In August 2001, the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) released the 25th annual statistical report on the nation's health. A special focus of this report was an investigation of the nation's health status relative to community urbanization level, making this the first effort to articulate rural health disparities in the United States.

This is a significant publication as it brought a needed focus to rural health issues and concerns. The report's findings demonstrated a number of disparities in health status between rural and nonrural citizens including the following: teenagers and adults in rural counties were the most likely to smoke; residents of rural communities had the fewest visits for dental care; death rates for working-age adults were the highest in the most rural and most urban areas; and rural areas had a high percentage of residents without health insurance, and residents of rural areas had the highest death rates for unintentional injuries, in general, and for motor-vehicle injuries specifically.1

Even before the CDC report, the Health Resources and Services Administration (HRSA) Office of Rural Health Policy and the National Advisory Committee on Rural Health were recognizing the need to address public health issues within rural communities and sought to learn more about the role of rural governmental public health systems in this regard. In 1999, the National Advisory Committee issued a report to the Secretary of the US Department of Health and Human Services assessing rural public health needs and decrying the lack of any data or analysis of the challenges faced by rural public health providers. That report led to a partnership between our office and the National Association of County and City Health Officials (NACCHO) to analyze existing survey data by geographic location. In many ways, the findings of the NACCHO survey were not that surprising. Rural health departments tended to face many of the same challenges as their urban and suburban counterparts but at a higher degree of severity. In this manner, these research findings were similar to many of our past research efforts. Rural and urban communities may have similar challenges, but the conditions often tend to worsen as one moves along the continuum from urban to rural.

Rural residents make up approximately 17 percent of the United States' population spread out over 80 percent of the country's land mass. The unique features of that geographic dispersion and isolation create unique health challenges that deserve more research attention. While the CDC and National Advisory Committee reports demonstrated that rural citizens experience significant health disparities and may lack the systems to address their unique needs and concerns, the majority of research and practice efforts in rural communities are aimed at ensuring access to healthcare services. Make no mistake that ensuring access to quality healthcare remains critically important to improving health status throughout rural America. Equally important, however, are issues such as health behavior, primary and secondary prevention, environmental health, infectious disease surveillance, ensuring a competent and well-staffed public health workforce, and many other issues that target health at the population level. To the extent that rural public health practice has been understudied, the rural practice community is left to extrapolate from studies of the urban underserved, which is less than ideal.

This issue of the Journal of Public Health Management and Practice is unique in that it features articles that address rural health at the population level. It sheds further light on many of the differences between urban and rural public health practices and, more importantly, focuses directly on a number of disparities issues.

The articles in this issue also provide another forum to highlight the important work of HRSA-funded Rural Health Research Centers, which house many of the nation's premier rural health researchers. The Rural Health Research Centers program is designed to help policy makers better understand the problems that rural communities face not only in ensuring access to healthcare but also in strengthening the health of their residents through population-level efforts. The centers work to understand the ways in which the health of rural Americans can be improved, analyze the implications of Federal and state policy options, and communicate research results to policy makers and others who may take action based on research results. The Rural Health Research Centers program, with a yearly budget of about $4 million, is the only Federal program entirely dedicated to producing policy-relevant research on healthcare and population health in rural areas.

More information about the research efforts of the Rural Health Research Centers can be found on the Rural Research Gateway Web site: http://www.ruralhealthresearch.org. The Gateway provides easy access to the centers' rural publications and authors, as well as summaries of research in progress or completed. Through their research and policy analysis, the centers bring to the forefront the healthcare challenges facing rural America.

As past and current directors of the HRSA Office of Rural Health Policy, we are delighted to have this opportunity to share what we believe is one of the nation's best-kept health research secrets-the work of our Rural Health Research Centers. We thank the Journal of Public Health Management and Practice for its support of this important effort.

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