Rural children's health

This is the 3rd article in a 4-part series on rural health in the United States. The previous 2 articles—“Physicians in Rural America” and “Hospitals in Rural America”—appeared in the November and December 2000 issues, respectively.

We profile rural children's health in the 1990s, using recent national data, rather than single-area or -state studies. Our intent is to describe the current situation, suggest recent trends, and inform policy decisions concerning child and adolescent health in rural America. The analyses of rural child health used for this article are shown in the first box.,

Table 1.

The data sets used in framing this article
National Health Interview Survey US Census National Survey of Family Growth Area Resource File National Crime Survey American Hospital Association's annual survey of hospitals Unpublished data provided by the Centers for Disease Control and Prevention and the National Center for Health Statistics

Table 2.

Demographic differences between children in rural and urban populations

A greater proportion of rural children are white Whereas black children and children of Asian and Hispanic descent constitute a greater proportion of the urban child population, the rural population includes a larger proportion of Native American children Rural children are more likely to reside in larger families with married parents, whereas a greater proportion of urban children live in families headed by a single mother Rural preschool-aged children are more likely to have both or their only parent working

DEMOGRAPHICS

As of 1996, 16 million children (<21 years) resided in nonmetropolitan areas, a significant decrease from the 1984-1985 estimate of 21 million.¹ Rural children account for 21% of all US children and represent 31% of the total nonmetropolitan population.

Rural children continue to reside predominantly in the South and Midwest. In contrast, the Northeast and West comprise small rural populations, and their proportions have decreased considerably over the past decade.

Summary points

• Rural children account for 21% of all US children and represent 31% of the total nonmetropolitan population

• Rural children are more likely than urban children to be uninsured, putting them more at risk of poor access to medical care, delays in necessary treatment, and inadequate immunization

• Trends in many aspects of children's health status cannot be determined, largely because of inadequacies of available data

• Despite these inadequacies, the health of rural children appears to be deteriorating with regard to crime, substance abuse, and infection with the human immunodeficiency virus or AIDS

• Fatal injuries continue to affect a disproportionate number of rural children

Demographic differences between rural and urban populations

Rural and urban populations differ in several important demographic aspects (see box 2).

Socioeconomic status

Rural families are, on the whole, poorer than urban families. Overall, 23.2% of rural children younger than 18 years live in poverty, compared with 21.0% of urban children. This difference is consistent across all categories of age, sex, and family status (table 1).

Table 1.

Percentage of children younger than 18 years living in poverty, 1996^*

Children, %
Category	Metropolitan	Nonmetropolitan
Age, yr
<1	23.8	29.7
1 to 5	24.1	27.3
6 to 17	19.4	21.2
Sex
Male	20.5	23.1
Female	21.5	23.4
Family status
Married parents	9.5	12.2
Single, female-headed	49.1	52.7
Single, male-headed	30.2	33.9

^*Source: 1996 Current Population Survey.

Housing characteristics and health

Several housing characteristics relate to health issues in the daily lives of children (table 2). Rural families are less likely to obtain water for residential use from a public system or private company and more likely to obtain their water from a well or another source. This may place rural children at a disadvantage in the need for fluoride supplementation, the availability of safe water for mixing infant formula, and the potential for bacterial contamination of drinking water. Rural families are also significantly more likely to use a septic tank or other sewage source, rather than a public system, and to have incomplete plumbing facilities; again, this may have a direct effect on health related to the transmission of bacteria and water-borne diseases.

Table 2.

Health-related characteristics of family dwellings, 1990^*

Distribution, %		Population, no. × 103
Variable	Metropolitan	Nonmetropolitan	Metropolitan	Nonmetropolitan
Water source
Public or private	89.5	64.4	72,076	13,993
Drilled well	9.0	28.6	7,244	6,224
Dug well	1.0	3.9	813	852
Other	0.5	3.1	387	676
Sewage source
Public system	81.8	48.6	65,891	10,564
Septic tank or cesspool	17.5	48.5	14,121	10,550
Other	0.6	2.9	506	631
Plumbing
Complete	99.5	98.5	57,766	13,174
Incomplete	0.5	1.5	317	205

^*Source: US Census of Population and Housing, Standard Tape File 3c, 1990.

