Living with Heart Failure in a Rural Community

Joan Grant Keltner, PhD, RN

Urban/rural differences have continued across America for the last four decades, with rural residents more likely to die from major diseases such as heart failure (Abrams et al., 2021; Faridi et al., 2025). These individuals also experience higher rates of smoking, diabetes, and hypertension associated with their heart failure (Pierce et al., 2025). Lower finances, limited access to and variability in their medical treatment, and lower distances to travel are just a few issues. These patients also experience difficulties in managing signs and symptoms, completing daily activities, taking multiple medications and daily weights, and adhering to dietary regimens. Inadequate community support adds to the complexity of this chronic disease, for both patients and their care partners. Inadequate socializations, depression, and anxiety are other outcomes (Celano et al., 2018).

Despite these barriers, rural nurses can explore innovative solutions for addressing heart failure in rural communities. These include:

• Providing incentives (e.g., loan forgiveness, professional development) to attract primary care medical professionals and cardiology experts;
• Build partnerships between rural healthcare providers and academic medical centers;
• Establish more outreach clinics in underserved or poorly resourced rural communities;
• Partner with academic medical centers in developing rural provider training programs;
• Expand and improve telemedicine offerings, developing community wide cardiovascular disease prevention programs;
• Offer virtual consultations for primary care, mental health, and specialist’s services;
• Merge funding with efforts to measure tangible health outcomes from mobile health clinics with diagnostic tools and preventive and focused services;
• Offer remote monitor of common chronic diseases, such as hypertension and diabetes mellitus;
• Provide training of rural individuals to be community health workers and increase heath literacy efforts;
• Offer transportation financial assistance;
• Expand health insurance coverage in rural areas, with continued government support of rural hospitals; and
• Offer state-of-the-art strategies to address rural factors such as poverty, food insecurity, unemployment, housing instability, and limited access to education (Javed, 2025; Pierce et al., 2025)

References

Abrams, L. R., Myrskylä, M., & Mehta, N. K. (2021). The growing rural−urban divide in US life expectancy: Contribution of cardiovascular disease and other major causes of death. International Journal of Epidemiology, 50(6), 1970–1978. https://doi.org/10.1093/ije/dyab158

Celano, C. M., Villegas, A. C., Albanese, A. M., Gaggin, H. K., & Huffman, J. C. (2018). Depression and anxiety in heart failure: A review. Harvard Review of Psychiatry, 26(4), 175-184. https://doi.org/10.1097/HRP.0000000000000162

Faridi, B., Davies, S., Narendrula, R., Middleton, A., Atoui, R., McIsaac, S., Alnasser, S., Lopes, R. D., Henderson, M., Healey, J. S., Ko, D. T., & Shurrab, M. (2025). Rural–urban disparities in mortality of patients with acute myocardial infarction and heart failure: a systematic review and meta-analysis. European Journal of Preventive Cardiology, 32(4), 327–335. https://doi.org/10.1093/eurjpc/zwae351

Javed, A. (2025). Bridging the health care gap in rural populations: Challenges, innovations, and solutions. The American Journal of Medicine, 138(5), 761 – 762. https://doi.org/10.1016/j.amjmed.2025.01.008

Pierce, J. B., Ng, S. M., Stouffer, J. A., Williamson, C. A., & Stouffer, G. A. (2025). Rural/urban disparities in cardiovascular disease in the US—What can be done to improve outcomes for rural Americans? The American Journal of Cardiology, 248, 10–15. https://doi.org/10.1016/j.amjcard.2025.03.033

Challenges in Home Healthcare in Rural Areas
Joan Grant Keltner, PhD, RN

Home health care nursing faces many challenges in rural areas, including a rise in older populations who require complex care, with inadequate general and specialized healthcare providers, long travel distances to appointments, and social determinants of health that impact the availability and acceptability of home healthcare interventions. Not only has there been an increase in our older population (i.e., increased from 7.4 million to 9.7 million in rural areas), there are fewer individuals working in these areas, creating a significantly higher demand for individuals who provide care for both younger and older individuals. While home healthcareproviders have grown in some areas of the U.S., other areas have seen a significant decline. These rural areas also are more likely to have fewer healthcare facilities because of closures and insufficient healthcare providers (Farrigan et al., 2024; Urgent Supply, 2025).

Rural areas also have a greater prevalence of chronic illnesses and lower health literacy rates, limited resources, and technological barriers. In comparing urban and rural populations, those in rural areas had lower usage and quality of home health care services, including both physical therapy and rehabilitation. They also experienced a greater prevalence of emergency department visits and hospitalizations (Quigley et al., 2022).

