Table 1 Published research relevant to rural definition of health: with comparison groups (N = 6) and without comparison groups (N = 24)

Qualitative – focus groups

Minnesota

• Rural respondents tended to characterize death as natural; death was seen as neutral or beneficent.

Rural respondents: “When the body starts shutting down there isn’t a need for food.” “Sometimes they just wear out. We [are] just like an old car.”

“Resistance to the approach of death was more characteristic of urban respondents, some of whom insisted upon aggressive medical care in advanced dementia.”

• 8 focus groups in rural and urban nursing homes

• Urban respondents described “fighting” for their relatives’ survival; death was not accepted by many.

Urban respondents: “You have to fight for their rights … to live.” “I think things should be done as if she were just 20 years younger.”

• 38 family members (average age 62) of elders (age 65+) with advanced cognitive impairment

• Resistance to approach of death more characteristic of urban respondents; some insisted upon aggressive medical care in advanced dementia.

Telephone survey

North Carolina

• Fear of hospitals was associated with effective compliance for rural residents and good health habits for urbanites.

(No quotes from participants)

“Affordability concerns of rural residents were associated with both noncompliance and irregular health habits.”

• Rural (N = 586, average age 46) and Urban (N = 433, average age 44) respondents based on random digit dialing

• Mistrust of doctors predicted low adherence for both groups and was also associated with poorer health habits for urbanites.

Longitudinal survey of health and service use

Iowa

• There were significant differences [by size of place] for financial distress, with the greatest levels of stress reported by farm residents, followed by persons living in rural villages and small towns.

(No quotes from participants)

“Persons living in the most rural environments were more likely to hold stigmatized attitudes toward mental health care and these views were strongly predictive of willingness to seek care.”

• 1487 adults completing the full battery of mental health questions in both waves of data collection (separated by >1 year)

• Persons in rural areas expressed significantly higher levels of stigma [toward seeking mental health care] than residents of population centers.

Qualitative - semi-structured interviews

Alberta, Canada

• Rural-living participants believed that a ‘work hard, eat hard’ ethic kept them healthy despite stressors related to the nature of their work and living in a rural environment.

Rural respondents: “See, the family depends on me. No matter if I work 24 hours a day or 12 hours a day, I have to be there.”

“…gender and culture (associated with place of residence) influence people’s ability to meet the challenge of managing [coronary artery disease] risk.”

• 42 urban- and rural-living Euro-Celtic men and women (average age 63)

• Participants persevered through CAD symptoms until they could no longer undertake their daily activities related to maintaining the household or farm.

“…when a farmer or a rancher phones you … you see them right now because they only let you know if it … is really, really serious.”

Survey, mailed to a stratified sample of adult drivers

Minnesota

• Rural drivers participate in risky driving behaviors more than their urban counterparts and tend to regard the risks of the behaviors, such as not wearing seat belts, as being lower.

(No quotes from participants)

“…traffic safety policy to improve seatbelt compliance in rural areas should focus on increasing the perception of danger associated with not using a seatbelt while driving.”

• 1399 valid survey responses from three age groups (age 18-26, 30-50, and 65+) of MN licensed drivers.

• Rural drivers had significantly lower confidence in the utility of safety interventions such as traffic enforcement and highway engineering.

Survey research

Nebraska

• Rural elders were less inclined to turn to health care providers for issues that they considered non-urgent.

(No quotes from participants)

“Those in the rural group expressed attitudes of independence and self-reliance, values consistent with concepts of pioneer virtues and responsibility.”

• 396 people (aged 65 or older) in Omaha (urban, n = 196) and Sand Hills (rural, n = 200)

• Rural residents emphasized independence items such as waiting long enough to get over illness and avoiding doctors and hospitals.

3-year ethnographic study; qualitative research (focus: health maintenance)

North Carolina

• Rural residents identified 7 salient health maintenance domains: eating right, drinking water, taking exercise, staying busy, being with people, trusting in God and participating in church, and taking care of yourself.

“[To be healthy] get involved in church and community activities.”

