Children living in rural areas have a shorter life expectancy and suffer from worse health outcomes compared with their urban counterparts. This disparity is highlighted by higher rates of perinatal conditions, mental and behavioral disorders, obesity, oral health, and other issues. Significant gaps in preventative health measures further exacerbate this. The root cause of these disparities can be traced back to the historic poverty experienced by rural communities. To address these health disparities, comprehensive solutions are needed to address the fundamental causes of child health disparities amidst pervasive poverty.
Key points
- •
There is a historic gap between the health of rural children and their urban counterparts that remains today.
- •
This gap is highlighted and exacerbated by the increased rates of poverty in rural children.
- •
Rural children experience higher rates of a multitude of health conditions, including obesity, behavioral disorders, overall disability, and alcohol/drug abuse.
- •
Rural children are less likely to receive recommended preventative medical and dental care and have lower immunization rates than urban children.
- •
Geographic, cultural, and economic factors play a significant role in the persistence of health disparities experienced by rural children and adolescents.
Introduction
Rural children experience worse health outcomes than urban children. This disparity is further widened when controlling for the poverty rate. Rural residents recorded smaller gains in life expectancy from 1990 to 2014 than their urban counterparts, resulting in an increased rural-urban disparity in life expectancy. Economic factors, geographic isolation, and inadequate health care infrastructure contribute to widening the gap between rural and urban children. Despite efforts to address these challenges, rural communities continue to struggle with higher rates of persistent poverty and limited access to available health services.
History
After the turn of the twentieth century, great strides were made in public health; through efforts such as modern sanitation, water and sewage facilities, and modern public health services, urban health improved by leaps and bounds throughout the early twentieth century. By the 1920s, a stark contrast regarding health between urban and rural populations began to develop. People living in rural areas saw a greater frequency of infectious and preventable diseases, including dysentery, typhoid, hookworm, and malaria. Rural children also shared a disproportionate burden of congenital disabilities, with many sources placing the rate as 5% to 20% higher among rural youth. Rural child mortality was far higher than that among urban populations of the time. Geographic conditions, including distance from medical care, significantly contributed to this disparity. Still, general poverty, inadequate public health programs, and lagging sanitation programs were the most significant contributors to childhood morbidity and mortality in rural areas of the United States during the early 20th century.
Through the mid-1900s, there were fantastic gains in public health, with a sharp decrease in rates of malaria through the use of insecticides and improvement of malarial land (swamp drainage), decreasing rates of hookworm infestation through widespread adoption of indoor bathrooms and running water, and a sharp decrease in rates of pellagra with the introduction of niacin-fortified foods. With improvements in sanitation and public health services, rural health continued to improve throughout the middle to late 1900s. Yet, rural children lagged and continue to lag behind their urban counterparts on many vital measures, including overall morbidity and mortality, access to care, chronic disease burden, mental and behavioral health, and preventative health.
The gap between rural and urban children has decreased and changed over time but persists. This article attempts to delve further into current trends and disparities and help identify some strengths to build upon and challenges for pediatric clinicians and others working with children and adolescents living in rural areas.
Definitions
Rural Defined
Most often, rurality is defined at the county level. The most used dichotomous measure is from the Office of Management and Budget (OMB), which delineates counties as either metropolitan or nonmetropolitan. A metropolitan or urban county is a county that contains a population cluster with more than 50,000 persons, and a county is considered nonmetropolitan or rural if it does not. This county-level delineation undercounts many rural populations, especially in states where counties encompass a large geographic area. The term rural has multiple definitions, typically based on policy or research needs. Throughout this article, the term rural, when used as a designation, will typically be based on county or zip code data (ZCTAs), or it will be clearly defined within context.