Despite these barriers, home health nurses can explore innovative solutions in providing important services to the rural community. These include:

 developing partnerships with local organizations such as community health programs, faith-based groups, and civic leaders to mobilize policy changes and offer innovative programs and services for health insurance, financial support; health literacy, and transportation);

• developing programs that offer financial incentives, loan forgiveness, and professional development for health providers who work in rural areas;
• training residents in basic health care practices through rural newsletters/newspapers, churches, community meetings, and networks;
• providing training and education for health providers regarding how to implement these innovative care solutions successfully into home healthcare services;
• improving health literacy through education and outreach campaigns;
• using telehealth platforms to assess chronic illnesses, provide education and support, and deliver services and care;
• utilizing mobile health clinics to deliver healthcare services, offering diagnostic tools, delivering screenings and preventive care, and providing specialized treatment for chronic illnesses (Javed, 2025);
• offering community health worker programs that provide information, education, support, and care coordination services to patients receiving home health services (Urgent Supply, 2025); and
• mentoring new health providers in understanding the critical role of societal and cultural dynamics for rural individuals to accept appropriate care and treatment (Nursing Education Staff, 2024).

References

Farrigan, T., Genetin, B., Sanders, A., Pender, J., Thomas, K. L., Winkler, R., Cromartie, J. (2024). Rural America at a glance (Report No. EIB-282). U.S. Department of Agriculture, Economic Research Service. https://doi.org/10.32747/2024.8722498.ers

Javed, A. (2025). Bridging the health care gap in rural populations: Challenges, innovations, and solutions. The American Journal of Medicine, 138(5), 761 – 762. https://doi.org/10.1016/j.amjmed.2025.01.008

Nursing Education Staff (2024, January 18). Nurse insights: What are the challenges of rural nursing? https://nursingeducation.org/insights/rural-nursing/

Quigley, D. D., Chastain, A. M., Kang, J. A., Bronstein, D., Dick, A. W., Stone, P. W., & Shang, J. (2022). Systematic review of rural and urban differences in care provided by home health agencies in the United States. Journal of the American Medical Directors Association, 23(10), 1653.e1-1653.e13. https://doi.org/10.1016/j.jamda.2022.08.011

Urgent Supply. (2025, June 6). Challenges and innovations in home health services for rural communities in the United States. https://www.urgent.supply/resources-7/Challenges-and-Innovations-in-Home-Health-Services-for-Rural-Communities-in-the-United-States

Creative Mental Health Care in Rural Communities: Bringing Innovation to Patients and Their Families

Nanci S. Claus, DNP, RN, CRNP; Shawona C. Daniel, PhD, RN, CRNP; Laura A. Steadman, EdD, RN, CRNP

Rural families face significant mental health challenges due to factors such as geographic isolation, stigma, and shortages in the healthcare workforce (Mack et aal., 2022). Similar to urban areas, approximately one in five adults living in rural areas experience some form of mental illness (NAMI, 2022). However, rural residents encounter barriers to care. According to the National Rural Health Association, these barriers are summarized by the "4 A’s": accessibility, availability, affordability, and acceptability (University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis, 2024). Rural communities are often designated as Health Professional Shortage Areas, with limited access to primary care and mental health professionals, including psychiatrists, psychologists, and psychiatric nurse practitioners (NAMI, 2022).

Additionally, many rural residents lack insurance coverage for mental health services. Stigma plays a significant role as well—individuals may fear being judged or perceived as weak for seeking help. Concerns about confidentiality, particularly in small communities where providers may be well-known, further discourage people from accessing care. Despite these challenges, innovative solutions are emerging that enable healthcare providers to deliver effective, compassionate mental health care directly to patients and their families.

Improving Access to Rural Mental Health Care

Telebehavioral health has greatly expanded access by allowing patients, especially older adults and those without reliable transportation or broadband—to connect with providers via video or phone. Virtual visits ensure privacy, reduce travel burdens, and help reduce stigma in tight-knit communities. To support patients lacking internet access, connectivity can be offered in schools, libraries, senior centers, and other community spaces (NORC Walsh Center for Rural Health Analysis, 2023).

• The Primary Care Behavioral Health Integration Model brings medical and mental health services together in a single setting—such as clinics, hospitals, or mobile units—offering a comprehensive approach to care (University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis, 2024). This model enables providers to assess both physical and mental health concerns and create personalized treatment plans for rural patients.

• SBIRT (Screening, Brief Intervention, and Referral to Treatment) is an evidence-based model that integrates mental health screening into routine medical care. Administered by nurses or medical assistants using tools that are specific to mental health, SBIRT helps normalize mental health care and reduces stigma by embedding services within general medical visits. Virtual consultations with mental health professionals are available when needed.

