Abstract
The unique health and aging challenges of rural populations often go unnoticed. In fact, the rural United States is home to disproportionate shares of older and sicker people, there are large and growing rural–urban and within-rural mortality disparities, many rural communities are in population decline, and rural racial/ethnic diversity is increasing.
Yet rural communities are not monolithic, and although some rural places are characterized by declining health, others have seen large improvements in population health. We draw on these realities to call for new research in five areas.
First, research is needed to better describe health disparities between rural and urban areas and, because rural places are not monolithic, across rural America. Second, research is needed on how trends in rural population health and aging are affecting rural communities. Third, research is needed on the ways in which economic well-being and livelihood strategies interact with rural health and aging. Fourth, we need to better understand the health implications of the physical and social isolation characterizing many rural communities. Finally, we argue for new research on the implications of local natural environments and climate change for rural population health and aging.
Population aging is among the most important trends in 21st-century America and is occurring more rapidly in rural than in urban areas.1 The rural United States is also home to disproportionate shares of people in poor health whose collective health profile has worsened over the past 40 years.2 Fresh approaches are needed to understand and address these trends and their drivers, including the multilevel and multidimensional roles of local demographic, economic, service, natural, and policy environments. Here we describe three major demographic trends with implications for rural population health and aging and propose five promising areas for research related to these trends.
The rural United States is characterized by three major population health and aging trends that have implications for research in the 2020s. The first is large and growing rural–urban disparities in health and mortality. After decades of lower mortality rates in rural than in urban areas, a rural mortality penalty emerged in the 1980s and has grown each decade.2 Smaller improvements in cardiovascular and cancer mortality in rural areas and increases in drug, alcohol, and suicide deaths contributed to the growing gap.3
Nationally, rural areas have lower life expectancy3 and higher mortality rates from most top causes of death,3,4 report worse self-rated physical and mental health,4,5 and have higher rates of most chronic diseases,4,6 activity limitations,4,6 and chronic pain.6 In addition, smoking,4,6 poor diets,6 and physical inactivity4,6 are more likely among rural adults. Despite observing a reduction in the magnitude of the rural penalty in older adult cognitive functioning between 2000 and 2010 (stemming from improvements in educational attainment), Weden et al. found a persistent disadvantage in cognitive functioning among rural adults relative to their sociodemographically similar urban peers.7
The second trend is depopulation. Reflecting chronic out-migration of working-age adults and natural population decreases (more deaths than births), nonmetropolitan counties were home to 26.3% of the US population in 1980 but only 14% as of 2017. This raises questions about the implications for the people and places left behind.
The third trend is increasing diversity. Members of racial/ethnic minority groups account for about 20% of the US rural population, are often geographically isolated, and face significant health challenges, including race-specific rural health and mortality penalties.8,9
Of course, places are dynamic, their composition and contexts shift over time, and rural health disparities are not static. Whereas some rural areas have suffered from a remarkably persistent mortality disadvantage over time, others have experienced vast improvements.2 Rural areas have diverse economies, health and social service infrastructures, natural amenities, and capacities to cope with economic and environmental stressors.
Health outcomes vary drastically across different types of rural areas. Although some rural areas are characterized by persistent poverty, chronic joblessness, out-migration, and poor health, not all rural people and places are in dire straits. Some rural areas have demonstrated tremendous resilience and are in the midst of a demographic and economic renaissance.10 However, explanations for why some rural places and populations are flourishing while others are floundering remain unclear. Moreover, research on intersections between race, rurality, and health and how these factors vary across different US regions (e.g., Appalachia, the Delta South, the Black Belt, the Rio Grande Valley, and Native American regions) remains sparse.
The urgency of examining these trends has been heightened by the macro-level economic, environmental, policy, and health shocks and stressors that have buffeted rural areas since the turn of the 21st century. Among the most recent of these are the opioid epidemic, which has manifested differently in rural than in urban areas,11 and the COVID-19 pandemic, in which the older age composition and higher prevalence of several chronic health conditions place some rural communities at risk for high COVID-19 fatality rates.12 New approaches are needed to understand how these factors affect and are in turn affected by health and aging trends in the rural United States. As noted, here we describe five promising areas for future investigation.
