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Abstract

Rural areas are home to a larger proportion of older adults and populations who age within these locales and suffer disproportionately from health, mental health, and economic disparities compared to their urban counterparts. This article will explore the disparities faced by persons that reside in rural communities across the lifespan. It will briefly discuss what is meant by rural. As a rural region at specific risk, the issues confronting those aging in Appalachia will be examined. Finally, best practices and future directions to combat health disparities among rural residents and elders will be discussed. This includes the Appalachian Gerontology Experiences: Advancing Diversity in Aging Research training program which recruits and trains minority and first-generation undergraduate students in aging and health disparity research.

Keywords

health disparities Appalachia rural areas life span aging

Health Disparities in Rural Areas

Before examining the health, mental health, and economic disparities faced by rural residents across the lifespan, it is necessary to point out the difficulty of defining what is “rural.” In the United States, there are 11 different definitions of rural used by federal agencies, such as the Bureau of the Census and the USDA. The discrepancy among definitions impacts not only research findings, but also policy, program decisions, and implementation (Krout & Hash, 2015). Perhaps the most used definition of rural refers to counties as units and categorizes them as nonmetropolitan/nonmetro or as an area that is outside of a metropolitan area. Despite this discrepancy among definitions, what is certain is that rural areas are aging.

Although urban areas are more common in the United States, a larger percentage of older adults aged 65+ years live in rural areas. In fact, 20% of residents in nonmetro areas are aged 65+ compared to 16% in metro areas. Between 2010 and 2020, the 65+ population in rural areas grew by 22% while other age groups declined (Davis et al., 2022). Interestingly, rural counties account for over 80% of what is designated “older age counties” or those with over 20% of their population aged 65 or older (Cromartie, 2021). Rural communities also have older populations, with a mean age of 43.5 years as compared to 38.2 years for the United States, as a whole (U.S. Census Bureau, 2015–2020). Reasons cited for the aging of rural areas include declining birth rates, the out-migration of younger residents to larger cities (often in search of employment), and the migration of retirees to specific rural communities (Berry & Kirschner, 2013). Between 2010 and 2020, the working-age population in nonmetro areas decreased by 5% and the population under the age of 18 declined by 6% (Davis et al., 2022). Interestingly, the beginning of the COVID-19 pandemic did initiate an increase in the nonmetro population in the United States as individuals sought to escape the increased risk of crowding and infection in larger metro areas (Davis et al., 2022).

In terms of aging, where people age is important. Rural areas offer unique challenges as well as opportunities to those who age within their boundaries. It is also critical to understand that rural communities and their residents are quite diverse, and they vary depending on economics and other factors (Krout & Hash, 2015). As Chuck Fluharty from the Rural Policy Institute asserted, “If you’ve seen one rural community, you’ve seen … one rural community” (Lohmann & Lohmann, 2005, p. xxii). Despite the diversity between rural communities, health disparities present significant challenges for rural residents, so much so that the National Institute of Minority Health and Health Disparities designates persons living in underserved rural communities as a health disparity group. This article will present current research on health, mental health, and economic disparities for rural residents and will also include a special focus on disparities in the Appalachian Region of the United States. It will conclude by discussing best practices and future directions to combat health disparities among rural residents and elders.

Health, Mental Health, and Economic Disparities for Rural Residents

Not only are rural areas home to a greater percentage of older adults, but persons who age in rural communities suffer disproportionately from health, mental health, and economic disparities compared to their urban counterparts. In terms of health disparities, the past few decades have seen the emergence and continual growth of what has been called the “rural mortality penalty.” This describes the slower decline in the mortality rate in rural as compared to urban counties. So, the mortality rate in rural areas is decreasing but not as fast as in urban areas. The strongest mortality penalty, in fact, has been found in high-poverty and highly rural areas (Cosby et al., 2019). Rural residents have a lower life expectancy overall and higher mortality rates from the leading causes of death, including heart disease, cancer, and stroke (Cosby et al., 2019; Garcia et al., 2019). In 2019, the largest discrepancy can be seen in the mortality rates between rural and urban areas in heart disease (189 compared with 156), cancer (164 compared with 143), and chronic lower respiratory disease (53 compared with 35; Curtin & Spencer, 2021). There is also evidence for higher mortality in rural areas resulting from dementia (Cato et al., 2022; Cosby et al., 2019). At the same time, rural communities have seen a rise in the mortality rates for outcomes of mental health conditions such as suicide and drug-related deaths (Jensen et al., 2020). Age is also a major factor in the mortality penalty in rural areas. Dwyer-Lindgren et al. (2017, p. 1008) note that “it seems likely that increases in geographic inequality in life expectancy over the past 3 decades have been driven largely by increases in geographic inequality in the risk of death in older ages.”