Rural Children Defined
Utilizing definitions of rurality provided by the Department of Health and Human Services, the US Food and Drug Administration, the American Academy of Pediatrics, and the US Dept of Agriculture (USDA), approximately 11.8 million children and adolescents lived in rural areas as of 2018. The demographic composition of rural children and adolescents shows a predominance of non-Hispanic white children (71.8%), with Hispanic (11.9%), non-Hispanic Black children (9.4%), Asian/Pacific Islander (0.9%), and other (6.1%) comprising the remainder.
Background
Economic Characteristics of Rural America
The economies of rural counties are more sensitive to economic pressure and trends that affect their largest industries. Although thought of as primarily agrarian communities, according to the USDA most rural counties rely on more than agriculture as a driver of local economies. Twenty percent of rural counties are considered farming-dependent; around 10% depend on mining and gas operations, and a further 20% depend on manufacturing as a source of employment and economic stimuli. The remaining rural counties have greater economic diversity and do not rely on 1 major industry. Rural communities lagged behind their urban counterparts from 2011 to 2018. Of the top 100 counties with the highest childhood poverty rates in 2014, 95 were rural. Manyof these counties also have a large minority population. There is an over-representation of adverse socio-demographic indicators; these include persistent child poverty, high unemployment rates, and low rates of education. Counties where the rates of children living in poverty have exceeded 20% for the past 30 years, known as persistent child poverty counties, are concentrated in specific regions, including the Deep South, the Southwest, the US-Mexican border, central Appalachia, the Central Valley of California, and the American Indian Reservations of the Northern Plains.
Economic Characteristics of Rural Children
Rural children are more likely than their adult counterparts to live in poverty. Twenty-four percent of children in rural areas live in poverty, compared with 17% of adults. The gap between urban and rural children is inversely correlated with age. In 2019, according to the USDA, the most significant difference between rural and urban poverty rates was for children under 5 (24% in rural areas and 17.3% in urban areas). Children between the ages of 5 and 18 still maintained a significant gap (21.1% in rural areas and 16.1% in urban areas), but the gap continues to close among working age (18–64 years of age) and is statistically nonexistent in seniors (over 65 years of age), with 10.3% of senior is rural areas living in poverty and 9.3% of seniors in urban areas living in poverty.
Race is an independent variable regarding poverty in rural areas and is correlated with increased poverty in children and an increase in poverty persistence for multiple generations. As of 2019, for all ages, rural African Americans/Blacks had the highest incidence of poverty at 30.7%. Rural Native Americans/Alaska Natives held the second highest rate at 29.6%. Rural Hispanics had the third highest poverty rate at 21.7%, while rural Caucasians/Whites had a rate of 13.3%; 51.1% of African American children living in rural counties live below the federal poverty level compared with 37.2% of African American children living in urban counties Table 1 .
| Rural c , % | Nonrural, % | |
|---|---|---|
| Overall, n (%) | 15,166,752 (19.5) | 62,721,267 (80.5) |
| Age | ||
| 0–1 y | 9.6 | 9.8 |
| 2–5 y | 20.0 | 20.7 |
| 6–10 y | 26.4 | 26.2 |
| 11–14 y | 21.7 | 21.5 |
| 15–18 y | 22.4 | 21.8 |
| Sex | ||
| Male | 51.4 | 51.1 |
| Female | 48.6 | 48.9 |
| Race/ethnicity | ||
| Non-Hispanic White | 70.4 | 46.0 |
| Non-Hispanic Black | 9.0 | 14.5 |
| Hispanic | 12.8 | 27.9 |
| American Indian or Alaska Native | 2.3 | 0.4 |
| Asian | 1.1 | 5.7 |
| Other | 4.4 | 5.4 |
| Health insurance | ||
| None | 6.1 | 4.9 |
| Private | 55.3 | 61.0 |
| Public | 42.9 | 37.5 |
| Income to federal poverty level | ||
| 0%–50% FPL | 10.6 | 8.4 |
| 51%–100% FPL | 11.8 | 10.0 |
| 101%–150% FPL | 12.8 | 10.9 |
| 151%–200% FPL | 11.8 | 9.8 |
| >200% FPL | 53.0 | 60.8 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
