Background

The passage of the Affordable Care Act (ACA) in 2010 heralded a significant shift in American health care, with increased emphasis on population health, disease prevention, and cost containment. These new areas of emphasis are prominent in several initiatives that have emerged in the wake of the ACA, including Accountable Care Organizations (ACOs), which tie provider reimbursements to measures of quality of care and reductions in the total cost of care for assigned populations of patients. The Patient Centered Outcomes Research Institute (PCORI) also emerged, charged with examining the relative health outcomes, clinical effectiveness, and appropriateness of medical treatments. Underlying these initiatives is a renewed emphasis on patient engagement in health care and, more specifically, on patient activation.

While patient engagement and patient activation are often used interchangeably, patient engagement denotes the broad involvement of patients and caregivers in all aspects of health care is based on the principle of shared responsibility [1]. Patient activation, a component of patient engagement, emphasizes patients’ willingness and ability to take independent actions to manage their health and care [2]. Patient activation has been found to be associated with better health outcomes, better health care experiences, and reduced probability of adverse markers such as emergency department use, obesity, and smoking [2,3]. Health care systems are encouraging primary care providers to practice patient-centered care, employing strategies that engage with and activate patients. This approach is grounded in the perspective that care should focus on patients and finding a common ground between patients and clinicians when choosing preventive and treatment care pathways.

This focus on patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Individuals define “health” on the basis of their personal health-related beliefs, values and knowledge. Improved understanding of how patients think about and define their health is needed to more effectively “activate” patients, and to nurture and support patients’ efforts to improve their health.

For more than 25 years, researchers have suggested that rural populations may have a distinct view of health that differs from other non-rural populations. Seminal research in 1987 by Weinert and Long reported that rural people predominantly associated health with “the ability to work” [4], but were less likely to regard cosmetic, comfort, or life-prolonging aspects of health as important. In subsequent work, Weinert and Burman concluded that the rural “function-based definition of health” may contribute to delays in seeking health care, even in the face of grave illness [5]. In a study of the health beliefs of rural elders, Davis et al. found that subjects described health in terms of autonomy and self-reliance; they feared loss of health primarily because it could lead to “being a burden to others” [6].

These early studies indicate the need for a richer understanding of rural “frames” for health, but they lacked a direct comparison to health views from non-rural counterparts. If rural and non-rural populations indeed commonly think about or define their health differently, then efforts to engage such populations in promoting and preserving health must be better informed, particularly as health care providers increasingly focus on patient-centered care. The purpose of this study was to systematically review and critique the extent and strength of the published literature regarding how persons living in rural areas define health. In addition, we sought comparisons between rural and urban concepts of health. We were interested in findings that could guide improved patient engagement and patient activation in rural communities of the United States and similar industrialized countries. We specifically examined health values and beliefs as constructs rather than knowledge per se, as knowledge generation is better understood as a continuous process influenced by values, beliefs, motivation, skills, and context [7,8].

Methods

We conducted a systematic review of the literature to assess the current scientific understanding of rural definitions of health [9]. The online databases PubMed, CINAHL, PsycINFO, AnthroSource, and Sociological Abstracts were searched, followed by a manual search of the reference sections of studies identified through the online database search. Key search terms that were used were “rural population, “attitude to health,” “health behavior,” “health promotion,” “health belief,” and “health values.” Studies were eligible for inclusion if they were published in English, reported on original research, presented findings or commentary relevant to rural definitions of health, were published over the last 40 years (01/01/1972-03/31/14), and were based on observations of rural U.S., Canadian, or Australian populations. These countries were selected because of their large rural populations, including remote/frontier communities, and their access to Western health care. No restrictions were placed on sample size, research design, or length of follow-up.

For data extraction and synthesis, two reviewers were assigned to each article and blinded to the other reviewer’s comments. For discordant reviews, a third blinded review was performed. Articles were reviewed for content, methodology and rigor, with information collected on study design, characteristics of the study population, whether articles related to rural definitions of health, the definition of rural, and whether there was a comparison group (e.g., rural vs. urban). All information was captured in a Microsoft Excel spreadsheet for summarizing and comparisons. Further details on the review process are provided in Additional file 1.

