red barn on a hillside, next to a field of grass. It's an analogy for rural health or the rural-urban divide.
Photo credit: Donald Lee Pardue/ Flickr Creative Commons

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By Taylor Knopf

For years, studies have pointed out the gaps between rural and urban communities when it comes to health outcomes. But there are also significant health divides between ethnicities within rural America, according to a recent Centers for Disease Control and Prevention report.

Though urban areas still have more diverse populations, the study authors found that in recent years, rural communities have displayed increasing racial diversity. They also found that different health issues were more prevalent among certain racial ethnicities.

The authors, who work mostly out of the CDC’s Office of Minority Health & Health Equity, found that rural white populations have better access to health providers than minorities. They also found that members of minority populations living in rural areas tended to be younger than the white residents, with lower incomes and less education.

Kim Schwartz, CEO of the Ahoskie-based Roanoke Chowan Community Health Center, said the area she serves in eastern North Carolina is particularly diverse, about 65 percent of her center’s patients are African American. She suspects this is common in many parts of the rural south.

Schwartz said her organization has an internal “health equity” team that works on identifying and addressing her organization’s own lingering racism that could affect patients’ care experience.

Poor, fair or good

There have been many studies examining disparities between rural and urban populations, but not much about the differences within rural communities themselves, the CDC study authors explain.

The goal of their study was to understand different health behaviors among rural residents. The authors used the National Center for Health Statistics’ 2013 Urban-Rural Classification Scheme for Counties to determine which areas qualified as rural and used self-reported data collected between 2012–2015 from rural residents in all 50 states.

They found that rural, non-white populations were more likely to report “fair” or “poor” health (as opposed to “good” health) and obesity. They were also less likely to see a doctor during the past year because of cost and were less likely than white folks to report have a regular doctor.

Meanwhile, whites were more likely to report binge drinking in the past month and more whites were current smokers.

The study is based on 263,054 rural residents:

231,221 white (87 percent)
12,751 black (4.9 percent)
10,947 American Indian/ Alaskan native (4 percent),
7,223 Hispanic (2.8 percent)
912 Asian (0.35 percent)

“Notice, for example, that rural black respondents are less likely than rural white adults to report binge drinking,” explained Janice Probst, who heads the South Carolina Rural Health Research Center and is a professor at the Department of Health Services Policy and Management at the University of South Carolina. “This stems from greater black membership in religious denominations that frown on alcohol. Similarly, black respondents are less likely ever to have smoked.”

Other research has shown that people tend to engage in health behaviors, such as smoking or quitting smoking, based on the behavior of their social networks.

“Folks tend to hang with folks like themselves,” Probst said.

Different struggles

The CDC study found that each rural ethnic population struggled with different health issues. For example, heart disease and stroke were higher among African Americans. Tuberculosis was more prevalent among Asians.

American Indians and Alaskans have higher rates of suicide compared to other rural populations. They also reported the highest rates of depression. And Hispanics struggled more than others with finding a regular source of health care.

The study pointed out that health outcomes have generally improved for all populations over time, but racial disparities still exist within rural populations.

“What we are seeing relates to generational poverty issues surrounding the social determinants of health and racial inequities,” Schwartz said.

“The challenges our populations face in order to try and implement any kind of healthy lifestyle are overwhelming: transportation across a wide rural area with no public options, food deserts, economic and educational barriers and cultural mistrust in a system that will take a few more generations to repair,” she added.

The study authors noted the importance of breaking down rural health data by race.

“Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data,” they wrote.

The study authors recommended that in the future the CDC should break down rural health data by different demographics to best understand any disparities and the unique needs of each community.

“Despite a few quibbles, those of us who do rural minority health are very excited about this report,” Probst said. “It puts the full weight of the major U.S. public health agency on the question of rural disparities, which has largely been ignored in the past.”

Small numbers, big differences

Probst noted there are several explanations behind the increasing diversity in rural areas. For example, if one person from an ethnic group moves into an area where there were few others from the same group, that could result in a large increase, percentage-wise.

“Because [Asians and Non-Hispanic Other Pacific Islanders] have generally been relatively small and concentrated in places like Hawaii and the West Coast, any influx seems large,” Probst said.

Additionally, Probst said there have been increases in rural Hispanic populations in certain rural states, such as Nebraska and North Carolina, because of new work opportunities.

During the early 2000s, North Carolina had the fastest growing Latino population in the country. In 1990, only 1.04 percent of the state was Latino, by 2016 that number had grown to 9.2 percent, according to the U.S. Census.

“Much of this is related to industries (e.g., chicken processing) that are relatively new to the areas and for which local residents cannot be found,” Probst said.

Taylor Knopf

Taylor Knopf covers rural and mental health news. She previously wrote for The News & Observer as a politics and general assignment reporter. Before that, she worked at a small daily newspaper in southern...