Biopsychosocial imperatives from the rural perspective.

Abstract Rural health issues are examined within a biopsychosocial framework by addressing three questions: what is meant by ‘rural’? what are rural health needs? what factors must be considered in understanding and addressing these needs? Probably the single most important characteristic distinguishing rural from urban areas is low population density. This factor is particularly important in terms of its impact on (1) communication and transportation patterns, (2) one's ‘sense of community’ and (3) the availability of specialized services and complex organizations and institutions. For statistical purposes two different definitional dichotomies exist: rural-urban and metropolitan-nonmetropolitan. Although the rural and nonmetropolitan populations are not conterminous, approximately the same percentage of the nation's population is included in each of the two categories. A serious misconception is that of equating agriculture with rurality. While most farmers live and work in rural areas only a small fraction of rural Americans are engaged in agriculture. In terms of health needs, infant mortality tends to be higher in nonmetropolitan than in metropolitan areas; and limitation of activity due to chronic conditions is more likely to occur among the nonmetropolitan than the metropolitan population. Similarly, the percent of people who perceive their health as either ‘fair’ or ‘poor’ is higher for the nonmetropolitan population. On the other hand, the incidence of acute conditions and disability days per person per year are lower for the nonmetropolitan population than for the metropolitan population. Limited data on mental health suggest that the halcyon picture of country life may be grossly distorted. Understanding and addressing rural health needs involves a close look at the social, economic and medical systems operating in rural America. Income and employment levels, and their interrelationship to nutrition, housing and transportation generally find rural areas at a disadvantage. Although attitudes and values between rural and urban populations differ, it is all too easy to exaggerate these differences. The areas of sharpest differences have to do with issues of morality, religion and political philosophy. Problems in the availability and accessibility of medical services—especially specialized services—continue to plague rural areas. Recently, the most important dynamic in rural areas has been the rapid population growth associated with urban-to-rural migration. Another important characteristic of rural America is its diversity. Greater diversity likely exists among rural areas than among urban areas. For example, some rural areas have medical systems that are as sophisticated as those found in most urban areas. Failing to recognize and appreciate the diversity within the rural sector may be the greatest impediment to designing and implementing effective public policies for dealing with rural health needs. Considerable research, recent books, the creation of statewide offices of rural health and the work of national organizations have been helpful in alleviating the misunderstanding which surrounds rural America, its health care needs and the ways to best address those needs.