AN AGENDA FOR THE 2020S
Cutting across the five areas is explicit attention to how “place” (the characteristics of the contexts in which people live) influences health and aging trends, affects different groups, and changes over time. Slow-moving stressors over the past 40 years (e.g., industrial transformation, rising income inequality, immigration, climate change) and short-term economic, policy, environmental, and health shocks (e.g., the recession, the Affordable Care Act, natural disasters, the opioid epidemic, COVID-19) affect rural people and places differently than their urban counterparts as a result of greater concentrations of vulnerable groups, less diversified economies, thinner institutions, and fewer local services in rural areas. Yet, rural places are not monolithic, and one cannot assess problems or develop adequate solutions without recognizing that rural settings are fundamentally different from each other.
DISPARITIES BETWEEN AND WITHIN RURAL AREAS
There is no shortage of research on the rural mortality penalty. However, the causal mechanisms (e.g., compositional, behavioral, structural, policy) driving worse rural health and the widening or narrowing of disparities over time are not clear. Moreover, mental health and cognitive health receive less attention than outcomes and are promising areas for future rural health research. For example, the link between rural environmental conditions and physical health is clear.13 However, we know very little about how contextual conditions (e.g., pollution, crime, security, walkability, aesthetics) affect mental and cognitive health among rural populations.
Beyond rural–urban disparities, more attention is needed on within-rural disparities in health and aging. Although research has moved beyond the rural–urban binary, often overlooked is that rural places are not monolithic. The smallest and most remote rural areas are not always the worst off.14 For example, life expectancy is much lower and has begun to decline in parts of rural Appalachia and the East South Central region while showing remarkable improvement in rural parts of the Mid-Atlantic, Great Plains, and Pacific.3 Moreover, although all-cause mortality rates are higher among rural than urban Blacks and Hispanics, certain cause-specific mortality rates (e.g., drug poisonings) are much lower among rural than urban Blacks.15 These realities push us to reconceptualize how we think about rural disadvantage so that we can better understand why some rural populations and places appear to be more resilient than others against declining life expectancy and rising morbidities.
Research on the intersections between aging, health, rurality, and different dimensions of vulnerability (e.g., race/ethnicity, nativity, gender, veteran status) is also sparse. Although there is a large body of literature on health disparities by race/ethnicity, socioeconomic status, and place, these factors are often treated as independent vulnerabilities, whereas the intersections between them may be particularly important for health outcomes.16 National studies tend to be prioritized in both academic journals and the media, but there are increasing regional disparities in multiple health outcomes. These regional patterns, including how they vary across demographic and socioeconomic status groups, need much more attention.17
PLACE-LEVEL EFFECTS OF RURAL HEALTH AND AGING TRENDS
Second, new research is needed to identify the implications (e.g., social, economic, political, and infrastructural) of rural health and aging trends. We know a great deal about the determinants of rural population change,18 but research on the effects of this change on rural health and well-being lags behind. There is much we need to know. For example, the increase in the rural elderly population will place greater demands on the already-underresourced rural health care infrastructure. Simultaneously, rural health care providers are themselves aging and retiring, and the remaining working-age population is insufficient to replace them.19 This has implications for rural elderly and nonelderly individuals alike.
Aging populations will also require infrastructure adaptation to deal with accessibility issues. Such accommodations are more expensive in rural places where infrastructure is older and there is less money to support upgrades.19 Recent health challenges, such as the opioid crisis and COVID-19, raise new questions about the service needs of older rural populations. More rural grandparents are raising their grandchildren than at any point in recent history partly because their own children are addicted to drugs, are incarcerated, or have died from overdose.11 This may have important but as of yet unaddressed implications for rural families and rural communities, where economic resources and housing for older populations are limited.