In addition to the mortality penalty, adults in rural areas report worse health (both mental and physical) than adults in urban areas and suffer disproportionately from chronic illnesses, limitations in activities of daily living, and chronic pain. Poor diets, smoking, and inactivity are also major problems for adults and older adults in rural areas (Jensen et al., 2020).

Cognitive impairment and dementia also occur more frequently in rural as compared to urban or suburban areas (Herd et al., 2021; Ho & Franco, 2022; Rahman et al., 2020 , 2021; Weden et al., 2018; Xu et al., 2022). It is known that many health conditions, including those that have been mentioned above, contribute to the onset of dementia. The health disparities that contribute include higher levels of comorbid chronic conditions such as obesity, diabetes, and heart disease (Nagar et al., 2022). As discussed above, these disparities are significantly higher in rural communities. It is also important to note that persons in rural areas were at particular risk for COVID-19 and at risk for worse outcomes as they tended to be older, had more preexisting conditions, lived further from hospitals, and lacked health insurance (for those under 65; Cromartie et al., 2020).

The health and mental health disparities faced by rural elders and communities have been investigated in comparison to the Healthy People (HP) initiative of the U.S. Centers for Disease Control (CDC, https://www.cdc.gov/nchs/healthy_people/index.htm). Rural Healthy People 2010 and now 2020 are companions to HP 2010 and 2020. Their purpose was to distinguish HP focus areas that are of primary concern for rural communities. This was accomplished through a survey of rural health stakeholders (N = 1,214, including health care administrators, providers, researchers, and educators), asking their opinions on the top ten rural health priorities. The results coincide with the conclusions made from the health and mental health disparities research. Nutrition and weight status, diabetes, and mental health and disorders were all identified by over 50% of those completing the survey. Some of the most selected concerns included substance abuse, heart disease and stroke, physical activity and health, and tobacco use. Aging/older adults were also an important priority according to 40% of the rural stakeholders (Bolin et al., 2015).

There are several contributors to rural health and mental health disparities in rural areas. Poverty is a disparity all its own and is found to be pervasive in many of these communities. The poverty rate in nonmetro areas in the United States in 2018 was 16% compared to 13% in metro areas (Cromartie et al., 2020). Additionally, over 85% of counties that are categorized by the U.S. Census as being persistently poor (or having 20% or more living in poverty for over three census measures and one American Community Survey estimates) are nonmetro. Nonmetro-African Americans, Hispanics, and American Indians are at particular risk for poverty (Farrigan, 2022). Looking specifically at the influence of poverty and rural residence on mortality rates, Long et al. (2018) noted that mortality is largely explained by differences in socioeconomic factors. Rural residents are also at a disadvantage when it comes to accessing health and mental health care, especially those in poverty. The lack of access to health and mental health care facilities includes medical and licensed professionals. Medical specialists, dentists, and mental health professionals may be in particular shortage in rural areas (Cai & Lalani, 2022; Dobis & Todd, 2022; Mattos et al., 2019; Morrone et al., 2021). This problem in rural communities was also confirmed by the stakeholders surveyed by Healthy Rural People 2020 as 75% (n = 555) identified access to quality health services as a public health and intervention priority (Bolin et al., 2015).

