Lack of Mental Health Care
Compared with their urban counterparts, rural Americans have higher depression and suicide rates, but are less likely to access mental health care services; specifically, 19.1% of residents aged 18 or older had a mental illness.6,72 In addition to having a mental illness, 4.9% of rural adults experienced suicidal ideation during the year.6

According to Lycette et al, for every 30,000 rural Americans, there is 1 psychiatrist.73 Rural Americans are also less likely to seek mental health services because of a prevailing sense of shame and stigma surrounding mental illness.72 In addition, rural residents are less likely to be able to afford mental health services because of financial constraints and lack of health insurance.6

Poverty also contributes to the prevalence of mental illness. With poverty comes stress, hopelessness, and depression, which contributes to mental illness.72 Black individuals are particularly susceptible to mental health strain as a result of persistent poverty, low educational level, and the experience of racism and discrimination in predominantly white rural areas.74,75

Substance Abuse
Rural America has been particularly hard hit by the opioid epidemic. Rural regions have high rates of opioid prescriptions, diversion, and misuse, as well as high incidence of nonlethal and lethal overdoses from prescription opioids.76,77 Incidence of drug overdose deaths in rural areas has surpassed rates in urban areas.78

Despite the high rate of addiction, rural regions have poor access to basic substance abuse treatment. There are fewer substance abuse treatment facilities, and available facilities are geographically too far away for many rural residents.79 Rural residents also lack education regarding lifesaving measures for persons with drug overdose (eg, the naloxone autoinjector), and emergency medical technicians lack access to naloxone.77,80

Lack of Sexual Health Care
Historically, there have been higher rates of sexually transmitted infections (STIs) among urban residents compared with rural residents. However, the lack of screening, preventive care, patient education, and treatment in rural regions has led to an increase incidence of gonorrhea, chlamydia, and syphilis infections, particularly among adolescents and young adults living in poverty.81,82 McKenney et al found a number of risk factors for STIs among men who reside in rural areas:83

  • Rural men were less likely to have ever been tested for HIV than men who lived in urban areas.
  • Rural men were also less likely than their urban counterparts to have received free condoms or individual prevention counseling in the past year.
  • Rural men were less likely to have been tested for syphilis, gonorrhea, or chlamydia during the previous year.
  • Rural men felt their communities were less tolerant of LGBTQ individuals than urban men.

According to a recent study, there are “hot spots” in the southern United States where there are high rates of STIs, particularly gonorrhea, chlamydia, and syphilis.84 The hot spot counties include Mississippi, Arkansas, Louisiana, and Alabama, and the persons most affected were black and Hispanic individuals between the ages of 25 and 44 years.

HIV Infection in the Rural United States
A recent population study showed that approximately 27% of rural residents are HIV positive, with the highest incidence affecting the southern United States.85 Thirty-two percent of all new HIV infections occurred in Georgia, Tennessee, Louisiana, and North Carolina, and black individuals made up 50% of all cases.86 Young, black women are the fastest growing group of people infected with HIV through heterosexual sex.87,88

Rural residents report difficulty accessing healthcare services and an absence of anonymity when seeking care in the South.89 Persons report a prevailing stigma and conservative belief system within rural communities that hinder their search for health care.90,91 This is a public health concern because rural patients who forego diagnosis and treatment are more likely both to experience disease progression and to infect others.

The US-Mexico border is considered an at-risk area for HIV contraction and transmission.92 Studies show that the Hispanic migrant population in rural borderland communities is medically underserved.93 The Patient Protection and Affordable Care Act explicitly excludes undocumented immigrants from purchasing any form of health insurance. Martinez-Donate et al found that HIV testing rates are unacceptably low among migrants: On average, less than half of migrants had ever been tested for HIV, two-thirds of migrants who were HIV positive had not been tested for HIV before, and 89% were unaware of their HIV status.94 

Challenges and Solutions
Three major themes emerge in studies focusing on the healthcare challenges in rural America: availability, accessibility, and affordability.9

Availability
The lack of available healthcare providers, particularly PCPs, is projected to worsen by 2050. The reasons for this include fewer medical school graduates choosing primary care, and in particular, rural health care.95,96 Recruiting and retaining primary care physicians for rural areas has been challenging.97

To help fill the shortage, rural areas should look toward advanced practice nurses, nurse practitioners, and physician assistants.98-100 Studies have shown that advanced practice nurses can fill the need by providing primary care independently with full prescriptive authority, as in 21 states and the District of Columbia (Table 1).101-104

About 12% of all PAs currently work in rural settings.105 PAs in rural areas are more likely to practice in primary care specialties, see patients who are uninsured or covered by Medicaid or Medicare, and provide care for patients with chronic conditions. The health care provided by PAs is cost-effective and can increase access for rural residents.105

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Educational loan repayment grants to primary care physicians, physician assistants, and nurse practitioners have been recommended in return for their service in rural and underserved communities.106 Also, healthcare educators should establish clinical education sites in rural areas to introduce students to rural healthcare delivery.107,108

Table 1. States allowing full practice authority for NPs 2019.101-104

  • Arizona
  • Alaska
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho
  • Iowa
  • Maine
  • Maryland
  • Minnesota
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Mexico
  • North Dakota
  • Oregon
  • Rhode Island
  • Vermont
  • Washington
  • Wyoming