There are also different types of aging rural areas. Some rural counties have higher concentrations of older adults because of persistent young adult out-migration. In population-loss places, tax bases, businesses, and services for older residents have declined.19 In these areas, cost-of-living differentials often “trap” elders in place because their nest eggs (e.g., home values, pensions, 401(k)s) were built in rural locales with substantially less income than necessary to support them in an urban area. Conversely, other aging rural counties are growing in size as retirees and preretirees target them as places to live.10 Although retirement and natural amenity migration can have positive economic, social, and civic effects on communities, health and other services are often unavailable for older populations, and the in-migration of affluent retirees can lead to residential segregation and resource neglect of low-income and young adults.20 Rural residents already face affordable housing shortages, a reality that is likely to intensify with retirement and amenity migration.
Immigration also provides opportunities for rural growth and renewal. Hispanic population growth has reversed or ameliorated population declines and “youthified” many rural places. Yet some rural communities struggle to accommodate the needs of this population, and rural Hispanics in new destinations are economically and residentially disadvantaged relative to their urban and established destination peers. Innovative data and analytic approaches are needed to understand the place-level effects of health and aging trends in these different types of rural areas.
RURAL LIVELIHOOD STRATEGIES AND WELL-BEING
Third, novel research is needed to understand relationships between rural economic livelihood strategies, economic well-being, and health. Official poverty measures do not capture the lived experiences of economically struggling rural people and families. Combining income from earnings, safety net programs, informal work, and other sources is common in rural areas, but we know little about how livelihood strategies have changed over time, vary by demographic group and place, and affect adult health. Underemployment is more common among rural workers.21 Such employment disadvantages carry over into older ages, but what are the implications of employment hardship in midlife for later-life health? Informal work is also more common in rural areas and can be critical for economic survival. More needs to be known about informal work in the rural economy and among rural elders and how it relates to population health.
Disproportionate and rising shares of rural workers are unable to achieve economic security and have fallen into a growing pool of the “working poor.”22 This calls for a better understanding of the nature of working poverty and underemployment among rural elders. Although impoverished elders are more likely to be considered “deserving poor,” we need to better understand the role of safety net programs in rural elderly households.
Relatedly, research on the effects of various federal and state safety net policy changes on rural health is also scant. Safety net policy changes may have unintended consequences because rural realities are often ignored in policy formulation. For example, a greater share of rural residents are covered by public insurance, making changes to Medicare or Medicaid policies (e.g., tightening reimbursement rates) consequential to rural patients and providers. A larger share of uninsured rural residents live in states that did not expand Medicaid under the Affordable Care Act.13 These trends necessitate research on the differential effects of recent safety net policy changes to insurance coverage, provider supply, and subsequent health outcomes among rural populations.
PHYSICAL AND SOCIAL ISOLATION
Fourth, research is needed to identify the influence of physical and social isolation (including access to health care and other necessary service infrastructure) on healthy aging in different rural areas. Broadly, the extant literature shows that many health- and aging-related services are simply less available in rural communities,13,20,23 but we know very little about how lack of access to these services actually affects specific outcomes in rural areas, including premature mortality, morbidity, and cognitive aging. For example, how does scarcity of diagnostic and pharmacy services affect outcomes related to Alzheimer’s disease and related dementias?
We also know little about the health implications of scarcity in other potentially important services and infrastructure in rural areas, including mental health, housing, legal, and end-of-life care services. Informal caregiving in rural areas can be critical for providers as well as recipients. Stronger community and social cohesion in some rural places may enable a variety of survival mechanisms and create an environment in which social entrepreneurship among elders can flourish. A common assumption is that rural residents have strong social relationships that substitute for market- or public-sector resources, but rural elders face challenges when attempting to access assistance from their support networks.24 More studies are needed on the substitution effects of social capital in the face of service limitations.