As an additional risk factor for poor health, rural areas have limited access to fresh, healthy, and affordable foods. These areas are also known as food deserts. Although these areas grow most of the nation's food, they experience greater food insecurity. In fact, rural counties accounted for over 80% of food-insecure areas (Hake et al., 2022). In addition to food insecurity, rural residents may also be exposed to unsafe water at a greater rate than those in urban areas (Allaire et al., 2018). Access to healthy foods as well as physical health and mental health services may be dependent on having reliable and affordable transportation. This has been a long-standing issue in rural areas and can be particularly challenging for older adults and persons with disabilities. Public transportation is often lacking in rural areas due to limited infrastructure, funding, and low population density. Other problems with transportation in these areas include traveling long distances (possibly in bad weather and over difficult terrain) to reach needed services. Barriers to transportation for older adults and others in these areas can delay or prevent the seeking of health-promoting and sustaining care (Henning-Smith et al., 2017). Additionally, with respect to poverty and access issues, the health behaviors of those living in rural areas may serve as a secondary risk. As mentioned, less healthy diets, smoking, inactivity, and substance use can contribute to health disparities for rural residents (Bolin et al., 2015; Jensen et al., 2020).

Disparities in the Appalachian Region

The Appalachian Region of the United States is defined by the geography that exists within the Appalachian Mountains. Designated in the 1960s by the Appalachian Regional Commission, the area includes all of West Virginia, and parts of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. It is estimated that almost 50% of Appalachia is rural and it has been traditionally identified as impoverished, although recent years have seen some economic improvement in certain areas of the region (ARC, n.d.). The area is often identified in terms of Northern, Central, and Southern Appalachia, and while great diversity exists within the region, many communities have preserved traditional culture including food, crafts, folklore, and music (Hilly, 2015). Due to a history of economic hardship and exploitation, the communities and residents of this region are thought to be fiercely independent and resilient. Studies have documented that people residing in Appalachia across the lifespan are not as healthy as those living in other parts of the United States. In fact, of 41 health indicators, the region performs worse than the national average on 33. This includes seven of the leading causes of death—heart disease, cancer, chronic obstructive pulmonary disease (COPD), injury, stroke, diabetes, and suicide—all of which have a higher mortality rate in Appalachia than in the United States as a whole. The rural areas of this region have higher mortality rates than the urban areas for these indicators. In addition, the number of physically and mentally unhealthy days as well as depression rates are higher in this region. The mortality rate for poisoning (which includes opioid overdoses) is substantially (37%) higher in Appalachia than the United States as a whole and suicide is 17% higher. The risk for suicide is 21% higher in the more rural parts of the region. Factors that lead to health conditions such as obesity and smoking as well as inactivity are also greater for residents living in the Appalachian region, and additionally, access to health and mental health professionals is more limited (ARC, 2017).

West Virginia is the only state that is entirely within the Appalachian Region, and it is highly rural. It is also perhaps the most striking example of health disparity. To begin, West Virginia has the highest prevalence in the nation of adults reporting fair or poor health (25.9%). The adult residents of West Virginia have the highest combined rate of obesity and overweight in the country at 67.9%. More than one in three West Virginia adults have arthritis (36.2%), which ranks West Virginia the highest in the nation. The overall cardiovascular disease prevalence is the highest in the nation at 14.0% and the state has the highest prevalence of high blood pressure in the nation at 42.7%. In terms of morbidity, the average adult in West Virginia reports feeling physically unhealthy 33% more often than the average American and mentally unhealthy 31% more often than the average American (ARC, 2020).

In terms of mortality, the heart disease mortality rate is 19% higher than the national rate and cancer mortality rate is 17% higher. COPD mortality rate is 53% higher than the national rate. The injury mortality rate is 70% higher than the national average and stroke mortality is 19% higher than the national rate. The diabetes mortality rate is 53% higher than the national rate. The years-of-potential-life-lost rate is 47% higher than the national rate (ARC, 2020). In terms of mental health, West Virginia has a higher rate of depression and a suicide rate that is 27% higher than the national average. Poisoning deaths in the state are 110% higher than in the nation. This is important as it includes drug overdoses (ARC, 2020).

West Virginia is like other rural areas in terms of its level of health disparities. Like other rural communities inside and outside of Appalachia, it also has a large proportion of older adults, with 20% of the population 65+ and a mean age of 43 (U.S. Census Bureau, 2016–2021). The state has similar risk factors for health disparities as rural areas in general, as it has a poverty rate that is 28% higher than the national average. Access to health and mental health care and professionals is also an issue, as the availability of specialty care physicians is 21% lower, access to mental health professionals is 45% lower, and the supply of dentists is 24% lower than the national average. Also, like other rural areas, West Virginia has a higher rate of physical inactivity and smoking among its residents (ARC, 2020).

