Vulnerable Population
Public health has focused on the vulnerable patients in our society for the past few decades, but now they are looking at how "place" plays a factor. According to the article, "Health in Rural America: Remembering the Importance of Place," In the 19th and 20th century, public health focused on the urban slums. Keeping these patients healthy meant they could continue to work for the industrial machines. Because of outbreaks such as cholera, smallpox, and yellow fever it was necessary to focus on these issues in order to keep the public as healthy and safe as possible. Expanding the horizon of public health awareness to rural areas has made it necessary to address how location plays a part.
Rural America
It is common to picture rural Americans as hardworking and traditional, having chosen to live in a farming small town community. Many rural areas look like small suburban towns with health risks much like those of urban patients such as obesity and smoking. Access to care is important but not always the total solution because as stated in the article mentioned earlier, the patients don't always respond to an increase in the number of health care practitioners. Prevention and education on healthy lifestyle is suggested to help this population in conjunction with access.
Obstacles to Health Care Access
There are many obstacles facing the delivery of healthcare to rural areas such as low population density, lack of access to grant funding, transportation issues, lower public funding, and the possibility of fragmented care. Also, the demographic changes of rural areas such as younger people moving out of the rural settings, leaving an increasingly aged population. Technology has changed the job market, decreasing the need for agricultural jobs. Addressing the needs of the rural population means building on the positive aspects of the community like the close social networks, high quality of life, neighborliness, and reciprocity. Helping these communities means recognizing their unique social qualities.
In a groundbreaking study, author Christie A. Befort PhD et. al. in the article, "Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005 - 2008)," it is found that "rural residents have higher rates of chronic disease compared to their urban counterparts, and obesity may be a major contributor to this disparity." The things measured were body mass index (BMI), height and weight, demographic, diet, and physical activity.
Obesity Statistics
The numbers show obesity is more common among rural residents with 39.6%, and urban 33.4% of the population being obese. Married rural residents were found to have a larger degree of obesity, while urban residents are at an increased risk for obesity related to less education and inactivity. With these numbers, there is reason to give greater attention to obesity in America.
There are more than 70 million rural residents who have higher rates of chronic disease and mortality. The obesity issue is a major contributing factor to these health problems. In the latter mentioned research article, these stats were listed:
Age 20 -39 rural obesity rate - 31.8%, and urban 41.8%, as we can see urban young people have a higher BMI.
Age 60 - 75 rural residents 26.1% obese, while urban had a 15.6%. We can see from the numbers that older rural residents have a higher percentage of obesity.
Gender percentage of obese residents is very similar between the two genders as well as rural versus urban.
Minority women who live in rural areas suffer from a larger rate of cardiovascular disease, which is the number one killer of women in this country. Over the past 30 years, a greater number of rural residents have been affected by CVD according to the article by Herman A. Taylor, et. al., "Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges."
Rural Life
As mentioned before, the thoughts of rural living evoke images of healthy food, active, less stress, and a strong community and family dynamic. However, there are many factors that inhibit a healthy lifestyle such as high levels of poverty, social isolation, and fractured healthcare. Rural people, according to the study by Taylor, have a higher percentage of diabetes, sedentary lifestyle, obesity especially in rural African-American women.
In the rural health facilities, women are less likely to receive an EKG, even though cardiovascular disease is the number one killer. Treatment to these women is often delayed, or not available. They are less likely to be given cardiac consultation or even a cardiac consult. Not only is good care hard to get, many of these rural residents are self-employed and insurance is too expensive. If they work for a company, these companies are often small and don't offer insurance or medical leave. Other factors that may affect rural residents from living healthier is a lack of trust towards healthcare workers, lack of preventative resources, and access to healthy food.
Need for Education
In the light of recent studies, we see the need for education and prevention among rural residents. There has been a weight management study performed by Michael G. Perri, et. al., and is presented in the article, "Extended-Care Programs for Weight Management in Rural Communities." The researchers performed a six month program in rural counties that had a higher rate of obesity, sedentary lifestyle, and chronic disease. The average weight was 96.4kg and there was an average weight loss of 10kg. They found the participants were more more compliant with the weight loss program when receiving counseling over the whole time period. Participants without counseling tended to regain their weight in the following year, but those who received the extended counseling, usually over the phone improved maintaining weight loss.
In conjunction with all the articles and research presented, we have first hand information from a nurse who works with rural patients named Judi. She listed the problems she sees that inhibit rural patients from getting the proper health care they need to live a healthy lifestyle. First, there are no fitness centers, making it difficult for people to find a place to get away from the house and focus on themselves. The only hospital accessible to her patients is a critical care hospital that runs of bare bones staff. Also, there are few primary care providers, and those are often from the "city." These providers come into the rural area only 1 -2 days a week, and not being a part of the community makes it difficult for them to connect with their rural patients. Specialist are not present in the rural community, forcing the patient to drive 65 miles to see them. On top of that the patients can have difficulty navigating the roads, buying gas, or even having access to a car.
To be more specific, Judi tells us about her dialysis patients:
"I will say that my patients (in nephrology, mostly end stage renal disease) are getting bigger and bigger. It is no longer unusual for me to have patients that weigh 200+kg (440#). Needless to say, their co-morbidities are huge also.
And...they require very long dialysis times and they still don't receive adequate dialysis even with five hours of dialysis. They are uncomfortable in the chairs - we have very few bariatric chairs in most dialysis units. They require extra long needles in order to go thru the additional adipose tissue. They are not eligible for transplant so they have no hope to ever get off dialysis which leads to depression."
Conclusion
As we have seen, rural residents have more obstacles to obtaining health care than to urban residents. Location often limits rural people access to healthy fresh food, and things like gyms that are readily available in cities. Recognizing that there is a problem of increased obesity in rural areas is a large step in getting these residents the help they need to live a healthier lifestyle. Please read my first article addressing how obesity increases the cost of healthcare, and look for the third article that addresses obesity among children.
Thank you to Judi for adding her experience, helping us to see the whole picture for her dialysis patients.
References
Befort, Christie A. PhD, Nazir, Niaman MD, Perri, Michael G. PhD. "Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005 - 2008). 31 May, 2012. The Journal of Rural Health. 28: 392-397. 1 Jan. 2016. Web.
"Health in Rural America: Remembering the Importance of Place." October 2004, Vol 94: 10. American Journal of Public Health. 1 Jan. 2016. Web.
Perri, Michael G. et. al., "Extended Care Programs for Weight Management in Rural Communities." 24 November, 2008. American Medical Association. 22 Feb. 2016. Web.
Taylor, Herman A. et. al. "Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges." 2 Jan. 2002. American Public Health Association. 22 Feb. 2016. Web.