HEALTH INSURANCE

Insurance status is a strong predictor of the adequacy of children's health care. Uninsured children experience problems with access to medical care, delays in necessary treatment, and inadequate immunization.^2,3,4 Being uninsured is more prevalent among rural (15%) than urban (13.6%) children. Urban children were somewhat more likely than rural children to have private insurance coverage (65% vs 63%). Of those privately insured, a greater proportion of rural than urban children were covered by a self-purchased policy, whereas more urban children were covered under an employer-sponsored group plan. The proportion of Medicaid-enrolled children was roughly equal, even though a higher proportion of rural children live in poverty.

In the past 2 decades, the most prominent change in the area of health insurance has been the dramatic increase in managed care organizations. Although more than 80% of rural counties are presently included in the service area of at least 1 commercial health maintenance organization, actual enrollment rates are low.⁵

AVAILABILITY OF HEALTH CARE PROVIDERS AND SERVICES

The presence of primary care providers in a community is an important marker of availability of health care for children. Trends in the supply of primary care providers have been discussed previously in this journal.⁶

Family physicians and general practitioners continue to provide care for many rural children; more than 20% of these physicians practice in rural areas, whereas pediatricians are predominantly concentrated in metropolitan areas. This likely creates a reliance on family physicians and general practitioners, as well as midlevel providers—physician assistants and licensed nurse practitioners—for pediatric care of rural children.

Hospital-based services for children and adolescents are considered specialty services and as such are less available in rural than in urban areas (table 3). However, an encouraging trend is that half of all rural hospitals are providing inpatient surgical services for general pediatric cases. Increases in outpatient child wellness and teen outreach services in both rural and urban areas are an important expansion of health care delivery offered in hospital-based settings.

Table 3.

Percentage of hospitals providing child and adolescent services, 1995^*

	Hospitals, %
Services	Metropolitan	Nonmetropolitan
Inpatient
Pediatric general medical surgery	63	50
Pediatric intensive care	23	6
Child and adolescent psychiatry	45	18
Outpatient services
Child wellness	24	11
Teen outreach	22	7

^*Source: Annual Survey of Hospitals, American Hospital Association, 1995.

CHILDREN'S HEALTH STATUS AND SOURCE OF CARE

Differences in child health status or health outcomes are difficult to detect using the measures of function typically used with adults. Furthermore, the primary focus of children's health care is prevention: immunization, growth monitoring, vision and hearing screening, blood lead levels screening, developmental assessment, and counseling for parents. These components of preventive care usually are provided during well-child visits, recommended at scheduled intervals during the first years of a child's life.⁷

Immunization rates

Because many aspects of preventive care are not recorded in the medical record or collected in national or state data sets, immunization rates have historically served as a proxy for the overall delivery of children's well-child care. Data from the Centers for Disease Control and Prevention (CDC) from 1994 for the primary immunization series^* showed that 66% of rural children received appropriate vaccinations compared with 71% of suburban children and 62% of urban children.⁸ National immunization rates for the primary series have risen considerably in the past 5 years, but recent data published by the CDC have not included national rural-urban trends. The ability to analyze trends in rural areas is limited. Furthermore, computerized immunization registry systems that can generate small-area immunization rates (and enable providers to determine which children are behind schedule on immunization) are being developed almost exclusively in urban areas.

Risk of unmet medical need

Another indicator of the adequacy of children's health care pertains to the ability to obtain needed medical care. Rural children are at increased risk of unmet medical need (table 4).⁹ Overall, rural children were more likely to need but not receive dental care and were more likely to delay care because of cost.