• Mobile Health Units deliver mental health services directly to rural communities, eliminating transportation barriers. Staffed with trained personnel, these units provide crisis care, counseling, case management, medication support, and education.

• School-Based Health Centers (SBHCs) address mental health needs of children by placing interdisciplinary teams—primary care providers, mental health professionals, and social workers—on school campuses. These teams screen for behavioral and developmental issues, create individualized treatment plans, monitor medications, and support educators in developing IEPs.

Nurses can provide valuable resources to their patients and families. By combining telehealth, integrated care, mobile services, and school-based support, rural communities gain access to high-quality, stigma-free, and culturally sensitive mental health care—bringing services closer to home and ensuring no one is left behind.

References

Mack, B., Whetsell, H., & Graves, J. M. (2022, February). Mental health in rural areas. National Rural Health Association Policy Brief. https://www.ruralhealth.us/getmedia/cf3c3922-25cb-49a0-bb04-0bad81d634f9/NRHA-Mental-health-in-rural-areas-policy-brief-2022.pdf

National Alliance on Mental Illness (NAMI). (2022, November 17). Confronting mental health challenges in rural America. https://www.nami.org/advocate/confronting-mental-health-challenges-in-rural-america/

NORC Walsh Center for Rural Health Analysis, 2023. Rural Telehealth Toolkit [online]. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/telehealth 

University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis. (2024). Mental Health in Rural Communities Toolkit [online]. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/mental-health

Supporting the Stroke Caregiver in Rural Communities

Stroke recovery in rural communities presents unique challenges for both survivors andtheir caregivers. Rural areas often face higher stroke prevalence and limited access to specialized services, though the stroke rate can be up to 1.5 times higher than in urban areas (Christensen, Golden, & Gessell, 2019). Caregivers in these settings frequently step into demanding roles without adequate preparation, and ensuring a smooth transition from rehabilitation back to home is crucial. The needs of caregivers and stroke survivors are complex, and rural nurses and community health workers are uniquely positioned to assess and implement validated tools and programs to improve outcomes in stroke survivors and their caregivers.

Entering the caregiving role after a stroke is overwhelming. Nearly all caregivers report a high need for information about stroke, its complications, and how to provide care at home. There is evidence to suggest caregivers are infrequently taught how to bathe loved ones, give medications, perform rehabilitation exercises, or handle falls (Kitzman et al, 2017). Rates of caregiver clinical depression, anxiety, and burnout are as high as 30 – 50%, and are often higher than psychological distress reported by stroke survivors (Hu et al, 2018).

In rural settings, caregivers may be especially isolated due to distance and scarce support services. Without these outlets or interventions to address their emotional struggles, the psychological toll can be devastating. While this is an often noted and well documented phenomenon in stroke caregiving, practical advice on handling and addressing the emotional impact of stroke is rarely offered, leaving this a crucial unmet need during care transitions (Kitzman, 2017).

Early Supported Discharge (ESD) is a care model that may help and bridge the gap of unmet needs of caregivers of stroke survivors. This model utilizes a mobile interdisciplinary rehabilitation team that provides intensive rehabilitation in the patient’s home for the first few weeks after discharge. Studies have found that ESD services, which range from a full mobile rehabilitation team to counseling, can shorten hospital stays, reduce long-term disability, and lover healthcare costs for eligible patients (Markle-Reid et al, 2023). Essentially, ESD shifts some of the rehabilitation that would normally happen in a facility to a patient’s home environment, without sacrificing intensity or quality of training. This is essential for those in rural areas where inpatient rehabilitation beds are far away or limited.

Unfortunately, barriers to care that ESD attempts to address become barriers to implementation of the model. These include geographic barriers, workforce shortages, and infrastructure limitations. And, though there is evidence to support the implementation of ESD (Carney et al, 2023), other evidence failed to strongly recommend its use, reporting inadequate information about specific components/protocols of interventions and methodological weaknesses in study designs (Jee et al, 2022).

Despite the mixed evidence base and implementation challenges, Early Supported Discharge remains a promising model for this in rural areas where traditional post-stroke care is often fragmented or inaccessible. To advance stroke recovery and reduce caregiver burden, rural nurses and organizations should advocate for and lead the adaptation of ESD principles within their local context. This does not require a fully resourced team. Instead, rural nurses can start by identifying high-risk caregivers, conducting needs assessments, coordinating telehealth-based follow-ups, and facilitating interdisciplinary communication across discharge. Nurses can also partner with community health workers and local organizations to deliver targeted education, emotional support, and resource navigation to caregivers in their communities. While full-scale ESD may not yet be feasible in all areas, rural nurses can operationalize its core values of early intervention, coordinated care, and home-based support, to ensure stroke survivors and caregivers are not left behind after discharge. Investing in nurse-led, community-integrated solutions that reflect the ESD model is a practical and scalable step toward more equitable stroke care in rural America.

