1. Coke, Lola A. PhD, ACNS-BC, FAHA, FPCNA, FAAN
  2. Hayman, Laura L. PhD, MSN, FAAN, FAHA, FPCNA

Article Content

Rural communities are widespread across the United States. Between 15% and 20% of the population and nearly three quarters of the land are considered rural. The term "rural" typically means the area has a low or geographically diffuse population. Although less dense, rural communities have higher rates of cardiovascular disease and diabetes. According to the US Department of Agriculture Economic Research Service, 19% of the rural population is older than 65 years, compared with 15% in urban areas.1 Rural areas are more racially and ethnically homogeneous than urban areas, with 80% of the population non-Hispanic white compared with 68% of the suburban and 44% of the urban population.2 However, ethnicity does manifest by geographical location, with a high proportion of non-Hispanic blacks in the rural South and Hispanics in the Southwest. American Indian/Alaska Natives, composed of 5.2 million people in the United States, live in rural or reservation locations in Oklahoma, the Great Plains, American Southwest, and Alaska.3 Compared with urban areas, rural communities face higher poverty rates, lower educational attainment, lack of transportation, and lack of access to health services.4 Rural communities have greater rates of morbidity and mortality and greater percentages of excess deaths from cardiovascular disease. There is a 40% higher prevalence of heart disease in rural residents (14.2% vs 9.9%) compared with urban areas and a 30% increased risk for stroke mortality compared with urban residents.5 Lastly, in a report from Morbidity Mortality Weekly Report that examined cardiovascular health by occupation, the category including farmers had the highest prevalence of poor scores for diet (84.3%), 47% had poor scores for physical activity, and 68.7% had poor scores for weight.6


In March, 2020 the American Heart Association (AHA) published a Presidential Advisory Call for Action to improve cardiovascular health in rural communities.5 Just recently, AHA also published a scientific statement on the cardiovascular health in American Indians and Alaska natives. Both of these documents stress the need to reduce disparities and improve cardiovascular health in these populations and increase research initiatives to augment the science base to guide and inform interventions that can effectively close the disparity gap. The Presidential Advisory states, "The AHA is in a unique position to leverage its many assets in science, education, programs and advocacy to bring to bear a comprehensive, systematic, and evidence-based approach to assess the assets and needs of rural populations and reimagine the way health care is delivered to improve the health of rural America."5(p615)


Rural communities have significantly higher rates of cardiovascular risk factors that are not well controlled. Risk factors are prevalent across the lifespan from childhood to old age in individuals residing in rural areas. Table 1 summarizes data on cardiovascular risk factors from the AHA Presidential Advisory.5

Table 1 - Click to enlarge in new windowTABLE 1 Cardiovascular Risk Factor Prevalence

Women who live in rural communities have additional CVD risk factors because they are more likely to be older, poorer, uninsured, less educated, and socially isolated and have higher rates of chronic health conditions and disabilities than those living in urban areas. They also have higher rates of smoking, hypertension, and obesity. Rural women are often isolated, without access to leisure-time physical activity, healthy foods, and primary and specialty healthcare providers.7 A systematic review examined studies conducted in rural communities in women.8 Four studies focused on CVD knowledge, 1 focused on physical activity, 1 focused on diet plus other factors, and 1 each focused on waist circumference, exposure to smoke from wood stoves, and social support. All of the interventions showed promise in improving the outcomes that were measured in each study. The interventions studied included health promotion education, community health advisor intervention, community-based interventions targeted at midlife and older women with obesity, and a walking program. The conclusions were that there continues to be a lack of research conducted in rural women and minimal depth in the body of evidence in this population. There is growing evidence to support community-based initiatives that have shown to improve risk factors, but there are little data on acute care experiences and efficacy of primary care.


In a qualitative study of cardiometabolic risk in rural men, Morgan and colleagues (2016)9 conducted focus groups to determine the level of knowledge that rural men had about modifiable cardiometabolic risk factors and their motivation to reduce risk. They also sought to explore individual, social, and community-level influences on heart-healthy behaviors specifically directed on diet, physical activity, and tobacco use. Study results showed that the rural men were somewhat knowledgeable about risk factors and despite being smokers and overweight/obese, felt they were in "fantastic" health. They felt they were physically active as long as they "got their heart rate up." For diet, they consumed a variety of fruits and vegetables and a significant amount of red meat, all of which they felt were healthy foods. Use of tobacco was common and associated with their role as a rancher. Overall, study results showed that the men were fatalistic regarding risk of myocardial infarction or stroke because they had a family history or based on their luck. They verbalized motivation to change only if they or a family member had a serious medical event. Seeking help was perceived as being weak. Participants were opposed to being told what to do and would resist restrictions unless they were on their own terms.


In children, the prevalence of selected cardiovascular disease risk factors in more rural geographic areas of the United States exceeds the prevalence of their urban and/or suburban counterparts. Rural children, compared with urban children, are 26% more likely to be obese.10 There has been little research conducted on rural children and cardiovascular health. One study that examined cardiovascular risk factors and rurality in Appalachian children and adolescents actually found that children living in mid-sized metro areas presented with more adverse CVD risk factor profiles than did children residing in more rural areas.


