Improving Health and Well-Being in Aging Rural America Through the Social Determinants Framework

Background

In the United States, rurality is defined by the Economic Resource Service, which is part of the U.S. Department of Agriculture, using Rural–Urban Commuting Area (RUCA) codes (see Table 1). For this paper, rural communities use RUCA codes 7–9. Over the next 40 years, the population of older adults (aged 65 or older) is projected to nearly double in size, from 49 million in 2016 to 95 million in 2060 (Vespa et al., 2020). Currently, older adults account for approximately 15% of the U.S. population, of whom, almost one fourth (10.6 million) live in areas designated as rural by the U.S. Census Bureau.

Table 1.

Rural–Urban Commuting Areas (RUCA) Codes

Code	Classification description
1	Metropolitan area core: primary flow within an urbanized area
2	Metropolitan area high commuting: primary flow 30% or more to an urbanized area
3	Metropolitan area low commuting: primary flow 10%–30% to an urbanized area
4	Micropolitan area core: primary flow within an urban cluster of 10,000–49,999 (large, urbanized cluster)
5	Micropolitan high commuting: primary flow 30% or more to a large, urbanized cluster
6	Micropolitan low commuting: primary flow 10%–30% to a large urbanized cluster
7	Small town core: primary flow within an urban cluster of 2,500–9,999 (small, urbanized cluster)
8	Small town high commuting: primary flow 30% or more to a small, urbanized cluster
9	Small town low commuting: primary flow 10%–30% to a small, urbanized cluster
10	Rural areas: primary flow tract outside of urbanized area or urbanized cluster

Note: Reference: Economic Resource Service, U.S. Department of Agriculture.

Beyond their demographic significance, the vulnerability of older rural-dwelling adults merits attention. As a group, older rural-dwelling adults have lower socioeconomic status and poorer health status (Singh & Siahpush, 2014; Smith & Trevelyan, 2018). The communities in which they live often are considered medically underserved and lack access to a range of services, including medical and mental health services (Smith & Trevelyan, 2018).

Health inequities among older rural-dwelling adults are significant. Inadequate access to health care services constitutes a critical challenge to many older rural residents. In addition to health care professional shortages, rural residents often lack resources for cost of services, transportation to access these services, and recommended treatment expenses. Although telehealth and telephone-based care management may improve access to health care (Gerlach et al., 2018; Nelson, 2017; Singh et al., 2010); these resources require stable internet or cellular services, which are not as readily available in rural communities (Levy & Langa, 2015).

Utilization of health and social services remains a primary determinant of health and well-being of older adults living in rural communities. Even in rural areas where health care is accessible, providers are often perceived by older adults as their friends and neighbors, rather than practicing professionals (Goins et al., 2005; Gonyea et al., 2014). These dual relationships raise concerns about stigma, discrimination, and confidentiality. In addition, cultural misalignment with healthy lifestyle choices and the lack of availability and access to comprehensive health systems (e.g., specialists and integrated care practices) impact health outcomes. Ultimately, these determinants of health result in patients having limited treatment and services, and families having limited resources and support (Anderson et al., 2015).

Therefore, the purpose of this editorial is to discuss determinants of health among community-dwelling older adults living in rural communities. We will provide a brief overview of each determinant with a corresponding recommendation for future programmatic and research endeavors. The authors intend to draw attention to the manifold determinants of health and well-being that face rural-dwelling older adults.

Conceptual Framework: Social Determinant of Health and Well-Being of Rural-Dwelling Older Adults

To address the broad array of factors and circumstances that contribute to these health disparities, we use the social determinants of health (SDH) framework. The SDH framework (Figure 1) acknowledges life-course factors, built and social environment, activities and social engagement, social capital, and demographics, among other domains. Using this framework, we provide recommendations based on important, yet underdeveloped areas of research that are needed to promote health and well-being tailored to older adults living in rural communities (see Table 2). These recommendations can be used by public health practitioners, health care providers, researchers, and community organizations to mitigate health disparities among older rural-dwelling adults.

Table 2.

