Rural communities represent about 20% of the US population and are as culturally diverse as urban communities. A combination of factors not generally found in urban areas contribute to health disparities in rural areas. A review of the data demonstrates a need in rural communities to address provider shortages, transportation problems, increased federal financing through Medicare and Medicaid, health insurance coverage, and rural regional differences. In addition, attention needs to be focused on the relationship between health behaviors and social status, income, occupation, education, employment, place of residence, and physical environment as determinants of health and life expectancy.

Recently, a series of policy briefs developed by the National Rural Health Association focused on rural health disparities.1 These policy briefs complement the Healthy People US 2010 Goal II: "[horizontal ellipsis]to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.",2 Disparities in health for rural residents are well documented. Living in a rural area is in itself a health risk factor due to numerous factors that can negatively influence health and access to healthcare. According to Ricketts,3 there are regional patterns of rural disadvantage, associated with economic factors, cultural and social differences, lower educational status, demographic make-up, population density, terrain, distance from urban areas, community resources, physical environment, lack of public health infrastructure, isolation related to living in remote rural areas, and lack of recognition of rural by legislators.4

Examples of rural disparities associated with leading causes of death and years of productive life lost include the following5-8:

* Heart disease is the leading cause of death, and ischemic heart disease is responsible for 60% of all heart disease deaths. The rural ischemic heart disease mortality rate for persons 20 years of age or older is 5% higher than the US rate.

* The fourth leading cause of death is chronic obstructive pulmonary disease. The rural chronic pulmonary obstructive disease mortality rate for persons 20 years of age or older is 8% higher than the US rate.

* The fifth leading cause of death is unintentional and motor vehicle traffic-related injuries. The rural mortality rate for this indicator is 50% higher than the US rate.

* Death rates for children and young adults (ages 1-24 years) have a large impact on another important health status indicator: Years of Productive Life Lost. The rural mortality rate for this age group is more than 20% higher than the US rate.

* Suicide rates for males 15 years and older are lowest in large metro counties and increase steadily as counties become less urban. For example, the suicide rate among rural men is significantly higher than among men in urban areas; the suicide rate among rural women is escalating rapidly and is approaching that of men.4

This issue of Family and Community Health focuses on rural healthcare issues. The articles herein represent a variety of topics and offer some novel approaches to addressing rural disparities. Two of the articles represent research using large datasets focusing on mental health care services in rural areas. Hauenstein et al describe how gender and place of residency---rural and nonrural---affect reports of mental health status and the use of mental health services. Using the Medical Expenditure Panel Survey, a national survey designed to provide estimates of the use of health services, medical expenditures, and sources of payment, they found that reports of mental health status decreased as rurality increased and that both men and women received less mental health service if they lived in a rural area. Also, men received less health service in rural areas than did women. The authors conclude that there are considerable unmet rural mental health care needs and nonspecialist health providers do not seem to contribute markedly to the mental health care of rural women. Merwin et al also used a national dataset and focused on access to quality healthcare in rural areas. The authors discovered that organizational providers such as community health centers and community mental health centers were less available in rural counties. The article includes a case study of an area in Southwestern Virginia that lacks these resources yet has instituted a unique community response to help fill the gaps.

Three articles address type II diabetes mellitus. Lohri-Posey studied low-income Appalachians living with type II diabetes mellitus. In this qualitative study, she discovered 4 themes that characterized the experiences of her participants: (1) balancing diet and family needs, (2) adjusting to variations in amount of energy, (3) balancing family relationships and self-reliance, and (4) dealing with the uncertainty of future health. Utz et al report on a study of 73 African Americans with diabetes living in rural counties in the south. Using focus groups, this team of researchers sought to discover the facilitators and barriers to self-management of diabetes, the use of prescribed and alternative therapies, and what the participants desired in terms of programs of diabetes care. Reporting on that same study, Wenzel et al were concerned with the stories these rural African Americans told about being diagnosed with diabetes. They noted that many of the participants were not surprised at being diagnosed with this condition. For them, illness was so common in their families and community that they almost expected receiving the diagnosis; therefore, this was not a particularly emotional event for them. While the stories differed by gender, the figurative and metaphoric language was similar and their narratives revealed aspects of the experience that could be very useful to care providers of this at-risk population.

The remaining articles differ by subject but identify a common need for better access to services and caregiver education in rural areas. Baffour et al write about African American pregnant and parenting women with children younger than 2. They highlight a program being tested in Florida that is based on an empowerment model, which includes advocacy, social support, health education, and referral for social and medical services. Their model includes social marketing strategies, recruitment efforts, and curriculum development. Annan provides a literature review of sexual assault in rural areas. She notes several themes that make sexual assault in rural areas different from the same crime in urban and suburban areas, including provision of timely services and fears associated with the loss of privacy. The article by Denham et al addresses death and dying in long-term care facilities in rural areas. The authors recognize that nurse aides are important in the care of dying people in these facilities and used focus groups to determine attitudes and learning needs. On the basis of themes that arose in these focus groups, these researchers developed and tested computer-based learning models to meet the needs of these nurses aides.

We hope that the articles in this issue will be useful to healthcare providers in various disciplines in their efforts to identify and eliminate health disparities in diverse rural communities.

Angeline Bushy, PhD, RN, FAAN

Issue Editor, Professor and Bert Fish Chair, University of Central Florida, School of Nursing, Daytona Beach

Richard H. Steeves, PhD, RN, FNP, FAAN

Issue Editor, Professor, School of Nursing, University of Virginia, Charlottesville

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