The review process identified 34 articles as having fulfilled the criterion of assessing how rural residents define health. These articles were assigned an evidence grade of A, B, or C depending on methodological quality and supporting evidence of the conclusions, based on a previously used adaptation of the American Diabetes Association's (ADA) evidence grading system [10,11].

Because this was a retrospective review of data from previous published studies, no patient informed consent procedures were applicable, and the study was exempt from review by the Essentia Health Institutional Review Board.

Results

Three hundred and eighty two articles were identified using the study’s search terms; an additional fifteen articles were identified as cited references during the review process. From these, 125 articles were selected for initial review by the lead author. Ninety-one articles were excluded because they did not report on original research or were outside of the scope of the current inquiry. Thirty-four were utilized for this review; 4 were commentaries about a rural definition of health [4,12-14] and 30 contained findings relevant to a rural definition of health (see Figure 1). Of the latter 30 studies, 6 [15-20] included an urban comparison group (see Table 1). The remaining 24 articles [6,21-43] did not include a comparison group. Few studies compared rural and urban definitions of health directly.

Figure 1
figure 1

PRISMA diagram of literature review process.

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Table 1 Published research relevant to rural definition of health: with comparison groups (N = 6) and without comparison groups (N = 24)
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The 6 studies that compared findings from both rural and urban populations were of primary interest. Findings relevant to a rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence (see Table 1). In a focus group study by Gessert et al., rural responders were more likely to express greater willingness to accept ill health and even death as natural phenomena, whereas urban residents expressed stronger aversion to death and greater insistence on aggressive end of life care [15]. In a study to examine factors influencing individual capacity to manage coronary artery disease risk, both gender and culture (rural vs urban) were identified [18]. Rural residents expressed belief that a “work hard, eat hard” attitude kept them healthy despite the stress of their work and living in a rural environment. Additionally, rural residents would only seek a physician’s help if physical functioning was severely impaired [18]. Rural vs. urban differences were also evident in driving behavior, with rural residents more likely to participate in risky behaviors and less likely to have confidence in the utility of safety interventions [16]. Another study found that persons living in the most remote environments were more likely to hold highly stigmatized attitudes toward mental health care and these views were strongly predictive of willingness to actually seek care [17].

Comments from participants in several of the reviewed studies (see Table 1) centered on three traits that influenced their definition of health: independence, stoicism, and fatalism. Thorson et al. found that rural elders were less likely than urban elders to turn to health care providers for issues they considered non-urgent, regardless of how long a particular symptom had been present [20]. Hoyt et al. concluded that the agrarian ideology of self-reliance and rugged independence, coupled with a lessened sense of confidentiality and increased pressure to conform due to the smaller, more intimate nature of smaller rural environments, was not conducive to seeking mental health care, particularly for males [17]. Attitudes of rural and urban residents toward seeking medical care were similar in the Harju et al. study [16], but were somewhat incongruent with self-reported care seeking behaviors. Fear of hospitals was associated with medical adherence in rural residents and good health habits in urbanites [16].

Original research articles that did not include a comparison group (n = 29) also revealed influential themes among rural residents’ definitions of health: autonomy, avoiding medical care, and spiritual health. Rural elders participating in a study in Alberta (Canada) reported that ability to work and ability to function, irrespective of symptoms or underlying illness, was their definition of “health” [29]. In a focus group study of individuals from rural communities in Wyoming, “cowboy up to continue doing what you have to do” was a prevailing theme in responses pertaining to how participants viewed health [34]. Arcury et al., reporting from interviews of elderly residents in two rural communities in North Carolina, concluded that the residents’ definition of health integrated physical, mental, spiritual, and social aspects of health [21]. Another study of rural elderly in New Mexico reported that the common definition of health consisted of remaining autonomous and independent, avoiding contact with the health care system [23]. Lastly, from a study that included interviews of rural health providers in Colorado, one provider’s perspective, based on a 90 year old patient still engaged in ranching, was that work at any age gave patients a sense of purpose that kept them going regardless of the physical challenges of getting around [35].