Summary of Recommendations

Social determinants of health and well-being	Topic	Summary recommendation
Social capital, activities and social engagement, social and economic factor	Caregiving and planning for caregiving needs	Develop and provide informal, culturally responsive caregiver interventions to offer emotional, education, and logistic support to family caregivers.
Demographics, social and economic factor, built and social environment	Access and utilization of technology	Assess opportunities for and facilitate intentional technology-supported interventions including low technology medical equipment for chronic disease self-care management and sustained mobile Health encounters using tablets or smart phones. Education is needed for preparing aging rural residents on how to leverage technology for daily tasks.
Social capital, built and social environment	Transportation	Early planning using evidence-based programs and interventions for assessing driver risk and supporting driving needs.
Social capital, social and economic factor, built and social environment	Access to resources and insurance coverage	Programs such as home health services, “hospitals at home,” other home-based care. Families in rural areas often also need supports for caregiving for grandchildren or, at times, adult children.
Life course, built and social environment, social and economic factor	Advanced care planning and palliative care	Community-based education programs on palliative for older adults, family members, and community members to reduce its stigma. Utilize community health workers to help develop advance care planning for older adults.
Life course, built and social environment	Cognitive decline and dementia	Education is needed for patients, families, and caregivers. Professional training for workforce development will help to reduce stigma about dementia. Dementia-friendly communities may also help to increase knowledge, acceptance, and accessibility of cognitive impairment care and treatment for rural areas.

Figure 1.

Conceptual framework outlining social determinant of health and well-being of rural-dwelling older adults. Adapted from the social determinants of health framework (Healthy People 2030, 2022).

Caregiving and Planning for Caregiving Needs

Rural caregivers (CGs) provide higher levels of care and experience worse health-related quality of life as compared with CGs in urban areas (Cohen et al., 2022). Consistent with inequities in health and social services for older rural-dwelling adults, support services for CGs are less likely to be available and used by rural CGs (Easter Seals and National Alliance on Caregiving, 2006), including dementia-specific CG support services (Bayly et al., 2020; Gibson et al., 2019).

It is important for rural-dwelling older adults who have fewer resources (Weaver et al., 2018) to consider future care planning (Bischoff et al., 2013). Future care planning is when individuals, couples, or families consider the possibility that frailty or disability might be a future health state, and seek information or make decisions ahead of time for the purposes of maintaining the quality of life for the frail or disabled person (Sӧrensen et al., 2011). To better address the care needs of older rural adults and challenges facing their formal and informal CGs, researchers have implemented numerous interventions to help encourage future care planning, including national social marketing campaigns, such as “Own Your Future,” that encourage people to actively plan for long-term care needs; multisession interventions such as SHARE (Support, Health, Activities, Resources, and Education), a counseling-based care-planning intervention for persons living with early-stage dementia and their family CGs (Whitlatch et al., 2006); and single-session interventions like the “Thinking Ahead Project (TAP),” which integrates aspects of an existing evidenced-based advanced care planning program along with motivational interviewing, and adjusts based on health literacy needs (Huang et al., 2016).

Existing efforts to provide information on a community level (e.g., “Own Your Future”), versus education tailored to the needs of individuals and families (Huang et al., 2016; Whitlatch et al., 2006), have been only moderately successful (Tell & Cutler, 2011). Public awareness campaigns may not be effective for older adults in small towns and rural communities, rather, identifying, and training lay leaders in the community might be more appropriate by “leveraging the strong social networks within rural communities” (Bardach et al., 2012, p. 6). Messaging on a community level is more likely to be meaningful for people who already see the need for planning ahead for later life. However, for individuals and families who do not yet see the value in planning ahead for care needs, interventions are needed that enhance awareness and motivation to plan through personalized counseling and conversation.

In addition to the rural inequities and resource scarcities, several issues salient to developing effective caregiving systems for rural elders must be considered. First, family and fictive kin are essential resources for older adults in their small towns. Practitioners need to be mindful of the complexities of family dynamics and the role that family (fictive and relational) plays in the aging process. While many rural regions in the United States have been characterized by their strong social support networks, it is crucial to have culturally competent and sensitive health workers (e.g., social workers) in such regions who can build upon the strengths of such social support networks. Lastly, rural older dwelling adults may themselves be CGs, adding an additional challenge to meeting the increasing needs associated with aging. Particularly, the increasing prevalence of grandparents as primary CGs raises questions about whether and how older adults can care for themselves in both the prevention and treatment of chronic and acute illness.

Recommendation 1

Interventions for informal CGs in a rural setting might alleviate the emotional burden of caregiving, provide educational support to strengthen their skills, and ensure logistic support to help CGs and care receivers in managing day-to-day life (e.g., care navigators; Morelli et al., 2019; Roberto et al., 2022). To address the needs of rural CGs, we must account for the nuances of different rural communities by involving rural CGs and other stakeholders in the development of culturally and contextually appropriate services (Morelli et al., 2019, p. 1371). Community-based interventions and programs that include locations where older adults and their CGs are likely to visit (e.g., physicians and other health care providers, public libraries, and senior centers) are critical to the uptake of such services.