“Elders in these rural communities hold a definition of health that overlaps with, but is not synonymous with a biomedical model. These elders concept of health seamlessly integrates physical, mental, spiritual, and social aspects of health,”

• 145 interviews with residents of 2 rural NC counties (aged 70+)

“And go to church… keep up your activity in the church, your singing, your praying and your studying the Bible…”

3-year ethnographic study; qualitative research (focus: complementary & alternative medicine)

North Carolina

• CAM therapies are widely used but are largely limited to folk and home remedies and vitamin and mineral supplements.

“I had high blood pressure. … The nurse … told me she had been to [a university medical center] and somebody had advised her to mix honey and vinegar for blood pressure. So for years I took honey and vinegar.”

“The CAM used by these older adults is clearly ‘complementary’ rather than ‘alternative.’ CAM remedies are an integral component of their health self-management strategies, integrated into rather than replacing conventional care.”

• 145 interviews with residents of 2 rural NC counties (aged 70+)

• [Rural elders’] discussions of CAM therapies … indicated that these therapies were integrated into their health behaviors and beliefs.

Qualitative research: ethnographic interviews and participant observation

New Mexico (SW)

• For elders retired from mining and/or ranching, health consisted primarily of… remaining autonomous (living on their own in their own homes, preparing their own meals).

“I just do without a lot of things to buy my medicine. As long as I can get both food and medicine, nothing else matters. But sometimes I skip a dose or cut pills in half to make it last.”

“It is important for nurses to expand their knowledge and understanding of issues affecting elder care in the rural communities, the elders’ definitions of health, and the economics of care delivery.”

• 22 interviews; 16 rural elders (65+ years)

• Definitions of health … encompassed … avoidance of contact with the health care system …remaining independent.

“I don’t like to call ‘em [health care providers] because they’ll just say, ‘well, you’re 85, what do you expect to happen?’”

Mixed methods research using questionnaire and Body Mass Index scores

Saskatchewan, Canada

• Cultural symbols of rurality such as “wide open spaces” and the sense of “safety” and “freedom” were described and explained as contributing to health and healthy behaviors by the children and their parents.

“Healthy means being active, and having fun, and being happy.”

“…. To this group of children the meaning of being healthy was an integration of three overarching themes: Knowing Stuff, Having a Working Body, and Feeling Happy.”

• 51 (of 99) rural students (grades 1-7) completed questionnaire and BMI; interviewed subset of 20 (age 9-12 years)

“If you don’t feel good about yourself you really have no reason to do either of the others.”

Qualitative; interviews

Rural Nebraska

• Ideas about independence and connection were more significant to the definitions of and responses to health and illness than was the actual diagnosis of disease. According to local beliefs, one needs to be engaged with others in order to stay healthy.

“It will kill some of them if they have to be dependent on somebody else.”

“The significant cultural measure of one’s health in this town was the ability to function independently.”

• 45 interviews with 29 selected adult respondents (more than 50% of respondents were 60+ years)

“Oh, I know I don’t go to a doctor like I probably should for a checkup … but I always feel as long as I feel half way good - why I guess it’s like a piece of machinery, as long as it’s running good, why fool with it?”

Qualitative research; focus groups

West Virginia

• Some participants reported that seeking help from a medical institution or provider was regarded as a last resort among people in the region.

“I believe in prayer, but I believe [God] gave doctors knowledge, also.”

“Participants stated that people in the region regard disease and accidents, like other hardships, as always a part of their lives.” “…health beliefs are strongly related to religious beliefs and practices among people in southern West Virginia.”

• 10 focus groups (5 men, 5 women) of 61 long-time adult residents (age 35+) in rural southern WV

Religious beliefs and faith in God were important resources when facing sickness and seeking healing. For some, divine help for healing seemed to be enough.

“We have strong beliefs, and it’s not beliefs you just pick up. It’s beliefs that have been passed down from generation to generation.”

Qualitative research; ethnographic design

Western plains US

Health was regarded as the ability to remain independent and not be a burden to anyone. Hardcore independents would not accept help from anyone.

