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  • Describe the demographics and characteristics of rural patients.

  • Identify common vulnerabilities among rural populations.

  • Outline the health issues faced by rural Americans.

  • Review the unique relationship between rural living and health.

  • Highlight challenges to care of rural patients from the perspective of the individual provider and the health system.

  • Discuss strategies and initiatives to improve health care of rural residents.


“Rural” is a term that elicits a variety of meanings and images such as farms, expansive landscapes, or small towns. For some, it is a state of mind or a feeling. Others contend its definition is quantifiable by population density or other measures. Although there are many definitions, all attempt to describe something socially and geographically different from urban areas.

The number of Americans living in rural areas has been declining; however, their numbers are substantial. The 2010 US census reported 19% of the population lives in rural areas and 75% of the US landmass is nonmetropolitan.1 Globally, 3.4 billion people, or just under half of the world’s population, live in rural areas.2 Within rural populations, there are many who struggle with health and health care. This chapter identifies and discusses some of the vulnerabilities and health challenges specific to rural populations, the context of rural health systems, and key issues for health-care providers in rural communities.


The social fabric of rural communities is complex and can vary greatly. The smaller scale of rural towns can frequently facilitate an interconnectedness and reciprocity among its inhabitants. People living in small towns tend to know their neighbors and interact with them in multiple settings. This interconnectedness lends itself to grassroots responses to local issues. Community action is frequently organized through churches, civic groups, and local government. These institutions and their leadership can often set the agenda for civic priorities.3,4 It is no surprise that community-oriented primary care, with its focus on broad community needs that are fundamental to health, has its roots in rural health.

Although there are pockets of prosperity and economic growth in rural communities, many rural economies are on the decline. In recent decades, particularly in developing countries, people are migrating from rural areas to urban centers. This rural flight is spurred by the lack of economic opportunities in rural areas and the perception that larger cities hold the promise of better jobs and more educational opportunities.5


Concentrated poverty, low education levels, and hazardous occupations have been major contributing factors in the health inequalities found in rural places compared to urban cities. In line with global trends, rural Americans experience a significantly higher mortality rate than those living in urban areas.6 Although activities such as mining, agriculture, and farming are on the decline, they are ...

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