Access and Utilization of Technology

Despite limitations in access to and use of technology to promote health and wellness in rural and geographically isolated communities, the potential of such approaches is notable. The use of technology for means of health care delivery increases outreach efforts to those who may be homebound, have transportation limitations, and/or need care beyond reasonable travel distance (Pappadà et al., 2021). Additionally, the use of technology can provide alternative care opportunities through wearable devices (Yang et al., 2021), social interactions (Shu & Woo, 2021), and care reminders (Ruggiano et al., 2021). The COVID-19 pandemic underscored the limitations of internet, cell phone, and other technology-related approaches in rural communities. In response, the U.S. government implemented the Affordable Connectivity Program, a $14.2 billion program to help offset the costs of internet access for low-income households (Affordable Connectivity Program, 2022). Still, there are limitations to receiving this service due to lack of cabling and fiber optics in remote areas and reliance of the government to invest the necessary infrastructure (Prieto et al., 2019).

Specifically, among older adults, there has been a notable trend in the use of technology during the COVID-19 pandemic, where 75% of older adults reported online activity daily (Morrow-Howell et al., 2020). There has also been the emergence of programs to help reduce the effect of social isolation for older adults such as Student and Seniors and Zoomers to Boomers, which suggests that older adults are willing and able to use technology as a means for social interaction (Morrow-Howell et al., 2020) and, potentially, to intervene on other concerns related to health and well-being.

Recommendation 2

We recommend acquiring low-technology medical equipment for chronic disease self-care management; identifying opportunities for sustainable mobile health encounters using tablets or smart technology; assessing older adults’ attitudes, comfort with, and actual utilization of technology to inform the integration of technology-supported interventions; and community-based educational opportunities should be offered that allow older adults to leverage technology to assist with daily activities and supportive care (Wójcik et al., 2021).

Transportation

Lack of reliable transportation constitutes a major barrier for many rural-dwelling older adults due to not having reliable access to a vehicle, not having family or friends who can provide rides, or an inability to safely drive due to disability or functional limitations (Arcury et al., 2005; Henning Smith et al., 2017; Syed et al., 2013). The inability to access reliable transportation indirectly creates barriers to aging in place, which is preferred by older adults, and access to timely preventative and nonemergency care (Pruchno, 2012). For example, in a sample of households living in rural counties in Western North Carolina, Arcury et al. (2005) found that adults with a driver’s license had an increased rate of attending both chronic and primary care health care visits compared to adults without a driver’s license. Although at a lesser rate, adults who relied on rides provided by family or friends also had a higher rate of attending more health care visits compared to those relying solely on public transportation. Although research has shown associations between transportation-related barriers and negative health outcomes (Ryvicker et al., 2018; Syed et al., 2013) and lower quality of life (Pope et al., 2022) in samples of older adults suffering from multimorbidity, it is unclear is if these associations differ by geography once other income indicators are controlled for (Syed et al., 2013).

Recommendation 3

Although app-based ridesharing use has increased among older adults (Jiang, 2019), there remain very few for-profit services in rural communities (Freund et al., 2020). Hence, we recommend evidence-based interventions, such as CarFreeMe, that have been designed and recently adapted in samples of older adults with dementia (Scott et al., 2019, 2020); design programs that facilitate older adults’ utilization of nonemergency medical transportation options that are covered through Medicaid benefits as well as some Medicare Advantage plans (Wolfe et al., 2020); and lastly, advocate for federal funding dedicated to improving roadway infrastructure and implementation of public transportation options in rural communities to increase access and mobility.

Access to Resources and Insurance Coverage

According to the 2018 U.S. Census Bureau report, 9.1% of people living outside of metropolitan areas lacked health insurance. Compared to urban counterparts, rural areas have limited numbers of health care providers who offer low-cost or free health care services (Rural Health Information Hub, 2022). To mitigate the effect of a lack of resources, community health workers (CHWs) can be instrumental in helping to address the lack of insurance coverage as well as promote health care literacy and barriers to care such as SDH. CHWs are equipped to assist patients in the outpatient setting with navigating the process of applying for private or government-supplied health insurance to meet their needs. Well-trained CHWs possess knowledge of programs such as medication assistance, durable medical equipment, glasses, food, and transportation that can be instrumental to older adults seeking health-related resources. In addition, CHWs can educate patients on their chronic disease states as well as how to access and use telehealth services, when available.

Recommendation 4

Utilizing CHWs as well as home health services may help reduce the burden of frequent hospital admissions by allowing at-home monitoring and chronic disease management. Given the near universal preference for remaining at home, newer models such as “hospital at home” may be useful to manage certain conditions at home and avoid hospitalization (e.g., IV antibiotics). Programs such as these bring the resources directly to the patient, thereby eliminating the barrier of transportation and limiting the unnecessary use of EMS transportation and hospitalizations. This would also allow patients to maintain some independence in their home and, in a lot of cases, be able to still provide care for their loved ones, if they themselves are CGs. Employing implementation and dissemination science frameworks and methodologies could be beneficial to understanding how to expand existing programs that provide access to care that support aging in place.