Table 4.

Percentage of children aged 0 to 17 years with unmet medical needs, 1993^*

Unmet need	Metropolitan central city	Children, % Metropolitan noncentral city	Nonmetropolitan
Any	10.3	9.8	13.4
Not able to get care	2.2	1.8	1.8
Care delayed due to cost	3.8	3.7	5.4
Needed dental care	6.1	5.3	8.4
Needed prescription	1.5	1.3	1.2
Needed glasses	1.4	1.2	1.6
Needed mental health care	0.4	0.5	0.3

^*From National Center for Health Statistics.⁹

Regular source of care

Having a regular source of medical care—often referred to as a “medical home”—enhances the likelihood that children receive recommended well-child care and appropriate follow-up for acute and chronic conditions.⁹ In 1993, 6% of US children (4.2 million) had no regular source of care. Overall, poor and black and Hispanic children were at increased risk of having no source of care. Most insured children have a regular source of medical care, but fewer uninsured children have a regular source of care. However, rural children are as likely as urban children to have a regular source of care. In fact, among children who are uninsured or enrolled in Medicaid, rural children are more likely than urban and suburban children to have a regular source of care. Nationally, the most common reasons for having no source of care were not being able to afford care (34%), not needing a physician (31%), and care being unavailable or not convenient (17%).⁹

MEDICAL CARE SETTING

Rural children, particularly those who are uninsured or enrolled in Medicaid, are substantially more likely than urban children to name a private practitioner as their regular source of care. Margolis and associates found that rural physicians are more likely to accept patients of varying insurance status,¹⁰ possibly because they must retain a high proportion of the available patient pool to remain financially viable, whereas urban physicians “self-select” their patient population by limiting the number of Medicaid-covered or uninsured children.

Although rural physicians are more likely to accept a broad patient base, they are less likely to offer immunizations.¹¹ Those who provide immunization services are more likely to refer uninsured and Medicaid-enrolled children to a health department for immunizations.¹² Such referrals may be attributed to the high cost of vaccines, or rural physicians may not see enough children to warrant offering costly immunization services.^13,14

Generally, any disruption of the medical home is thought to create additional barriers to care related to increased waiting time, problems with transportation, and parental loss of work. However, in an analysis of public health department immunization data from 11 states, health departments in rural areas were highly effective in providing timely immunizations, often more so than urban health departments and private practitioners.¹⁵

In addition, the federal Vaccines For Children program and several state programs aim specifically to reduce the referral of children for immunizations only by decreasing patient charges for vaccines. Some evidence indicates that such programs are effective for this purpose.^11,16,17

DEATH AND INJURY AMONG CHILDREN

Mortality rates among children older than 1 year reflect both the quality of children's health care and societal problems such as violence and substance abuse. In 1992, more than 84,000 children younger than 25 years died. Twenty-three percent of deaths were among rural children.

For children older than 1 year, mortality is associated primarily with injury: motor vehicle crashes, firearm injuries, drowning, burning, suffocation, and poisoning. Mortality data from the National Vital Statistics System¹⁸ are shown in the box.

HUMAN IMMUNODEFICIENCY VIRUS INFECTION AND/OR AIDS

Through June 1997, a cumulative total of 612,078 cases of the acquired immunodeficiency syndrome (AIDS) were reported in the United States: nearly 1% of these cases were in children younger than 13 years.¹⁹ Between 1990 and 1995, the incidence of AIDS in children decreased 19% despite an increase of 30% in the overall incidence of the disease nationwide. Furthermore, although the incidence of AIDS in children declined 24% in urban areas, in rural areas it increased 5%.¹⁹

CRIME AND VIOLENCE

Detailed data on victims of criminal activity are collected through the National Crime Survey.²⁰ In the past 20 years, victimization of rural residents to violent crime has increased, but crimes of theft and household crimes have decreased. Overall victimization rates are lowest in rural areas and highest in urban areas. However, in all areas, rates are substantially increased among youths aged 12 to 19 years. In each of the 3 criminal categories, the victimization rate for rural youths is higher than that for the overall urban population. Furthermore, the urban-rural rate ratio is 1.9 for all categories of the total population; among youths, that gap narrows, with a rate ratio of 1.4 for crimes of theft and 1.2 for household crimes.