References

Carney, M., O'Connor, S., O'Reilly, J., Shaw, D. N., Hanley, J., & Hickey, P. (2023). 31 Stroke early supported discharge: continuing to improve patient and organisational outcomes. Age and Ageing, 52(Supplement_3), afad156-063.https://doi.org/10.1093/ageing/afad156.063

Christensen, E. R., Golden, S. L., & Gesell, S. B. (2019). Perceived benefits of peer support groups for stroke survivors and caregivers in rural North Carolina. North Carolina Medical Journal, 80(3), 143. https://doi.org/10.18043/ncm.80.3.143

Hu, P., Yang, Q., Kong, L., Hu, L., & Zeng, L. (2018). Relationship between the anxiety/depression and care burden of the major caregiver of stroke patients. Medicine, 97(40), e12638. https://doi.org/10.1097/MD.0000000000012638

Jee, S., Jeong, M., Paik, N. J., Kim, W. S., Shin, Y. I., Ko, S. H., ... & Sohn, M. K. (2022). Early supported discharge and transitional care management after stroke: A systematic review and meta-analysis. Frontiers in Neurology, 13, 755316. https://doi.org/10.3389/fneur.2022.755316

Kitzman, P., Hudson, K., Sylvia, V., Feltner, F., & Lovins, J. (2017). Care coordination for community transitions for individuals post-stroke returning to low-resource rural communities. Journal of Community Health, 42, 565-572. https://doi.org/10.1007/s10900-016-0289-0

Markle-Reid, M., Fisher, K., Walker, K. M., Beauchamp, M., Cameron, J. I., Dayler, D., ... & Whitmore, C. (2023). The stroke transitional care intervention for older adults with stroke and multimorbidity: A multisite pragmatic randomized controlled trial. BMC Geriatrics,23(1), 687. https://doi.org/10.1186/s12877-023-04403-1

Addressing Chronic Obstructive Pulmonary Disease (COPD) in Rural Communities: Challenges and Innovative Solutions

Laura Steadman, Nanci Claus, Shawona Daniel

Chronic Obstructive Pulmonary Disease (COPD) is a significant public health concern in many rural areas, where smoking prevalence, occupational exposures, and limited healthcare access contribute to higher morbidity and mortality rates. Notably, rural residents experience a 12% higher prevalence of COPD compared to urban populations from risks and delayed medical interventions (American Lung Association, 2022). COPD management is hindered by inadequate healthcare infrastructures, pulmonologists’ shortages, and limited access to pulmonary rehabilitation programs. Addressing COPD requires an innovative, multi-faceted approach, including access to telemedicine, community-based interventions, and policy initiatives.

Telehealth is a vital tool in disease management in rural areas. Telehealth facilitates remote consultations, spirometry monitoring, and virtual pulmonary rehabilitation, improving disease management and reducing hospitalizations (Bhatt et al., 2020). Integrating home-based oxygen therapy programs and digital platforms for symptom tracking empowers patients to manage their condition more effectively. Community involvement and access to healthcare settings aids in closing the care gap for individuals with COPD. Training community health workers (CHWs) to provide smoking cessation, inhaler techniques, and symptom management enhances self-care and reduces exacerbations (Parekh, et al., 2019). Mobile health clinics equipped with diagnostic tools facilitate COPD screenings and follow-up care to underserved areas, while addressing transportation and healthcare access barriers.

While innovative technologies improve access to COPD care, policy efforts focused on expanding insurance coverage for pulmonary rehabilitation and increasing funding for rural healthcare initiatives to improve long-term outcomes are imperative. These efforts improve COPD management in rural areas and reduce existing healthcare disparities.

References:

American Lung Association. (2022). National indicator report: Chronic obstructive pulmonary disease (COPD). https://www.lung.org/getmedia/0557b57b-9863-4737-a400-3247a3446eb1/National-Indicator-Report-COPD.pdf

Bhatt, S. P., Patel, S. B., Anderson, E. M., Baugh, D., Givens, T., Schumann, C., & Judd, S. E.(2019). Video telehealth pulmonary rehabilitation intervention in chronic obstructive pulmonary disease reduces 30-day readmissions. American Journal of Respiratory and Critical Care Medicine, 200(4), 511–513. https://doi.org/10.1164/rccm.201902-0314LE

Parekh, T. M., Copeland, C. R., Dransfield, M. T., & Cherrington, A. (2019). Application of the community health worker model in adult asthma and COPD in the U.S.: A systematic review. BMC Pulmonary Medicine, 19(1), 116. https://doi.org/10.1186/s12890-019-0878-7