Access to quality healthcare is an important issue that impacts cardiovascular health in rural communities. Rural hospitals have fewer numbers of beds and fewer specialty services and are geographically more distant from specialty referral services like cardiology or endocrinology services. On average, rural residents live 10.5 miles from a hospital, compared with 4.4 miles for urban residents. Approximately 20% of the US population does not have access to a cardiac catheterization laboratory because they live in a rural area.11 In 2016, 77% of rural counties were in Primary Care Health Professional Shortage Areas. Federally Qualified Health Clinics and Rural Health Clinics play an important role in the provision of primary care, dental, and mental health services, but they struggle to recruit and retain providers. Nurse practitioners (NPs) and physician assistants are more likely to practice in rural areas, with 25.2% of providers in rural practices being NPs.5 Scope of practice laws need to ensure that these providers can practice to the full extent of their education and training so they can provide safe, competent care.


A public health infrastructure is vitally important for health surveillance and provision of healthcare education and services. Sixty-two percent of local health departments in the United States are classified as rural and small, serving fewer than 50 000 people and 17% serve fewer than 10 000 people. Because of their size, they have few staff, are often ill-equipped and without the skill sets needed for comprehensive surveillance, education, and monitoring of cardiovascular and other health issues. Of the population-based primary prevention service offered by local health departments, 72% have programs focused on tobacco, 70% on nutrition, 55% on physical activity, and 50% on chronic disease. However, only 29% have implemented school or childcare policies that promote physical activity and only 35% have implemented in policies related to access to healthy food resources.12


Community health workers are central to the delivery of care in rural areas. They are a "frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served."13 Including this role as part of healthcare teams can increase health literacy within communities, and studies have shown that the inclusion of community health workers in health education and outreach to increase physical activity, healthy eating, and smoking cessation has been successful and is cost effective.13


Improving rural community health can be accomplished by collaborative multidisciplinary team efforts and new approaches to delivering healthcare and education and working on advocacy and policy reform efforts. Based on the literature and the AHA Call to Action,5 the following are strategies that have promise and potential for improving the cardiovascular health of individuals residing in rural areas. All healthcare providers have a role in improving the health of our rural Americans.




1. Rural communities do not have access to the same level of information about cardiovascular risk factors, or strategies to improve them.


a. Provide CVD risk education and risk reduction strategies applicable across the lifespan.7


b. Implement telehealth approaches that have been shown to be an effective delivery mechanism for education and health assessment.14


2. Modifications in dietary and physical activity habits should be based on social determinants of health and around the food and exercise norms for the community based on rural conditions, that is, exercises while hunting or fishing.9


3. Seasonal implications impact physical activity, that is, winter months, when less physical work is being completed. Strategies for activities indoors or outdoors in the snow should be developed with emphasis on staying in shape for farm work in other months.9


4. Partnerships with healthcare systems, LHDs, school districts, local employers, and other community organizations are critical to plan programs that encourage healthy rural environments.


5. Expansion of the healthcare workforce is essential. The number of all healthcare professionals (physicians, NPs, physician assistants, nurses, medical assistants, and other allied healthcare professionals) must be increased.


a. Training and degree opportunities need to be provided digitally, virtually, or community based to improve access.


b. Development and incorporation of content and models of care that focus on team-based rural healthcare and culturally specific norms especially for American Indian/Alaska natives need to be included in education across the lifespan.


6. Use of telehealth and digitally enabled healthcare to connect providers with rural communities will improve access to services. The hub-and-spoke model that connects large urban centers to small rural settings should be expanded.


7. Expand home-based services including cardiac rehabilitation to improve access to care.


8. Expand place-based care in pharmacies and clinics in retail areas to deal with common risk factors, medication adherence, and behavioral issues.


9. Expand school-based health centers and health ministries in faith-based organizations to support common aspects of health and delivery of social services.


10. Expand Medicaid in rural areas to improve preventive care and cardiovascular risk factor prevention and improve mental health.


11. Extend the reach of educational initiatives like Go Red for Women and Healthy for Good into rural areas through media channels to increase education.




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8. Alreshidi BG, Kalman M, Wells M, Stewart Fahs P. Cardiovascular risk reduction in rural women: a literature synthesis. J Cardiovasc Nurs. 2020;35(2):199-209. [Context Link]


9. Morgan EH, Graham ML, Folta SC, Seguin RA. A qualitative study of factors related to cardiometabolic risk in rural men. BMC Public Health. 2016;16:305. doi:. [Context Link]


10. Johnson JA, Johnson AM. Urban-rural differences in childhood and adolescent obesity in the United States: a systematic review and meta-analysis. Child Obes. 2015;11(3):233-241. [Context Link]


11. Lam O, Broderick B, Toor S. How far Americans live from the closest hospital differs by community type. 2018. Accessed May 22, 2020. [Context Link]


12. 2016 National Profile of Local Health Departments. Washington, DC: National Association of County and City Health Officials; 2016. [Context Link]


13. American Public Health Association. Community health workers. 2019. Accessed May 25, 2020. [Context Link]


14. Schweickert PA, Rutledge CM, Cattell-Gordon DC, et al. Telehealth stroke education for rural elderly Virginians. Telemed J E Health. 2011;17(10):784-788. [Context Link]