Palliative Care and Advanced Care Planning

Hospice and palliative care remain stigmatized in many rural areas. For many people, “calling in hospice” means that they are giving up on the dying person. However, hospice can offer a range of services beyond end-of-life care. Educating the public about what palliative care means could encourage the use of these services in small towns and rural communities. Advanced care conversations should be had whenever appropriate for hospitalized patients or at routine clinic visits, especially for those who are frequently readmitted for the same issue. Having an intentional dialog with patients could prevent readmissions, while also allowing the patient to remain home and be cared for in a way that is most suitable for them. One tool that might be useful for health care providers and social workers is the Serious Illness Conversation Guide (SICG; Bernacki et al., 2015). The SICG provides a framework for having value-based conversations about serious illness and aims to support providers (Paladino et al., 2020, p. 4551). The tool is available free online and has been used and adapted for settings that include oncology, pediatrics, and emergency departments.

Recommendation 5

It is imperative that research is done to develop community-based, culturally relevant education programs on the use and various components of palliative care to reduce its stigma. In addition, CHWs can assist with advances care planning programs for community-dwelling older adults in rural communities.

Cognitive Decline and Dementia

In many rural communities, there is limited access to early diagnosis and early intervention for cognitive decline and dementia. Cultural misconceptions about cognitive decline include: “memory loss is a normal part of aging”; “there’s nothing you can do about it”; and “we don’t talk about it” (James et al., 2021). The misconceptions are likely due to the lack of knowledge of why, where, and how to get care; and limited availability of relevant health care providers. Other factors for seeking memory-related support include point of entry to receive care and delay of seeking care due to acceptance of memory loss as part of the aging process (Bayly et al., 2020; James et al., 2021).

Recommendation 6

Increased educational opportunities to demystify and correct misconceptions about cognitive impairment and dementia, especially for rural communities, are critically needed (Bacsu et al., 2020). Expanded educational programming for medical and health care professionals related to geriatrics, as well as indicators of cognitive impairment, can improve earlier recognition and treatment (Padala et al., 2020). Additionally, community-based programming has been shown to be beneficial in shifting social attitudes toward cognitive impairment and dementia (Ebert et al., 2020). Dementia-friendly communities are evidence-based campaigns aimed to increase knowledge, acceptance, and accessibility of cognitive impairment (Thijssen et al., 2022). However, there is limited evidence of current initiatives specific to rural communities despite the heightened need due to limited resources. Concentrated efforts for holistic educational programming, both community-based and formal education, are urgently needed to prepare for the societal impact of cognitive impairment as the population continues to age.

Conclusion and Limitations

Despite our attempts to contribute to this topic, we acknowledge several limitations. First, older rural residents are a diverse population. When considering specific regions or subgroups with shared sociodemographic characteristics, it is important to acknowledge heterogeneity. Consequently, frameworks that account for health behaviors or outcomes and potential solutions to vexing problems must be carefully tailored and targeted. This editorial focuses primarily on aging among rural adults in the United States. While some challenges and recommendations discussed may be shared across cultures and counties, we acknowledge that many may differ and require local context and knowledge to address this complex issue. Second, our knowledge of this complex, heterogeneous group is stymied by limitations in existing datasets and research in the United States. Rural-dwelling older adults are underrepresented in longitudinal studies, making it challenging to take a long-term perspective on the health and social needs of this population. Whether this underrepresentation derives from the reality or perception of being a hard-to-reach population, the inaccurate assumption that rural-dwelling older adults do not merit special attention due to their demographic significance is baseless. The reality is that we continue to lack a grounded and longitudinal understanding of rural aging. Finally, and related to the above points, rural communities like all environments are in constant flux, making it difficult to recommend static policies and research approaches. For example, the Public Health Emergency proved to be a tremendous impetus in the uptake of telehealth among rural populations, including older adults. While, for many years, gerontologists have noted that rural older adults constituted some of the fastest growing users of technology, rural older adults historically were not as active in this technological expansion. Over the past several years, the mode of health care delivery in rural areas has transformed to embrace telehealth, telemedicine, and remote assessments. Although we address technology and other trends in this editorial, it is important to acknowledge that such evolutions are constant and that researchers may overlook macro and micro social trends. Moving forward, we hope that the broad perspective embodied in the SDH framework will encourage a comprehensive, contextually appropriate, and current consideration of the challenges facing older rural residents and their communities.

Funding

None declared.

Conflict of Interest

None declared.