Best Practices and Future Directions

With an increasing older adult population residing in rural communities combined with the health and mental health disparities faced by rural residents across the lifespan, it is imperative to identify ways to reduce and eventually eliminate these inequities. The contributors to and risk factors for the disparities that were previously discussed can be viewed in terms of social determinants of health (SDOH). The CDC defines these as nonmedical factors that “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Office of Disease Prevention and Health Promotion, n.d.). Some SDOHs that can impact health and have been mentioned as disparities in rural areas include poverty, access to health, mental health, and transportation services, and the quality of drinking water and access to healthy foods. Thus, it seems that the most logical approach to eliminating health disparities in rural areas is to focus policy and programming efforts on recreating healthier environments in which individuals can live and age. As there is great diversity between rural areas, it may be most productive to target research and resulting interventions on specific areas and allow rural communities to identify their specific needs and solutions to their challenges. Cosby et al. (2019) suggest that funding and programs for high poverty focus on highly rural areas, as these areas are at the greatest risk for health disparities. While a rural environment often puts its residents at risk, it is also important to consider that persons residing in these communities could have other, intersecting identities that increase vulnerability in terms of SDOHs, including older adults, ethnic minorities, women, immigrants, lesbian, gay, bisexual, and trans persons. Groups that are marginalized in this way can be at greater risk for health disparities (Baah et al., 2019).

Fortunately, there are federal agencies and state and national organizations that aim to address health disparities in rural areas. The Federal Office of Rural Health Policy (https://www.hrsa.gov/rural-health), which is under the Health Resources and Services Administration (HRSA), offers information and resources as well as grant funding opportunities and programs specific to rural health and reducing disparities. It also houses the Rural Health Information Hub, which is the most comprehensive site for information, data, and resources on rural issues and rural health. The hub offers a Rural Health Equity Toolkit (https://www.ruralhealthinfo.org/toolkits/health-equity) which is a collection of evidence-based strategies to help organizations work toward health equity in the United States. The modules include resources, information on model programs, evaluation tools, and ideas related to funding, sustainability, and dissemination of findings. Several states have a rural health association and there is also the National Rural Health Association (https://www.ruralhealth.us/about-nrha), which holds an annual conference, hosts a health equity council, and provides advocacy. The Robert Wood Johnson Foundation (https://www.rwjf.org/) works toward improving health and health equity in rural and other communities through funding research and programs.

Telehealth has been a steadily growing practice for reducing health disparities in rural areas. The COVID-19 pandemic has made this technology more commonplace and reimbursable for providers. It can be accomplished by the use of a computer, tablet, or cellular phone where the patient and practitioner can be in two different geographic locations. Most of the articles reviewed by Rush et al. (2022) found that telehealth was useful for promoting health and mental health among rural residents 55+. Some of the challenges noted across the articles reviewed involved difficulties experienced by patients including low digital literacy, inadequacy of equipment or connectivity problems, cognitive or physical impairment, and lack of confidence or technological support or training.

Training and educational programs specifically directed toward recruiting and retaining health care professionals to work with older adults and others in rural areas can go a long way towards reducing health disparities. For example, the Teaching Health Center Graduate Medical Education Program of the U.S. HRSA is a funded residency program in medicine and dentistry that has a focus on rural and underserved areas. Geriatrics is considered one of the high-need specialty areas of the program (https://bhw.hrsa.gov/funding/apply-grant/teaching-health-center-graduate-medical-education). Similar programs offered at select universities require rotations in rural areas for students in disciplines such as medicine, pharmacy, and nursing.

The significant disparities in physical health, emotional well-being, and economic security among those residing in rural Appalachia, in general, and West Virginia, in particular, were detailed above. Given the critical nature of these disparities and the disadvantage that they create across the lifespan, an interdisciplinary team in the heart of Appalachia developed a program to address these issues through a research lens. The Appalachian Gerontology Experiences: Advancing Diversity in Aging Research program is a 5-year, National Institutes of Health/National Institute on Aging funded program at West Virginia University (https://age-adar.wvu.edu/). It is an R25 training program that recruits and trains undergraduate students in medicine, science, technology, engineering, and mathematics majors to conduct aging research and to integrate this training into their future careers. To address the need to diversify the workforce, students are sophomores and juniors who are members of ethnic minority groups or are first-generation college students from Appalachia. The rationale behind this recruitment was that “In order to successfully solve the new and emerging problems facing older adults, and to better deal with existing and future health disparities, we need to increase the training opportunities and retention efforts aimed at scholars of historically under-represented groups” (Patrick et al., 2022, p. 3).