Hemodialysis Nurse Practitioner Challenges in Rural Areas 

Shawona Daniel, RN, PhD, CRNP, ANP-BC & Laura Steadman, Ed.D., CRNP, MSN, RN

Nurse practitioners (NPs) play a crucial role in delivering specialized care to rural patients with chronic kidney disease (CKD), where nephrologist availability is limited (Schreiber, 2020). While NPs have the expertise to fill this gap through patient assessments, complication monitoring, and dialysis prescriptions (Kaiser et al., 2019), hemodialysis NPs in rural areas face several challenges that potentially impacts the quality of care provided to these patients. One of the most significant challenges is scarcity of healthcare resources, such as primary care providers, specialized providers such as nephrologists, and other vital medical resources (Jones & Smith, 2020). Additionally, many patients living in rural areas must travel long distances to reach dialysis centers, resulting in missed or delayed treatments and increasing complications’ risks (Anderson & Roberts, 2021). Lack of public transportation options and financial constraints compound this issue. Insufficient resources and adequate support further hinder the NP’s ability to manage complex cases, making it difficult to provide the highest level of care.

Despite these challenges, hemodialysis NPs in rural areas are key in improving patient outcomes. For example, NPs reduce the need for patients to travel long distances for care, which is particularly beneficial for individuals with limited mobility or financial resources (Ryan & Stone, 2021). NPs offer education related to treatment adherence, diet modifications, and the importance of regular follow-ups, which also significantly improve patient outcomes. Overall, NPs ensure a holistic approach to CKD treatment and support the broader healthcare infrastructure in rural regions, highlighting their importance in the healthcare system. Addressing CKD care barriers through community stakeholders, policy changes, and community, regional, and national resources also significantly enhance care in underserved rural communities.

References

Anderson, L., & Roberts, L. (2021). Transportation barriers for dialysis patients in rural areas: Implications for care. Journal of Rural Health, 37(2), 201-208. https://doi.org/10.1111/jrh.12456

Jones, T., & Smith, D. (2020). Barriers to nephrology care in rural communities: The role of nurse practitioners. Nephrology Nursing Journal, 47(3), 221-228.

Kaiser, M., Jones, T., & Smith, D. (2019). The role of nurse practitioners in managing chronic kidney disease in underserved areas. Journal of Rural Health, 35(3), 357-365. https://doi.org/10.1111/jrh.12345

Ryan, R., & Stone, M. (2021). Addressing healthcare gaps in rural communities: The role of nurse practitioners in dialysis care. Nephrology Nursing Journal, 48(4), 297-305.

Schreiber, M. (2020). The impact of nurse practitioners on rural healthcare: Enhancing dialysis care in underserved populations. Journal of Nephrology, 40(5), 411-418. https://doi.org/10.1016/j.jn.2020.06.017

Let’s Stop Suicide in our Rural Communities

Joan Grant Keltner

Suicide is among the top 15 leading causes of death, currently ranking as #11 in the United States (CDC Wonder, 2025) and a high priority in rural American. In fact, suicide rates in rural areas have steadily inclined and almost doubled over the last decade, with rates increasing 46% in more rural and less densely populated locations compared to 27.3% in urban areas. American Indians and Alaska Native people in rural areas have the highest rates of suicide (CDC, 2024). For both males and females, firearms, suffocation, and poisoning are the most common forms of reported suicide. Suicide rates for males are significantly higher than females and those who live in rural areas have 1.5 higher rates for emergency department visits for nonfatal self-harm when compared to their urban counterparts (Garnett et al., 2022).

So how can health providers implement strategies to lessen suicide in their communities? The Suicide Prevention Resource for Action offers strategies, methods for advancing these strategies, and the best evidence to lessen suicide in communities and states (CDC, 2022). Select strategies include: 

• Enhancing economic assistance programs (e.g., finances and better housing)

• Promoting safe environments (e.g., lessen access to common methods used for suicide, such as firearms, develop community and organizational policies that enhance and support healthy living, and develop community policies and practices that lessen access to and use of illegal substance use),

• Increasing access to and delivery of suicide prevention programs (e.g., promote health insurance policies to promote coverage of mental health conditions, offer grants and other incentives for health providers, and create emergency help lines and resources),

• Generating healthy connections (e.g., enhance healthy norms by peers, and engage community constituents in shared activities),

• Enhancing coping and problem-solving skill training (e.g., provide social support and resilience programs, offer parenting programs regarding healthy parenting skills and relationships),

• Identifying and assisting suicide-risk individuals (e.g., train gatekeepers such as personnel staffing hotlines in suicide prevention assessment and dialogue, and promptly respond to crises, ensuring safety and follow-up after a suicide), and

• Decreasing potential personal and environmental harms (e.g., intervene after a suicide, using debriefing sessions, counseling, and support groups for surviving friends, family members/significant others; report and message about suicide safely and provide suicide prevention public messaging among community members about warning signs and resources available to help individuals at risk for suicide before a crisis occurs).