ENVIRONMENTAL CONDITIONS AND CLIMATE CHANGE
Finally, research is needed to identify where and how exposures to environmental change and hazards have affected rural population health and aging. Environmental changes can occur suddenly (e.g., floods, hurricanes) or gradually (e.g., climate change, natural resource extraction). Importantly, environmental shocks and stressors expose and often exacerbate existing health inequities. This issue is especially relevant to rural people and places given the unique relationships between the environment and livelihoods in rural areas and the intensification and concentration of corporate agricultural production and natural resource extraction.13
The uneven distribution of resources and infrastructure necessary for effective planning, adaptation, and mitigation makes studying the effects of environmental shocks and stressors on health and aging paramount for rural America. Research must identify specific rural populations at risk and potential responses to such risk. Resilience is also important to consider. Research shows that community-based groups with appropriate ties, resources, and other capital can help reduce vulnerability in the face of environmental shocks and stressors, including in rural communities with persistent poverty and disinvestments.25 Research is needed on the challenges facing resource-constrained rural communities and their ability to respond to environmental shocks and stressors. We also need to understand how place-level characteristics lead to greater vulnerability or resilience and the recovery challenges faced by the elderly and other vulnerable groups.
CONCLUSION
Population health and aging trends are driven by multilevel and multidimensional factors, including place-level population composition and local economic, service, social, natural, and policy environments. Rural areas are more demographically and economically diverse than ever before, and we cannot assess problems, develop policies, or deliver adequate resources to rural areas without recognizing these fundamental differences and without a clearer understanding of the exposures shaping health and aging among different rural populations.
In addition to asking new questions, future rural health and aging research should assess what data resources exist or should be developed to answer these questions. Ultimately, better understanding the multilevel and multidimensional causes and consequences of contemporary trends in rural health and aging requires asking new questions, building interdisciplinary collaborations, recruiting and training new scholars with diverse perspectives, developing data and analytic resources, and aggressively disseminating findings to policymakers and the public.
ACKNOWLEDGMENTS
Support for the development of this commentary was provided by the Interdisciplinary Research Network on Rural Population Health and Aging, which is funded by the National Institute on Aging (grant R24-AG065159). We also acknowledge support from the National Institute of Food and Agriculture, USDA (multistate research project W4001, “Social, Economic and Environmental Causes and Consequences of Demographic Change in Rural America”). In addition, this commentary benefited from support provided by the Population Research Institute at Pennsylvania State University (project 5P2CHD041025-19) and the University of Colorado Population Center (projects 2P2CHD066613-06 and 1R21HD098717); these projects were funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Note. The content of this commentary is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the authors’ affiliate institutions.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
Footnotes
REFERENCES
- 1.Glasgow N, Berry EH. Rural Aging in 21st Century America. New York, NY: Springer; 2012. [Google Scholar]
- 2.James W, Cossman J, Wolf J. Persistence of death in the United States: the remarkably different mortality patterns between America’s Heartland and Dixieland. Demogr Res. 2018;39:897–910. [Google Scholar]
- 3.Vierboom YC, Preston SH, Hendi AS. Rising geographic inequality in mortality in the United States. SSM Popul Health. 2019;9:100478. doi: 10.1016/j.ssmph.2019.100478. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Michael M, Knudson A, Gilbert T The 2014 update of the rural-urban chartbook. Available at: https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf. Accessed June 10, 2020.
- 5.Monnat SM, Beeler Pickett C. Rural/urban differences in self-rated health: examining the roles of county size and metropolitan adjacency. Health Place. 2011;17(1):311–319. doi: 10.1016/j.healthplace.2010.11.008. [DOI] [PubMed] [Google Scholar]
- 6.National Center for Health Statistics. National Health Interview Survey tables of summary health statistics. Available at: https://www.cdc.gov/nchs/nhis/shs/tables.htm. Accessed June 10, 2020.