“I wish I wasn’t so damned independent … I could get more of what I need, but it just goes against my grain.”

“The definition of health as the ability to remain active, the importance of independence, and the insular nature of communities are frequently mentioned in the literature, whereas the value of community participation is less well documented.”

• Interviews of 104 people in a farming community; 59 with older residents (65+ years), plus community leaders and care providers

• The participants described reciprocal relationships between the community and older residents, to the benefit of both.

Qualitative research; interviews

Rural Alabama

• To determine whether they considered themselves healthy or no longer healthy, subjects tended to rely on how they felt. They assumed that they were healthy if they felt good, whereas they knew they were no longer healthy when they felt bad.

“I know I’m healthy when I feel good. I get up and I’m not tired and I don’t have a headache.”

“The clients described a need to experience themselves as competent and self-determining. Despite multiple health problems and treatments, the subjects tended to rely first on their own appraisal and resources to manage health problems.”

• Interviews and data collection from 31 participants ages 65-94 (n = 25 women)

“My greatest fears are that I’ll have a stroke and be a burden to my family.”

Qualitative research; individual and focus group interviews

Rural West Virginia

Barriers to participating in cholesterol screening programs were identified: in addition to lack of knowledge, concerns about the outcomes of testing and concerns about needles, traditional cultural beliefs were identified as barriers.

“People basically don’t come running to the doctor for minor issues and in some instances they don’t necessarily go to the doctor for major issues. … I know a lot of parents who are not open to suggestions or wanting to try new things …”

“…there are environmental, financial, and attitudinal barriers to participation in health screenings for West Virginians … denial and fatalism may also function as barriers to cholesterol screenings.”

• Interviews with 14 community leaders, 36 parents, and 92 fifth-graders

• These beliefs included resistance to a preventive approach to health, resistance to new people and ideas, using denial as a coping strategy, and having a fatalistic view toward health.

“… you know, I’m going to die anyway. I might as well enjoy what I’m doing.”

Qualitative research; interviews

Alberta, Canada

• Work and place were seen to be indivisible with work seen as integral to life in the rural setting.

“It’s not the painfulness that bothers me, it’s the unableness.”

“To be able to work was to ‘be healthy’ in the rural setting irrespective of any symptoms or underlying illness.”

• Interviews of 42 rural elders (mean age 76) and 30 caregivers

• Accounts of heart failure and self-care were framed around narratives of work, its benefits, and the threats and disruptions made to work by heart failure.

“I don’t want to die .. I’ve still got work to do, what the hell…”

“[Work] was reported to be pleasurable and vital to a meaningful existence in the rural places.”

“I don’t want to go [to community events] if I can’t do my share of help … I don’t like just sitting on my butt and letting everyone else to do it.”

Qualitative research; focus groups and brief surveys

West Virginia

• These participants described clean living as one of the keys to health, and endorsed a conventional Christian way of life (i.e., reading the Bible, praying, attending church).

“…the definition of health to me is to be active.”

“…compared to more urban adults, our study participants may place greater value on functional independence due to a greater reliance on their ability to chop wood or tend to a garden.”

• 13 focus groups and surveys (101 rural participants age 61+; average age 75 years)

• These older adults assigned a high value to health because health enabled them to remain active and to fulfill social roles.

“Keeping clean and keeping yourself busy and no idle time because idle time is in the hands of the devil…”

“The meaning of health for rural elders transcends the physical/behavioral dimensions [and includes] psychosocial and spiritual well-being.”

“I think health is a state of mind…if you think you are healthy and you feel healthy then you are healthy.”

Qualitative research; interviews

Midwest US

Participants placed a high value on remaining in their own homes and remaining independent. They were creative in changing their environment and everyday practices and patterns to be able to complete most desired activities.

“I’ve worked it out. I really don’t stand up and walk up steps. I kind of crawl up. I put my hands on a couple of steps up. … You can learn to do something if you have to. I couldn’t go up stairs in public.”

“The ability to walk and other activities that were necessary for them to take care of themselves were of primary importance to participants.”

