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msJAMA
January 2, 2002

The Effects of Socioeconomic Status on Health in Rural and Urban America

Author Affiliations
 

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JAMA. 2002;287(1):109. doi:10.1001/jama.287.1.109-JMS0102-3-1

Several factors contribute to the health of people and communities including economic resources, level of income and education, access to health care, and environmental quality.1 In 1999, approximately 80.2% of Americans lived in urban areas as compared to 19.8% in rural communities.2 While rural and urban America have unique geographic and quality-of-life characteristics, a recent report found that people who live in the most rural (areas with fewer than 10 000 people) and inner-city areas have several things in common: they are more likely to live in poverty, experience higher mortality rates, and have poorer health status than suburban residents.1

Poverty, a major risk factor for poor health outcomes, is more prevalent in inner-city and rural areas than suburban areas. In 1999, 14.3% of rural Americans lived in poverty compared to 11.2% of urban Americans.3 Irrespective of where they live, persons with lower incomes and less education are more likely to report unmet health needs, less likely to have health insurance coverage, and less likely to receive preventive health care. When combined, these variables raise the risk of death across all demographic populations.4 Many of the ills associated with poverty, including lower total household income and a higher number of uninsured residents, are magnified in rural areas.1 In addition, rural communities have fewer hospital beds, physicians, nurses, and specialists per capita as compared to urban residents, as well as increased transportation barriers to access health care.1 The highest death rates for children and young adults are found in the most rural counties, and rural residents see physicians less often and usually later in the course of an illness.1 People in rural America experience higher rates of chronic disease and the health-damaging behaviors associated with them; they are more likely to smoke, to lose teeth, and to experience limitations from chronic health conditions.1 While death rates from homicide are greater in urban areas, mortality rates from unintentional injuries and motor vehicle crashes are disproportionately more common in rural America.1

Health concerns such as violence, mental illness, substance abuse, and environmental issues affect both urban and rural communities, as do serious racial/ethnic health disparities including shorter life expectancy for some population groups. Poor inner-city urban residents often live in overcrowded and inadequate housing, resulting in decreased quality of life and higher rates of respiratory disease, substance abuse, stress, violence, and death from heart disease and cancer.5 While cities have some of the best health care facilities and attract high concentrations of medical professionals, these services are not equally distributed to inner-city areas and many poor urban residents lack access to them. This is due, in part, to a shortage of primary care physicians and cultural barriers in inner cities, as well as lack of insurance and awareness of available health care services by residents in these areas.

A top priority for the US Department of Health and Human Services (DHHS) is to eliminate health disparities across racial/ethnic groups, sex, age, and geographic location. To achieve this goal, the public health infrastructure must be strengthened. Collaboration between government and private sector agencies is essential to address issues related to health, education, employment, housing, and transportation. Many health programs and initiatives are under way including the establishment of a DHHS Rural Task Force to strengthen existing department programs, enhance state health service delivery systems, and foster telemedicine. The National Health Service Corps increases access to primary care services for people in rural and inner-city communities through the recruitment and retention of community-responsive, culturally competent primary care clinicians. The National Institutes of Health supports research on a broad spectrum of rural and urban health concerns. The US Centers for Disease Control and Prevention recently published an epidemiologic report of urban and rural health statistics providing a framework for building future interventions and policies.1

The relative scarcity of health resources in rural areas and limited access to them in the poorest parts of large cities is a problem that continues to affect the health of these communities. Efforts to increase access to health care, enhance educational, economic and occupational opportunities, improve housing and transportation, emphasize disease prevention at the individual and community levels, and strengthen social supports should improve health for all Americans in the 21st century irrespective of where they may live.

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Article Information
Acknowledgment: The authors thank Mark Lassoff, MBA, MPH, Molly Moore, and Rinat Peretz for their help in the preparation of this article.
References
1.
Eberhardt  MSIngram  DDMakuc  DM  et al. Urban and Rural Health Chartbook. Hyattsville, Md National Center for Health Statistics2001;
2.
Not Available, Population Estimates Program, Population Division, US Census Bureau, Washington, DC. Available at http://www.census.gov/population/estimates/metro-city/ma99-06.txt. Accessed December 3, 2001.
3.
Not Available, Rural Health Statistics.  Rural Information Center Health Service, National Agricultural Library, US Dept of AgricultureAvailable at http://www.nal.usda.gov/ric/richs/stats.htm. Accessed December 3, 2001.
4.
Pamuk  EMakuc  DHeck  KReuben  CLochner  K Socioeconomic Status and Health Chartbook.  Hyattsville, Md National Center for Health Statistics1998;
5.
American College of Physicians [Prewit E, writer], Inner-city health care [position paper, ACP-ASIM]. Ann Intern Med. 1997;126485- 490Article
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