We know that to be successful, understanding contributing factors and successful suicide prevention and action efforts must be developed in collaboration with rural community leaders to make them culturally appropriate. Because few treatments ae successful in preventing suicide, programs focused on prevention are key. These programs specifically focus on significant factors in their rural communities that increase the risk of suicide, such as limited financial means and access to firearms. Evidence supports the use of web-based programs that are anonymous and more available in rural areas, with the ability to be expanded (Barnhorst et al., 2021). Together, it takes a community of rural advocates, organizational and policy leaders, and health professionals to address this issue.

References

Barnhorst, A., Gonzales, H., & Asif-Sattar, R. (2021). Suicide prevention efforts in the United States and their effectiveness. Current Opinion in Psychiatry, 34(3), 299–305. https://doi.org/10.1097/YCO.0000000000000682

CDC. (2022). Suicide Prevention Resource for Action: A compilation of the best available evidence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/suicide/pdf/preventionresource.pdf

CDC. (2024, May 16). Suicide in rural America. https://www.cdc.gov/rural-health/php/public-health-strategy/suicide-in-rural-america-prevention-strategies.html

CDC Wonder. (2025). Provisional mortality statistics, 2018 through last week results form: Deaths occurring through February 08, 2025 as of February 16, 2025. https://wonder.cdc.gov/controller/datarequest/D176;jsessionid=9B483D0152104F6CE5EA87902C99

Garnett, M. F., Curtin, S. C., Stone, D.M. (2022). Suicide mortality in the United States, 2000–2020. NCHS Data Brief, no 433. National Center for Health Statistics. 2022. https://dx.doi.org/10.15620/cdc:114217

Rural Illicit Drug Use and Drug Overdose Deaths 

Joan Grant Keltner

While individuals who report illicit drug use is lower in rural areas, deaths from drug overdosages now exceed those in urban areas (CDC, 2024). Even though urban districts have higher rates for cocaine, heroin, and synthetic opioid (e.g., fentanyl, fentanyl analogs, and tramadol) use, deaths from psychostimulants with an abuse potential is about one-third higher in rural counties when compared to urban ones. Death rates from using natural (e.g., opium, morphine, codeine) and semisynthetic (e.g., oxycodone, hydrocodone) opioids also is higher in rural counties when compared to individuals living in urban counties (Spencer et al., 2022). Ongoing contributors to this problem include chronic health problems; limited finances; higher rates of unemployment; greater usage of prescription opioids to increase productivity in manual labor industries, such as mining; and limited health providers and treatment facilities within a reasonable distance to address substance use disorders. Stigma and negative opinions that using these agents is an individual weakness are other factors (NORC Walsh Center for Rural Health Analysis, 2020). 

Rural communities have a variety of barriers including inadequate detoxification and behavioral health services. The need to travel long distances to access these services is another barrier. Prevention programs are too few, spread over large geographic areas in rural communities. Inadequate fiscal and support services for long-term recovery programs and a lack of privacy in some rural communities are other barriers to treatment. Limited health provider training for individuals presenting with a drug overdose is another significant issue (Rural Health Information Hub, 2024). 

Gale and colleagues (2020) offer numerous strategies for rural community leaders to address this problem by assessing, engaging communities, and screening for illicit drug use. These experts also suggest employing strategies for preventing (school-based educational programs, drug take-back programs, and prescribing guidelines), treating (integrated substance use assessment and treatment within primary care, telehealth, and medication-assisted treatment programs), and recovery (use of support groups and self-health, coaching, recovery coaches, and vocational training) in addressing substance use and associated deaths in rural communities. Other strategies also include:

1. Engaging rural communities through community coalitions identifying financial and personal resources to assist rural communities in implementing these broad-based coalitions;

2. Developing models and programs using specific interventions to help individuals with lower incomes who sell their prescription medications to meet their basic needs; 

3. Disseminating programs, providing key information focused on strategies to lessen stigma and physical and psychological harm; 

4. Preventing accidental deaths through programs to enhance safe storage and disposal of these drugs; 

5. Providing technology to enhance implementation of these educational programs; 

6. Engaging key rural community stakeholders and organizations (e.g., RNO, Rural Health Organizations, etc.) in sharing educational materials and implementing these programs and supportive funding to support these efforts;

7. Supporting the availability of recovery and peer support services for drug users; 

8. Encouraging local public health departments in developing community-based prevention, harm-reduction, and overdose prevention programs;

9. Engaging rural law enforcement officials and public health officials, and substance use professionals in a process to support develop models and programs that focus on using substance use treatment instead of judicial consequences; and

10. Encouraging governing authorities to share prescribing guidelines and supportive programs with rural providers through telemedicine and video technology (Gale, 2016).