In 1989, a special supplement to the National Crime Survey contained questions on youths' victimization experiences at school, their opinions about crime, the availability of drugs, and the awareness of gangs (table 5).²¹ Only a narrow difference existed in crime experiences among students in rural versus urban locations—a stark contrast to the larger rural-urban differences found in the regular National Crime Survey data.

Table 5.

Percentage reporting various criminal activity in the school setting, 1989^*

Report	Metropolitan central city	Children, % Metropolitan noncentral city	Nonmetropolitan
Being a victim of property crime	8	7	7
Being a victim of violent crime	2	2	1
Drugs available at school	66	67	71
Have attended drug education classes	40	35	44
Gangs active in school	25	14	8
Avoid certain places at school	8	5	6
Fear being attacked at school	24	20	20
Fear being attacked going to or from school	19	12	13

^*From Bureau of Justice Statistics, Office of Justic Programs, Washington, DC.²¹

Gang activity in school was cited 3 times more frequently by urban than rural youths. However, a substantial number of rural students exhibited fear about violence at school. These results indicate that rural youth are experiencing crime at a level and in ways similar to youth from the cities and suburbs.

SUBSTANCE ABUSE

Criminal activity is often linked to drug use, particularly among children. A 1992-1993 survey of rural and urban 8th and 12th graders showed that rural-urban differences in drug use have decreased nationwide. More rural students reported that drugs were readily available at their school, and rural students were more likely to have attended drug education classes. Of the overall trends demonstrated, most surprising was that inhalant use was more common than marijuana use among 8th graders. It appears that during the 1990s, inhalants, which are inexpensive and easily accessible, have replaced marijuana as the “gateway drug.”²² For all other drugs, lifetime prevalence among 12th graders was higher than for 8th graders. With respect to rural-urban differences, urban youths are more likely to have used marijuana, cocaine, and LSD whereas rural youths are more likely to have used smokeless tobacco. The use of alcohol and cigarettes is high in both groups.

CONCLUSION

Rural areas appear to be experiencing an increase in the availability of health care services and health care providers. A provision in the 1997 Balanced Budget Act that allocated funds to states to offer coverage to uninsured children holds great potential. However, because eligibility and implementation will vary from state to state, the effects of this policy for urban children remain unclear.

Important rural-urban differences in child mortality

• In 1992, the incidence of fatal injuries was 44% higher among rural children aged 1 to 19 years than among their urban counterparts

• Among children aged 1 to 14 years, death rates for all races were at least 20% higher in rural than urban areas

• For children aged 15 to 19 years, mortality among urban black children was 50% higher than that among rural black children; for all other ethnicities, mortality rates were higher in rural areas

• Homicide rates were 4 times higher among urban male adolescents aged 15 to 19 years, but suicide rates were higher among rural male adolescents of the same age group

• In all age groups, mortality from motor vehicle crashes is higher in rural areas, reflecting the increased travel time and distance required of rural populations

• During 1985 to 1992, rural injury mortality rates remained consistently higher than urban rates, with 1 exception: the mortality rate for rural and urban male adolescents aged 15 to 19 years is equal¹⁸

Figure 1.

Rural children are at increased risk of unmet medical need

^{© National Archives and Records Administration/Visual Image Presentations}

Figure 2.

Rural families are less likely to use public water and sewage systems, increasing the potential for contamination of their drinking water

^{© National Archives and Records Administration/Visual Image Presentations}

Figure 3.

^{© Jennie Haydel}