The relationship between rural status, individual characteristics, and self-rated health in the Behavioral Risk Factor Surveillance System.

More than 90% of the landmass of the United States (US) comprises rural areas; however, less than one-fourth of the US population resides in these areas with estimates varying according to the definition of rural.1–5 Most often, the definition of rural varies by scale, such as census tract, metropolitan area, or county. For example, the US Department of Agriculture’s Economic Research Service identified that 17% of the US population (approximately 49 million individuals) lived in “nonmetropolitan counties” in 2000, whereas the 2000 US Census estimated that 21% of the population (approximately 58 million individuals) lived “outside a metropolitan area.”3,5 Using the same data, the 2000 US Census found that the proportion was similar (approximately 59 million individuals) when rural was defined as “outside an urban area;” however, these criteria captured different segments of the population, as illustrated by the fact that the estimate dropped to 12% (approximately 33 million individuals) when rural was defined as both “outside a metropolitan area” and “outside an urban area.”2 Definitions can also be based on urbanization or land use, administrative or economic considerations, distance from a metropolitan area, or population density.4 The differentiation between urban and rural status has been theorized to be important for public health and health interventions due to differential access to amenities and disamenities that may influence health. The concept of an urban health advantage centers on the idea that city dwelling benefits health, possibly due to socioeconomic heterogeneity, greater opportunities for social support and cohesion, exposure to varied economic development, frequent contact with health-promoting built environments, and other characteristics of urban areas.6 In contrast, the literature on urban health penalty suggests that living in urban areas harms health through exposure to concentrations of crime, pollution, poverty, poor housing, inadequate medical care, infectious disease, and other conditions.7,8 Research studies evaluating the implications of rural status often highlight a specific outcome that is either more or less prevalent in urban areas and assesses the environmental features associated with the outcome.9,10 Conceptualizing rural as simply the opposite of urban, however, may ignore attributes or influences that are unique to the rural environment. Such characteristics are hypothesized to include exposure to agricultural, forestry, or mining methods, reduced water quality, landscape-induced isolation, access to resources, and aggregation of disadvantage.11,12 Accordingly, rural areas have a higher prevalence of many social, behavioral, and environmental factors that may affect health risk. For example, a higher percentage of both male and female rural residents smoke tobacco products, compared to urban residents.13 Residents experience higher levels of poverty and unemployment in rural areas than in urban areas.14,15 In rural areas, the population is more likely to be older in age, to suffer from activity limitations due to chronic morbidities, and to be uninsured.13 Most rural counties are health professional shortage areas.12 As a result, individuals living in rural areas have more problems accessing health care, including assisted living facilities, dental professionals, mental health professionals, primary care physicians, and specialists other than family medicine practitioners, compared to those living in urban areas.13,16–18 Such differential access to care may be due to the cost or distance of travel to health care and often results in an impaired ability to attain both preventive services and timely health care.19–21 Co-morbidities such as non-fatal injuries, depression, and obesity are a few of the potential effects of this geographic health disparity.22,23 In particular, rural areas have a higher prevalence of obesity.13 Rural living has also been associated with higher rates and higher odds of obesity.24,25 The prevalence of overweight and obesity in the US has been growing in all areas during recent decades.26–29 This rapid growth has been labeled as an “obesity epidemic.”30 The obesity epidemic has continued, despite interventions such as Healthy People 2010, which included a goal of reducing adult obesity to 15% by 2010; however, in 2010, adult obesity was estimated at approximately 27.5%.31 Similar to other factors that could result from rural-urban disparities, obesity has been associated with a number of co-morbidities, such as hypertension, coronary heart disease, and cardiovascular disease; stroke; sleep apnea and respiratory problems; Type 2 diabetes; and breast, endometrial, prostate, and colon cancers.32 Not only do obesity and other factors increase the national disease burden, but these characteristics and the resultant morbidity increase economic burdens on individuals, workplaces, and governments.33 Previous studies have typically investigated the extent to which these social factors vary by urban or rural status or the extent to which such social factors are associated with adverse health effects. Accordingly, our goal was to identify the characteristics that may account for differences in health by rural status and to determine whether the relationship between social factors and health is modified by rural status.