Discussion

This review assessed the extent and strength of evidence regarding how rural people in the United States, Canada and Australia view health differently than their urban counterparts. The overarching objective of this review was to better understand rural definitions of health and how they might be applied in health education messaging and patient engagement/ activation strategies related to disease prevention and treatment. This review largely confirmed many general characteristics previously observed on rural views of health, but also documented the extensive methodological limitations of studies that empirically compared rural vs. urban samples. The evidence in this area is particularly weakened by the routine absence of parallel comparison groups and standardized assessment tools, among other limitations.

Despite these limitations, several consistent characteristics of a rural definition of health were identified. Rural populations tend to emphasize functional aspects of health, especially the preservation of the ability to work and to fulfill (traditional) social roles. Rural people tend to frame health in terms of independence and self-sufficiency, and to accept ill health with higher degrees of stoicism and seemingly more fatalism. If more rigorous future studies can confirm these findings in rural populations, health education and patient engagement/activation programs can be better structured in ways that capitalize on the strong underlying motivations to preserve independence through good health practices. Our findings suggest that rural populations might be more responsive to health messages that emphasize physical function, independence, self-sufficiency, and the ability to reciprocate in social roles and perceived obligations.

Projects designed to improve the health of rural populations face a number of challenges. At a macro level, rural settings are not homogenous in terms of culture, economic hardship, or sense of history/community. Accordingly, findings from one rural community or similar group of rural communities may not be applicable to other rural communities or regions. Much of the previous research on rural health reported findings from primarily agrarian samples, which is an increasingly small subset of rural settings and not necessarily similar to other rural areas that rely heavily on manufacturing, forestry, or subsistence occupations. This distinction has become more pronounced in recent years with the growth of rural recreation and retirement communities, as well as other rural environments where the agrarian economy or culture has limited influence.

Individual characteristics are also important in rural health attitudes and beliefs. Several investigators reported that religious or spiritual health was an integral part of the definition of health in the rural communities studied. Socioeconomic status is recognized as a key factor in health attitudes and practices, yet few studies in the current review controlled for the socioeconomic status of rural participants. Age and length of time in the community may also be important because some of the most distinctive rural definitions of health were held by older residents (particularly those who had a life-long history of rural residence). The current review also suggests that some work histories such as lifelong farming or ranching may be associated with the more distinct views of health framed by physical function and capacity to work. A better understanding of rural attitudes and beliefs is needed to engage and activate rural residents in managing their health and care. Thus, further study of how rural residents define health will contribute to the implementation of patient-centered care in rural communities.

This study was limited principally by its focus on industrialized Western countries. Additional research is needed both to examine rural concepts of health in a wider range of settings, especially in the developing world. This study was also limited by the paucity of rigorous studies that compared rural and urban perceptions of health directly. This is a rich arena for future research.

Conclusions

There is increasing interest in engaging and activating patients in their own healthcare. To do so effectively in rural areas, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed define health in their own way (e.g., functional independence). However, a formal assessment of the risk of bias was not performed in this paper because the vast majority of studies were qualitative and did not include direct comparisons between rural vs. non-rural samples. As such, selection bias remains an overshadowing concern in this collective body of literature, highlighting the need for more rigorous studies to confirm our findings. Research on rural definitions of health is further complicated by continuously changing rural lifestyles and landscapes as demographics and economic emphases shift. Despite such challenges, however, further research on rural health beliefs and attitudes is critical as American healthcare reform legislation calls for broader, systems-based strategies to improve the public’s health. To better engage and activate rural patients in their own healthcare, a better understanding of the health beliefs of targeted rural populations is needed.