, work, and age, will influence their well-being. Known as social determinants of health, such nonmedical factors can affect a person’s health for better or worse.
For example, lacking stable housing or consistent access to food can cause excessive stress, which in turn can lead to serious health problems. Limited or poor education about nutrition and healthy behaviors can lead to unhealthy eating habits and risky activities, such as unprotected sex, resulting in diabetes, sexually transmitted infections, and other negative health outcomes.
On the other hand, access to a safe and secure living situation, recommended medical screenings, and stable employment can help support a healthy lifestyle that leads to better overall health outcomes.
The Need for Rural-Specific Health Care Interventions
Statistically, people living in rural communities experience higher rates of unemployment and more often fit into low-income brackets than city dwellers. The USDA estimates that 15.3% of rural households live in poverty. In contrast, 11.9% of urban households live in poverty.
Additionally, approximately 1 in 4 rural residents rely on Medicaid for their health insurance, according to the Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission.
These and other unfortunate circumstances likely contribute to the higher prevalence of multiple chronic conditions and other health disparities experienced in rural communities, as outlined in a recent call to action on rural health from the American Heart Association and American Stroke Association. These include higher rates of:
- Death caused by suicide and drug overdose
- Disabilities caused by health problems that limit one’s ability to work
- Maternal mortality
- Diabetes
- Obesity
These are just some of the factors that highlight the need for health systems to do more to improve health care access for rural patients, including improving the availability of rural community-specific health interventions.
For example, CDC data has shown that rural patients have higher mortality rates from lung, colorectal, and cervical cancers than urban patients. Health care systems can help by prioritizing interventions that educate people living in rural communities about the risk factors for these preventable diseases along with improving access to cancer screenings.
Tackling rural health care disparities also involves considering cultural factors. A recent study published in BMC Health Services Research noted that people from rural cultures may embrace notions of hardiness and self-reliance that make them reluctant to seek preventive care or treatment for chronic conditions. Health care systems can formulate strategies to overcome such barriers.
As an example, health care institutions may partner with faith-based organizations, often influential in rural communities, to encourage people to get cancer screenings and even provide nontraditional settings for these screenings that are more comfortable and accessible for people.
Additional priorities for addressing rural health care disparities include:
- Education and support for self-management of diabetes
- Integrating mental health care into primary care
- Increasing access to naloxone and other drugs that can reverse overdoses
Rural Health Care Challenges
People in rural communities face recurring challenges when it comes to accessing health care. These challenges exacerbate the health disparities they experience. Barriers to accessing rural health care can take many forms.
For example, despite a rise in telehealth services that could, in theory, improve access for rural patients, many residents don’t have the necessary internet speeds to take advantage of that option. Approximately 22.3% of rural residents and 27.7% of Americans in tribal areas lack access to fixed broadband services that meet minimum speed requirements, according to a recent Federal Communications Commission report.
Additional challenges to rural health care access include:
Challenge 1: Health Professional Shortage Areas
A shortage of health care professionals in rural communities poses a significant challenge to health care access. Today, rural communities represent nearly two-thirds of the nation’s health professional shortage areas, or HPSAs, according to the Health Resources and Services Administration. The HPSA designation means a location has a deficit in health care professionals who can deliver primary care, dental, mental health, and behavioral health services.
The unfortunate fact is, many people living in HPSAs don’t get their health care needs met, with rural communities disproportionately affected. An exacerbating factor is that people living in these areas miss out on preventive care such as vaccinations and screenings that help prevent disease.
Several factors contribute to health professional shortages in rural areas. According to the December 2021 Rural Health Research Recap, they include:
- Low annual salaries and compensation for rural nurses compared to urban nurses (urban nurses, on average, earn nearly $4,500 more per year than rural ones)
- Higher patient-to-nurse caseloads than in urban areas
- Lack of essential equipment, supplies, and resources
- Increased reports of professional isolation
Challenge 2: Geographic Distance and a Lack of Public Transportation
While the growth of telehealth has improved access to some health care services, many types of care still demand in-person visits. Getting in-person care can prove especially difficult for rural residents who often have to travel long distances to get to medical clinics and facilities. The costs of these journeys can make health care unaffordable. A lack of public transportation in many rural areas adds to the challenge of getting to health care facilities.