• 59 interviews of 19 “oldest-old” rural adults (85-98 years)

• These elders viewed themselves as having strong reciprocal social networks.

Mixed methods; health diary and interviews

Rural Australia

• Rural families encountered some health problem in 1 out of 2 weeks.

(No quotes from participants)

“… there was abundant evidence from the health diaries to suggest that mental-health issues remain something of a ‘sleeping giant’ in rural areas and certainly one of the most significant health problems characterizing rural families.”

• Interviews and 4-month diary from 112 families with preschool or primary school age children

• Health care services were accessed for a wide range of illnesses.

“…notable …is the high proportion who consider the health problem not serious enough to seek assistance, even though it affected their activities.”

• A high proportion of families experienced health problems that were sufficiently serious to affect function. Stress was widespread and impacted all members of families.

Survey of farmers and ranchers

Montana

• The survey found that the farmers and ranchers tended to reject “the sick role.” This may be consistent with other findings that rural people experience fewer days in bed and less restricted activity and work loss, and may imply a partial reason for delays in seeking treatment for acute and chronic illnesses.

(No quotes from participants)

“In any culture, health behaviors are the result of values learned during childhood. In farming and ranching environments, children grow up in a culture that values productivity, industriousness, role performance, and independence.”

• Survey of 162 farmers and ranchers

Qualitative research; focus groups

Wyoming

• Four themes emerged from the focus group data: “cowboy up” (minor health concerns should not interfere with chores and work); access to health care providers and quality care is a concern; personal and family knowledge of how to manage minor health concerns is valued; and the community is family, providing advice and care.

“You’ve got cows to feed and stuff like that. So you’ve got to ‘cowboy up’ and continue doing what you have to do.”

“…rural families may not seek treatment at the first sign of symptoms.”

• Focus groups with 42 individuals from five rural communities (age 23-89; average age 53 years)

“We are kind of a tough lot … this community, and I think when you talk about respiratory, upper respiratory infections, most everybody ‘foofoos’ it off and takes care of themselves.”

“Mothers in our study were adamant regarding knowledge that they had regarding the symptoms and care of their family members, and in particular, the care of family members with special concerns.”

Qualitative research; interviews

Colorado

• The rural elderly identified several factors that influenced their acceptance of health care services, including self-perception (active minds but bodies that were less cooperative); fear of dependency; financial issues; and maintaining dignity.

“In rural areas, most seniors have the attitude of, ‘if it ain’t broke, don’t fix it.”

“Nurses and other health care providers working with the rural elderly need to be sensitive to the perspective of rural older adults, which is often characterized by a lifestyle of simplicity and frugality.”

• Interviews with 32 rural providers & 28 rural seniors (age 62-94)

“I know one old man who is 90 years old and he feeds 50 head of cattle every morning on his ranch. When he comes into my office, he can barely walk down the hallway … But he has a sense of purpose on his ranch and this keeps him going.”

Phenomeno-logical; inductive, descriptive research

NW Plains, US

The participants emphasized the value of hard work, acceptance of life’s uncertain challenges, acceptance of health and health problems, faith in God, and the importance of independence and determination.

“If something happens, it just happens, and you have to take things as they come.”

“While independence and self-care are very important qualities for the participants, their lives were so interdependent in the early years on the prairie that the stories all reflect the same underlying grounding theme.”

• Interviews with 9 rural homesteaders (age 80-97)

• The subtheme of “acceptance” encompassed strong currents of stoicism and fatalism.

“…health I think is being able to get around to do things that you like to do and do for yourself and not have to rely on somebody else.”

Qualitative research; interviews

Iowa

• Rural men take health for granted and only become concerned with health when it interferes with their work and other responsibilities. They seek health care “only when the problem becomes so intense that it interferes with assumption of their roles and responsibilities.”

“Illness means you cannot go out the door to work.”

“All key informants equated health with being able to work and meet responsibilities.”

• Interviews with 7 rural “key” male informants (age 25-49) & 12 others

“Office nurses understand how busy we [farmers] are and if it is May and you’re in the fields and come in for something, you must be near death.”