Together rural health providers in conjunction with key stakeholder leaders in rural communities can address and lessen negative outcomes associated with illicit drug use and drug overdose deaths in rural communities.

References

Centers for Disease Control and Prevention. (2024, May 16). Drug overdose in rural America as a public health issue. https://www.cdc.gov/rural-health/php/public-health-strategy/public-health-considerations-for-drug-overdose-in-rural-america.html

Gale, J. A. (2016). Rural communities in crisis: Strategies to address the opioid crisis. https://www.ruralhealth.us/getmedia/fb3ba3cc-ac75-4828-833c-a1aa5f060917/RuralCommunitiesinCrisisStrategiestoAddresstheOpioidCrisisPolicyPaperApril2016.pdf

Gale, J, Kahn-Troster, S, Croll, Z, First, N. (2020, June). Engaging critical access hospitals in addressing rural substance use. University of Southern Maine. Flex Monitoring Team. Briefing Paper #44.

NORC Walsh Center for Rural Health Analysis. (2020). Rural prevention and treatment of substance use disorders toolkit. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/substance-abuse.

Rural Health Information Hub. (2024). Substance use and misuse in rural areas.  https://www.ruralhealthinfo.org/topics/substance-use#local-treatment

Spencer, M. R., Garnett, M. F., & Miniño, A. M. (2022). Urban–rural differences in drug overdose death rates, 2020. NCHS Data Brief, No. 440. National Center for Health Statistics. https.  https://dx.doi.org/10.15620/cdc:118601

Infant Mortality Related to Premature Births in Rural Areas

Jennifer E. Humphries, DNP, CRNP, NNP-BC 

Premature birth is defined as babies born prior to 37-weeks’ gestation. Out of the top 10 most rural states (World Population Review, 2024), three of those states. Alabama, Mississippi, and West Virginia, have the highest rate for premature births, with rates ranging from 12.84-14.8% (Centers for Disease Control [CDC], 2022). An ongoing assessment and intervention are imperative to promote healthier pregnancies. Identifying the barriers and creating awareness can help reduce premature births and reduce infant mortality rates.

Many risk factors contribute to preterm birth. Women with previous preterm labor or birth, multiple infants (twins, triplets, etc.), and reproductive anomalies are some factors that can’t be changed. However, there are risk factors that can be prevented or managed to help reduce the risk of premature labor. These conditions include sexually transmitted diseases, infections such as urinary tract infections (UTI) or vaginal infections, hypertension, obesity, and diabetes or gestational diabetes (National Institute for Health, 2023). Often, medical conditions such as hypertension and diabetes mellitus, women waiting longer to access prenatal care, and inadequate maternal healthcare services offered by too few health providers in rural areas magnify this issue. 

Social determinants such as ethnicity, maternal age, poverty, level of education and environmental factors also play a role in preterm labor or birth that contributes to increased mortality rates, especially in rural areas. African American women are more likely to have preterm infants compared to white women (National Institute for Health, 2023). Educating women about their health can be the first step in improving healthy pregnancies. Education should include avoiding alcohol, smoking, and drugs. Additionally, the importance of seeing the provider regularly should be discussed with women (Alabama Department of Public Health, 2024). No prenatal care or limited prenatal care can lead to a delay in discovering any underlying concerns. With the decrease in the number of birthing hospitals and maternity access in rural areas, also known as maternity care deserts, the complexity of maternal care remains a concern (March of Dimes, 2023).

The importance of creating awareness and addressing factors contributing to preterm births is imperative to improve the overall health of babies and mothers. Collaborations among individuals and organizations (e.g., state public health agencies; state perinatal programs designed to improve the physical and psychosocial well-being of women, infants, and families; and health providers) can create an awareness to address these health disparities, implement evidenced based practice, and improve the overall health of women in rural areas.

