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City health and country health

By Matthew C. Wiencke

In her work as a nurse practitioner at the Maine-Dartmouth Family Medicine Center in the rural town of Fairfield, Maine, Alane O'Connor, D.N.P., noticed something about her patients. They seemed sicker and more likely to have a chronic disease than had her patients in Boston, where she had practiced previously. She began to wonder if what she had noticed reflected a real trend: Was there a higher prevalence of chronic disease in rural environments?

Research has shown that two of the most commmon chronic diseases in rural and urban areas are diabetes and coronary heart disease. Much work has been done looking at specific risk factors for both, such as obesity and smoking. But "nobody has looked at [the issue] from a rural-health perspective," says O'Connor.

So O'Connor, who is a Geisel adjunct instructor of community and family medicine, studied data from a 2008 national survey conducted by the U.S. Centers for Disease Control and Prevention. People were asked about their chronic health conditions, socioeconomic status, weight, and other risk factors. O'Connor found that diabetes and coronary heart disease are more prevalent in rural locations than in cities. The prevalance of diabetes was 8.6% higher (9.7% versus 9.0%), and the prevalence of coronary heart disease was 38.8% higher (5.5% versus 4.0%).

O'Connor also wanted to know if the effect of income on the likelihood of disease was different between rural and urban areas. Were low-income people in rural areas sicker than people in the same socioeconomic bracket in urban areas? She found that this was true for coronary heart disease but not for diabetes. In rural areas there was also a higher percentage of current and former smokers, which is a risk factor for coronary heart disease, and a higher percentage of people who were overweight or obese, which is a risk factor for both diabetes and heart disease.

Overall, people living in rural environments, O'Connor found, are more likely to be diagnosed with diabetes and coronary heart disease than people living in urban areas. This difference, she wrote in an article on the research, "exacerbates many of the disparities already found in the rural U.S. health setting, including more difficulty obtaining health insurance and longer distances to reach health-care facilities." Higher rates of poverty and less insurance coverage can mean that many rural residents cannot afford treatments such as smoking-cessation therapies, diabetic medications, and gastric bypass surgery. The shortage of primary-care physicians in rural areas makes the situation even more challenging.

This research is crucial to increasing people's awareness of rural health issues—which is very much needed, O'Connor believes. "Folks are more aware of urban health issues," she says. "We need more champions of rural health."


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Geisel School of Medicine at DartmouthDartmouth-Hitchcock Medical CenterWhite River Junction VAMCNorris Cotton Cancer CenterDartmouth College