Additionally, 43 rural hospitals have closed since 2010 and 186 have closed since 2005, according to data published by the Cecil G. Sheps Center for Health Services Research. This means rural patients in the affected areas now need to travel even farther if they want to access care. Many cannot, and they often end up forgoing primary, emergency, and specialty care.
Challenge 3: Lack of Cultural Competency in Rural Health Care
Given that language and culture influence health care delivery, culturally competent care is crucial in rural communities. Cultural competency refers to an individual’s capacity to learn and build an understanding of cultural differences. Culturally competent practitioners acknowledge their biases and are committed to an ongoing reflection on their thoughts and behaviors to address the cultural assumptions and biases they may have.
Showing respect for their patients’ cultures helps health care providers build trust and understanding with patients from diverse backgrounds. This nurtures openness and empowers both practitioners and patients to arrive at truly personalized treatment plans that achieve the best health outcomes for patients.
Meeting the cultural and linguistic needs of rural patients comes with major challenges. Rural communities have become increasingly diverse in recent years. In the 2020 Census, 24% of rural residents identified themselves as belonging to a racial or ethnic minority.
Unfortunately, rural people of color experience even higher rates of poverty than their white counterparts, according to the USDA. Additionally, rural people of color also have lower rates of health insurance than other rural residents. This translates into even more extreme health disparities for rural people of color, particularly regarding their access to primary care and rates of chronic kidney disease, diabetes, and hypertension, as indicated in a recent National Healthcare Quality and Disparities Report.
To further complicate the problem, practitioners can lack sufficient intervention strategies designed with the cultural contexts of rural patients of color in mind. Developing approaches that reflect the unique needs of diverse rural populations can help health care systems reduce the barriers to care that people of color living in rural communities experience.
How to Improve Rural Health Care Access
Improving rural health care access requires a comprehensive approach. By implementing key strategies, health care systems can work toward health care equity and achieve better health outcomes for people living in rural communities. Three policy and strategy responses that could help are expanding the rural nurse pipeline, supporting mobile clinics, and promoting telehealth access.
Improvement 1: Expand the Rural Nurse Pipeline
The most current data from the Health Resources and Services Administration shows that rural communities have proportionately fewer nurses than urban communities. For example, for every 10,000 rural residents, there are:
- Sixty-five registered nurses (compared to 94 registered nurses in urban areas)
- Seven nurse practitioners (compared to eight nurse practitioners in urban areas)
- One nurse anesthetist (compared to two nurse anesthetists in urban areas)
This often leads to burdensome nurse-to-patient ratios in rural care settings. A study in Public Health Nursing found a ratio of about seven patients to every one nurse in isolated rural hospitals. In urban hospitals, the researchers found a ratio of about five patients to every one nurse, a considerable difference.
A critical shortage of physicians in rural areas means that nurses in these communities are increasingly responsible for delivering primary care. Additionally, the overall health provider shortage in rural areas means rural nurses often practice as generalists.
To reduce nurse shortages in rural areas, health care leaders can focus on expanding the pipeline for rural nurses. This entails improving recruitment. Ways to achieve this include:
- Strengthening partnerships between rural health care providers and college nursing programs
- Offering nursing curriculums that concentrate on rural health
- Selecting more students from rural communities for nursing programs
- Providing professional support to rural nurses to improve retention
Improvement 2: Strive for Telehealth Parity
Striving for telehealth parity is another way to improve access to health care in rural communities. Telehealth parity refers to equitable access to traditional in-person health care and telehealth care. It requires equitable funding and insurance coverage for both types of care as well.
Telehealth delivers notable benefits to patients and health care providers in rural areas.
Benefits of Telehealth Parity for Rural Patients
Better access to telehealth services removes some of the barriers rural residents experience trying to access health care. Telehealth visits remove the transportation challenges of getting to an appointment. Telehealth also helps eliminate the transportation costs of health care visits and expenses related to child care. In addition, rural patients may pay less for telehealth services.
Benefits of Telehealth Parity for Rural Health Care Providers
Telehealth offers several advantages to rural health care providers. Telehealth visits can help reduce avoidable emergency room visits and hospital readmissions. Telehealth also can save rural health care providers money, since these visits mean less utilization of costly on-site resources.