“…rural men take health for granted and only become concerned with health when it interferes with their work and other responsibilities.” …

“…rural men seek health care only when absolutely necessary.”

Mixed methods; interviews

Appalachian states, US

• The participants provided a highly functional definition of health, including being able to get out of bed, having energy, able to participate in activities, able to care for family and home, and able to give service to others. Health was also associated with feeling good, belief in God, feeling no pain, and never having to see a doctor.

(No quotes from participants)

“Values characteristic of the Appalachian culture include emphasis on religion, importance of family, independence, individualism, self-care, sense of place, and love of place.”

• Interviews with 129 women from 7 states (age 19 to 101)

Interviews; survey

Central Minnesota

• Most patients identified themselves as taking responsibility for their own health. Seventy-six percent of patients who were “careful to live a healthy lifestyle” agreed that doctors should have educational programs on healthy lifestyles available for patients.

(No quotes from participants)

“…this rural patient group had very strong interests in both primary and secondary preventive medical services.”

• Questionnaires returned by 270 patients (age 14-90 years; average age 40 years) and 8 physicians in a rural clinic.

“Patients’ interest in physician involvement in preventive medical care … decreased significantly with increasing age, male gender, and lower levels of education.”

Qualitative research; focus groups

West Virginia

• In a resource-poor area like West Virginia, people adopt creative strategies for coping with chronic illness like diabetes. They may lack access to appropriate care and have limited access to [diabetes education, providers with knowledge to educate patients about diabetes management, exercise facilities and even appropriate foods for diabetes care.

“There is lots of things I have go wrong that I need to tell the doctor. But I know that I can’t go out here and pay for all these tests, so I will keep it to myself. I don’t even tell him because I know he’s going to want extensive blood work …”

“What is medically labeled as non-adherent behavior … is often a common-sense adaptation for the patient from within his or her belief framework, cultural context, and outside influences, such as financial constraints, limited knowledge, and lack of availability of appropriate medical care …”

• 101 rural adults in 13 focus groups (average age 59)

Ethnographic study; interviews

Calgary, Manitoba

• Although a number of participants identified living with chronic illnesses, they considered themselves to be healthy; they had adapted to their illnesses. Being healthy included being able to do what they wanted to do, to cope, to enjoy themselves, to not be bored and to feel that they were productive citizens.

(No quotes from participants)

“Being healthy was described as involving the physical, mental, social, and spiritual aspects of a person. … Those health professionals who truly listen to their patients and view them as whole persons rather than disease entities are highly valued.”

• Interviews of 29 from small towns near Calgary (age 21-84 years), 26 from northern Manitoba (age 21-76 years)

Multi-phase project

West Virginia

• Forty-six percent of telephone survey responders agreed that “there is nothing I can do to prevent cancer.” Sixty-four percent … agreed with the statement “I would not change my habits to avoid getting cancer.” Thirty-eight percent … agreed … “I would rather not know if I have cancer.”

(No quotes from participants)

“The barriers to prevention identified by the project committee were inadequate knowledge and sources of information, physical and economic access to care, and attitudes and beliefs regarding cancer.”

• 282 telephone surveys and (adults: 55% over the age of 45 years); 5 focus groups in rural WV

Qualitative research; interviews

Ontario

• Many of the women in this study exhibited characteristics of self-reliance and stoicism, sometimes in the extreme. The findings raised the question of how much self-care is reasonable. The promise of increased access to health information through the internet should be examined cautiously, as it may be of limited value to some rural populations.

[one respondent] “… told the interviewer that after breaking her arm, she did not visit the emergency service at the hospital, because she ‘didn’t want to bother the doctor or tie up the emergency … no reason to make a big drama about it’.”

“A number of women told the interviewer they would not use hospital emergency or nurse telephone triage services, even in response to the acute medical scenario, but would instead self-medicate, rely on information in home remedy books, and/or wait until morning to call their family doctor.”

• Interviews of 40 rural women (age 20-82)