- 7.Weden MM, Shih RA, Kabeto MU, Langa KM. Secular trends in dementia and cognitive impairment of US rural and urban older adults. Am J Prev Med. 2018;54(2):164–172. doi: 10.1016/j.amepre.2017.10.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.James W, Cossman JS. Long-term trends in black and white mortality in the rural United States: evidence of a race-specific rural mortality penalty. J Rural Health. 2017;33(1):21–31. doi: 10.1111/jrh.12181. [DOI] [PubMed] [Google Scholar]
- 9.James CV, Moonesinghe R, Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. Racial/ethnic health disparities among rural adults—United States, 2012–2015. MMWR Surveill Summ. 2017;66(23):1–9. doi: 10.15585/mmwr.ss6623a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Brown DL, Schafft KA. Rural People & Communities in the 21st Century: Resilience & Transformation. Malden, MA: Polity; 2011. [Google Scholar]
- 11.Monnat SM. The opioid crisis in rural America: trends, causes and consequences. In: McHale S, Glick J, King V, editors. Rural Families and Communities. New York, NY: Springer; 2020. pp. 117–143. [Google Scholar]
- 12.Johnson K. An older population increases estimated COVID-19 death rates in rural America. Available at: https://carsey.unh.edu/publication/older-rural-pop-increases-estimated-COVID-death-rates. Accessed June 10, 2020.
- 13.Rhubart DC, Engle EW. The environment and health. In: Sherman J, Tickamyer A, Warlick J, editors. Rural Poverty in the United States. New York, NY: Columbia University Press; 2017. pp. 299–321. [Google Scholar]
- 14.James WL. All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health. 2014;104(11):2122–2129. doi: 10.2105/AJPH.2014.301989. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Centers for Disease Control and Prevention. CDC WONDER online database. Available at: https://wonder.cdc.gov. Accessed June 10, 2020.
- 16.Hinze SW, Lin J, Andersson TE. Can we capture the intersections? Older black women, education, and health. Womens Health Issues. 2012;22(1):e91–e98. doi: 10.1016/j.whi.2011.08.002. [DOI] [PubMed] [Google Scholar]
- 17.Green JJ. The status of African Americans in the rural United States. In: Bailey C, Jensen L, Ransom E, editors. Rural America in a Globalizing World: Problems and Prospects for the 2010s. Morgantown, WV: West Virginia University Press; 2014. pp. 435–452. [Google Scholar]
- 18.Winkler RL, Johnson KM. Moving toward integration? Effects of migration on ethnoracial segregation across the rural-urban continuum. Demography. 2016;53(4):1027–1049. doi: 10.1007/s13524-016-0479-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Berry EH, Kirschner A. Demography of rural aging. In: Glasgow N, Berry EH, editors. Rural Aging in 21st Century America. Dordrecht, the Netherlands: Springer Netherlands; 2013. pp. 17–36. [Google Scholar]
- 20.Sanders SR, Erickson LD, Call VRA, Rugh JS, McKnight ML. Healthcare use in the Heartland: how health care selection varies between rural, retirement-age migrants and long-term residents. Rural Sociol. 2016;81(1):66–98. [Google Scholar]
- 21.Slack T, Jensen L. Employment hardship among older workers: does residential and gender inequality extend into older age? J Gerontol B Psychol Sci Soc Sci. 2008;63(1):S15–S24. doi: 10.1093/geronb/63.1.S15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Thiede BC, Lichter DT, Slack T. Working, but poor: the good life in rural America? J Rural Stud. 2018;59:183–193. [Google Scholar]
- 23.Goins RT, Krout JA, editors. Service Delivery to Rural Older Adults: Research, Policy and Practice. New York, NY: Springer; 2006. [Google Scholar]
- 24.Cohen AL, Bennett CR. Support network connectedness in the lives of community-dwelling rural elders and their families. Marriage Fam Rev. 2017;53(6):576–588. [Google Scholar]
- 25.Kleiner AM, Green JJ, Montgomery JP, Thomas D. Using research to inform and build capacity among community-based organizations: four years of Gulf Coast recovery following Hurricane Katrina. In: Brunsma D, Overfelt D, Picou J, editors. The Sociology of Katrina: Perspectives on a Modern Catastrophe. Lanham, MD: Rowman & Littlefield; 2010. pp. 155–172. [Google Scholar]