Additionally, improved access to telehealth can allow health care providers to better monitor their rural patients and exchange timely communications. Other reasons for rural nurses concerned about health care access to support telehealth parity are because it can lead to:
- Fewer missed appointments
- Shorter wait times
- Improved patient adherence to treatment plans
Improvement 3: Support Mobile Clinics
Mobile clinics are especially useful in expanding health care access in rural and remote areas. These repurposed trucks, vans, and recreational vehicles serve as a space for practitioners to deliver health care services outside of traditional care settings. The flexibility of mobile clinics to get up and move to where they’re needed positions them to close care gaps in rural communities.
Services provided through mobile clinics include:
- Immunizations
- Health screenings
- Eye and dental care
- Laboratory services
- Referrals to specialists
- Chronic disease management counseling
Research has consistently shown that mobile clinics both lower health care costs and improve community health. They can reduce the number of visits made to emergency rooms, and their ability to deliver preventive care can lower people’s overall need for health care services.
Mobile clinics also lend themselves to the delivery of patient-centered care. That is to say, they make it conducive for practitioners to care for patients on their own terms. The proximity of mobile clinics to people’s homes and the limited physical space within these self-contained units tend to nurture trust and an emotional closeness between patient and provider.
Nurses often play instrumental roles in running mobile clinics. Throughout the pandemic, nurses have run mobile clinics in rural communities that provide access to COVID-19 tests and vaccinations. Nurse-led mobile clinics also successfully provide wound care, hypertension and diabetes screening, behavioral health support, and many other services to rural communities with inadequate access to the care they need.
Support Rural Communities with an Advanced Education
Strategies for reducing health disparities in rural populations rely heavily on improving rural health care access. While rural communities confront many obstacles to getting the health care services they need, nurses can prove instrumental in expanding access to care in rural areas. Nurses specialize in the empathic and interpersonal skills most needed to deliver culturally competent care; they are qualified to provide a range of preventive services; and they are often available to staff the mobile clinics that can reach these areas.
If you’re interested in advancing your nursing credentials to position yourself to address health disparities in rural and underserved communities, explore Regis College’s post master’s certificate nurse practitioner online today. By earning a post-master’s certificate from Regis College, you can prepare yourself to not only advance your career but also expand services as a health care provider.
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Sources:
American Academy of Family Physicians, “Study Examines Telehealth, Rural Disparities in Pandemic”
American Hospital Association, 2023 Rural Advocacy Agenda
BMC Health Services Research, “A Qualitative Study of Rural Healthcare Providers’ Views of Social, Cultural, and Programmatic Barriers to Healthcare Access”
Cecil G. Sheps Center for Health Services Research, Rural Hospital Closures
Centers for Disease Control and Prevention, Rural Health
Centers for Disease Control and Prevention, Telehealth in Rural Communities
Centers for Medicare and Medicaid Services, “Advancing Rural Health Equity”
Circulation, “Call to Action: Rural Health: A Presidential Advisory from the American Heart Association and American Stroke Association”
Economic Research Service, Rural Poverty & Well-Being
Federal Communications Commission, Mapping Broadband Health in America
Federal Register, National Rural Health Day 2022
Health Affairs, “Survey Confirms Effectiveness of Telehealth in Rural America and Beyond”
Health Resources and Services Administration, Health Workforce Shortage Areas
Health Resources and Services Administration, Office for the Advancement of Telehealth
Journal of the American Medical Informatics Association, “Telehealth in Response to the COVID-19 Pandemic: Implications for Rural Health Disparities”
Journal of Community Health, “Racial and Ethnic Differences in Self-Rated Health Among Rural Residents”
Journal of Medical Internet Research, “Telehealth Interventions and Outcomes Across Rural Communities in the United States: Narrative Review”
NIH News in Health, “Health in Rural America: Connecting to Care”
Public Health Nursing, “Isolated, Small, and Large Hospitals Have Fewer Nursing Resources Than Urban Hospitals: Implications for Rural Health Policy”
Rural Health Information Hub, “Telehealth Use in Rural Healthcare”
Rural Health Research Gateway, “Rural Nursing Workforce”
U.S.Department of Agriculture, “Rural America at a Glance: 2021 Edition”