Effective public health systems in rural communities are central to securing quality care and promoting well-being among our nation's veterans. The highest concentrations of veterans in the civilian population 18 years and older are found in many rural counties. Of those enrolled and eligible for care by the Veterans Health Administration (VHA), 36 percent reside in rural areas and an additional 1.5 percent live in highly rural areas. Of those veterans served by the VHA, 39 percent reside in rural areas and another 1.6 percent live in highly rural areas. Soldiers from geographically rural areas make up a disproportionate share of casualties from Operation Iraqi Freedom and Operation Enduring Freedom, perhaps as a result of the higher enlistment rates in rural areas, and many of our veterans are returning to their rural communities. The state of our rural public health systems directly impacts our veterans.

The Office of Rural Health (ORH) within the VHA, Department of Veterans Affairs (VA), was established in 2006 to better address the healthcare needs of the growing number of veterans residing in rural and highly rural areas of our nation. Public Law 109-461, Section 212, requires the ORH to promulgate policies, best practices, and innovations to improve healthcare services to rural veterans. The ORH has a further responsibility to conduct, coordinate, promote, and disseminate studies and analyses into issues affecting veterans who reside in rural communities.

The VA's ORH has a broad mandate to improve the quality and access to care of rural veterans. Through its Veterans Rural Health Advisory Committee, its field-based Rural Health Consultants, its regional Veterans Rural Health Resource Centers, and a myriad of other pilot and demonstration projects, studies and analyses, and policies and programs, the ORH continues to advocate for rural veteran interests across a number of key focus areas. We recognize the caliber of researchers and investigators at the Rural Health Research Centers and the immense support provided by the Federal Office of Rural Health Policy. Veterans live within rural communities, and this special theme issue on rural public health issues offers important contributions relevant to veterans and their families.

Our understanding of rural/urban dichotomies in veteran populations is improving. Many disease categories are significantly more prevalent in rural veteran populations than in urban veteran populations, even after adjustments for age, gender, employment status, priority level, comorbidities, and geographical residence area. Despite these higher disease burdens and need for health services, rural veterans appear to use fewer services than their urban counterparts, suggesting different care preferences or differential access to care. Veterans in rural communities have reported lower health-related (physical and mental) quality-of-life scores than their urban or suburban counterparts, and these disparities seem to persist over time.1 As with our efforts to improve quality and access to care, expanding clinical preventive services and health education programs, managing environmental health concerns and occupational exposures, establishing disease surveillance systems and targeted patient registries, and other population health initiatives remain critical development areas for our rural veterans.

There is also a recognition that veterans may have unique medical and social needs, and the VA and other federal and community partners have increasingly been focused on the plight of veterans whose needs may be exacerbated by the challenges of access and geographical distance and of poor existing health system infrastructure in rural communities. The ORH has promoted collaborative approaches to work with community-based providers and public health organizations to improve the health services and resources available for rural veterans.

A related issue is the mental healthcare infrastructure available in rural communities. Traumatic brain injury, posttraumatic stress disorder, and mental health concerns have received greater attention in recent years, and rural veterans rely on the public health workforce and infrastructure in broader rural communities to improve care coordination and access to needed services. Geographic and cultural isolation, poverty, and even language barriers present unique challenges. The VA has aggressively addressed this by implementing robust programs for rural mental health. For example, the Mental Health Intensive Case Management-Rural Access Network Growth Enhancement program and the Care Coordination Home Telehealth telepsychiatry initiatives are critical strategies for supporting rural veterans. With these mental health challenges particularly burdensome to the veteran population, the VA continues to establish and support a more capable mental health infrastructure that serves veterans in rural communities.

To effectively address each of these challenges, it is critical to have strong public health systems and a strong public health workforce able to support veterans and other rural community members. The VA must remain a critical partner in the search for federal-state funding streams for local public health activities, the recruitment and retention of emergency medical technicians and other healthcare professionals, understanding the causes and impacts of health disparities and reduced access to services, and the other important issues addressed in this edition. The ORH has been actively pursuing strategies to partner with local rural communities to strengthen public health systems and to promote a more effective public health workforce.

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