References

Alabama Department of Public Health. (2024, September 10). Infant mortality. Retrieved from Alabama Department of Public Health: https://www.alabamapublichealth.gov/perinatal/infant-mortality.html 

Centers for Disease Control [CDC]. (2022, February 25). Percentage of births born preterm by state. Retrieved from National Center for Health Statistics: https://www.cdc.gov/nchs/pressroom/sosmap/preterm_births/preterm.htm

March of Dimes. (2023). Where you lives matters: maternity care in Alabama . Retrieved from Healthy Moms. Strong Babies: https://www.marchofdimes.org/peristats/assets/s3/reports/mcd/Maternity-Care-Report-Alabama.pdf 

National Institute for Health. (2023, May 9). What are the risk factors for preterm labor and birth? Retrieved from U.S Department of Health and Human Services: https://www.nichd.nih.gov/health/topics/preterm/conditioninfo/who_risk

World Population Review. (2024). Most rural states 2024. https://worldpopulationreview.com/state-rankings/most-rural-states

Managing Food Insecurity in Rural Areas

In 2023, almost 14% of U. S. households had food insecurity. In rural areas, thisprevalence is even higher at 15.4% (Rabbitt et al., 2023). We also know that healthy food is difficult to obtain in low-income households, especially in rural communities. Ultimately, fewer monies and geographic access to healthy foods leads to lower dietary quality among those in rural households with low-incomes (Ohri-Vachaspati et al., 2019). These food struggles relate to many factors including the inability to buy nutritious food (e.g., high-quality protein, fruits, and vegetables) because of either unemployment, low-income or seasonal jobs, high food prices, needing to use funds for essential household and medical needs, selecting poor food choices because of tiredness from working long hours, and because grocery stores with wholesome foods often are many miles away from their home (Byker Shanks et al., 2022).

These families use many support systems to obtain food, such as local food pantries, food assistance programs, school meals, and borrowing either money or food from family and friends. Rural residents also take advantage of gardening, hunting, fishing, and canning food for later use by their families. They also use money-saving strategies to buy more food by visiting stores who offer coupons or sales, purchasing generic brands, buying bulk items or dented /damaged packages and cans, and comparing grocery store unit prices for specific items. They also serve simple meals with fewer food options (Byker Shanks et al., 2022).

Despite these various strategies, many rural households with low incomes still struggle to feed their family desirable and nutritious food, which requires a multi-level approach to this problem. Nurse practitioners, nutritionists, social workers, other health providers along with community stakeholders are key in developing creative strategies to help these families secure more nutritious food options for themselves and their families. Health providers can share information about federal nutrition programs and do referrals to departments of human services during wellness examinations. Free educational programs on nutrition are important. Community stakeholders can advocate for policies to address food insecurity. Community efforts to emphasize the value of food programs for children and their parents and the elderly are a high priority, including community food trucks, food shelters/pantries, and emergency food programs. Community connections and events can provide opportunities to enhance social networks, with shared transportation to food stores, farmer’s markets, and neighborhood sponsored community gardens, with childcare/supervision. These social events also provide opportunities to make friends and share ideas for nutritious meals and strategies to prepare time-saving meal plans (American Hospital Association, 2024; Schuler et al., 2024). Together, these group efforts can improve rural food insecurity.

References

American Hospital Association. (2024). Hospitals and food insecurity. https://trustees.aha.org/articles/1299-hospitals-and-foodinsecurity#:~:text=Hospitals%20and%20health%20care%20providers,dietitians%20and%20nutritionists%20for%20counseling

Byker Shanks, C., Andress, L., Hardison-Moody, A., Jilcott Pitts, S., Patton-Lopez, M., Prewitt, T. E., Dupuis, V., Wong, K., Kirk-Epstein, M., Engelhard, E., Hake, M., Osborne, I., Hoff, C., & Haynes-Maslow, L. (2022). Food insecurity in the rural United States: An examination of struggles and coping mechanisms to feed a family among households with a low-income. Nutrients, 14(24), 5250. https://doi.org/10.3390/nu14245250

Ohri-Vachaspati, P., DeWeese, R. S., Acciai, F., DeLia, D., Tulloch, D., Tong, D., Lorts, C., & Yedidia, M.J. (2019). Healthy food access in low-income high-minority communities: A longitudinal assessment-2009–2017. International Journal of Environmental Research in Public Health. 16, 2354. https://doi.org/10.3390/ijerph16132354

Rabbitt, M. P., Reed-Jones, Hales, L. J., & Burke, M. P. (2023, September). Household food security in the United States in 2023. USDA, Economic Research Service, ERR-337. https://www.ers.usda.gov/webdocs/publications/109896/err-337.pdf

Schuler, B. R., Shipe, S. L., O'Reilly, N., Uhl, A., Vazquez, C. E., Tripicchio, G. L., & Hernandez, D. C. (2024). Balancing nutrition and budgets: Socio-ecological impacts on nutritional environments of families with low incomes. Appetite, 203, 107706. https://doi.org/10.1016/j.appet.2024.107706