Students in the program take courses on aging and health disparities with a particular emphasis on the Appalachian Region, as well as participate in intensive hands-on mentored research through a 2-year paid program. They also take part in courses and workshops focusing on written and oral communication skills and professional development. The first summer involved a research project in which the students conducted a literature review, developed a hypothesis, and used the CDC's Behavioral Risk Factor Surveillance System (BRFSS; https://www.cdc.gov/brfss/index.html) data set to test their hypothesis related to a health indicator for older adults in the Appalachian Region. For example, is there an association between physical activity and cognitive ability? Students worked in groups and received instruction and guidance from a team of graduate students and faculty. Students presented their work at a symposium on campus. Some students expanded their work and presented it at state, regional, and national forums. The following fall and spring, students worked with a faculty mentor in their home departments on an aging research project related to their discipline (Patrick et al., 2022).

Conclusion

Health disparities still persist, continuing to pervade rural communities. Those who live and age in the Appalachian Region including the state of West Virginia are at particular risk. Telehealth, recruitment and retention of professionals, and building healthier environments by targeting the SDOH in these areas can help reduce and effectively eliminate disparities across the lifespan. Engaging a cadre of multidisciplinary students to explore these disparities through research and consider ways to address these disparities in future careers can additionally contribute to this effort.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kristina M. Hash

Author Biographies

Kristina M. Hash, LICSW, PhD, is a Professor in the School Social Work at West Virginia University. She holds a PhD in Social Work from Virginia Commonwealth University, a Master of Social Work Degree and Graduate Gerontology Certificate and Graduate Certificate in Health Professions Education from West Virginia University, and a Bachelor of Arts Degree from St. Catherine University. Her research interests include geriatric education, rural gerontology, LGBT issues, and the use of technology in teaching and research. Her work has been published in the Journal of Gerontological Social Work, Journal of Gay and Lesbian Social Services, Clinical Social Work Journal, and Geriatric and Gerontology Education as well as in edited books. Her book, Aging in Rural Places, was published in 2015 and her edited volume, Annual Review of Geriatrics and Gerontology: Contemporary Issues and Future Directions in Lesbian, Gay, Bisexual, and Transgender (LGBT) Aging, was published in 2017.

Bernard G. Schreurs is a Professor of Neuroscience in the Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University. He received his BSc in psychology from the University of New South Wales, and an MA and PhD in psychology from the University of Iowa. He did a postdoctoral fellowship at the National Institutes of Health. His interest areas include learning and memory, models of Alzheimer's Disease and post-traumatic stress disorder, and the risk factors and health disparities that lead to dementia.

Sheridan M. Tolley is studying at West Virginia University at the undergraduate level in Neuroscience, BS. In pursuit of a MD/PhD degree in Neuroscience, she hopes to gain more experience in research labs while fulfilling her position as STEM Section Editor of the Mountaineer Undergraduate Research Review.

Amy Fiske is an Associate Professor in Clinical Psychology at West Virginia University. She received her Bachelor of Arts degree in English from Stanford University, her Master of Arts degree in social psychology from San Francisco State University, and her PhD degree in clinical psychology with a focus on aging from the University of Southern California. She completed an internship at the Veterans Affairs Palo Alto Health Care System. She completed postdoctoral work and a visiting faculty appointment at the University of Southern California and joined the faculty in the Department of Psychology at West Virginia University in 2005. She was promoted to Associate Professor in 2011 and currently serves the department as director of Clinical Training and the coordinator of the Clinical Psychology Program Area. Her primary research interests involve the etiology of depression and suicidal behavior in late life and the implications for prevention. She also has interests in the assessment of sleeping problems and treatments for insomnia and other sleep disorders.

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Health Disparities in Appalachian and Other Rural Communities

Abstract

Keywords

Health Disparities in Rural Areas

Health, Mental Health, and Economic Disparities for Rural Residents

Disparities in the Appalachian Region

Best Practices and Future Directions

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Author Biographies

References