Prepared by John A. Krout, PhD Professor Emeritus in Gerontology and Founding Director of the Ithaca College Gerontology Institute.
A small but significant area of study within gerontology examines aging in rural places and compares elders based on rural or urban residence. Researchers and practitioners working in “rural gerontology” focus on the impact of rural community characteristics and life styles on the quality of life of elders.
Aspects of rural communities (compared to more populated communities) that impact elders include:
- smaller and less-dense populations;
- less-differentiated social, economic, and organizational institutions;
- fewer service options;
- different socio-demographic profiles;
- more traditional values and cultural traditions; and
- fewer resources to address the needs of older adults.
Using the definition of rural as outside of a metropolitan area, two-thirds of the nation’s 3,142 counties are rural and include well over 50 million persons. However, the size and significance of America’s rural population has been waning for decades. Between 2000 and 2010, the size of the rural population declined from 21% to 19% of the nation’s total. At the same time, rural America is becoming much more diverse, with 83% of rural population growth during that same decade accounted for by nonwhites. Regions and states vary widely in how rural they are, as do economic and social trends in different rural places. Thus the experiences of elders in rural communities also vary.
A diverse population
Contrary to popular myth, rural places are very diverse economically and demographically. Some are predominately white while others are primarily African American or Hispanic. Some are primarily agricultural and others have much more diversified economies. Rural areas with a heavier manufacturing base have fared better in recent decades as have those participating in the recent oil and natural gas production boom. Rural areas that have qualities attractive to retirees or have colleges or universities offer unique opportunities to elders. Predominately agricultural areas, on the other hand, have seen out-migrations of young adults due to farm consolidation, suffer from a lack of services, and tend to have a much greater percentage of the population that is old.
Impact of rural aging
The rural population includes over 8 million people age 65+, and rural areas are older than urban ones with a greater percentage of population age 65 and over (16.2 vs. 12.6) and a higher overall median age (40.3 vs. 36.6).
Existing studies have consistently shown that, compared to elders living in more urban areas, rural elders generally:
- have higher poverty rates, lower incomes, and fewer employment opportunities;
- live in less adequate and older housing;
- rely more heavily on themselves and informal networks for transportation;
- are less healthy;
- have less access to a wide range of community-based social, health, and mental health services; and
- have fewer long-term care options.
Elders living in rural places often face a “double jeopardy” as they encounter the physical, social, and economic changes that accompany aging in communities that offer fewer resources to counter them. Despite this, very little research has focused on the unique aspects of aging in rural places and even less on specific policies, best practices and programs, and professional competencies to address the needs of rural elders and their families.
Quality research and funder attention on rural aging have not kept pace with that on other aging topics, for several reasons.
First, the term “rural” is broad and vague, and not consistently defined by state and federal funding and policy agencies. Thus, it is difficult to conduct meaningful rural analyses with many existing data sets.
Second, as an umbrella factor, rural does not elicit the same level of concern or interest as does a specific topic such as Alzheimer’s disease or falls prevention, partly because most gerontological studies use the individual not community as the unit of analysis.
Third, advocacy for rural aging issues does not match that for many other aging topics. Some rural aging topics have received more attention than others, often because they impact rural persons of all ages. Health status, including nutrition and obesity, transportation needs and programs, and family caregiving are a few examples.
Grantmakers in Aging has begun a three-year Rural Aging Initiative entitled “Creating a Sustainable Network for the Rural Aging Movement," funded by the Margaret A. Cargill Foundation. Its goal is to create ways to connect and support key players concerned with rural aging, share knowledge, and expand the resources and services available to older adults in rural areas. Specific project activities will include:
- Building an infrastructure to bring together key representatives in the rural aging movement, including face-to-face and virtual meetings.
- Identifying the most useful information and materials on rural aging that are already available, identifying gaps, and creating and sharing new resources as needed.
- Establishing a broad-based, partners-in-funding group comprised of government, civic organizations, United Ways, Area Agencies on Aging, philanthropy, and other key players.
- Launching a “Rural Aging in America” website and an associated learning community, and adding briefing materials on rural aging to GIA’s own website.
- Producing a short video and several infographics on the challenges and important work being done in rural aging.
- Developing a messaging tool, “Talking about Rural Aging,” to share messages and strategies that have been effective in raising the profile of rural aging.
The Cargill Foundation also supports other organizations that extend services to seniors in rural communities focused on maintaining dignity and independence, supporting aging in place, increasing the direct-care workforce in home and community-based settings, and developing technologies and tools to support these strategies.
The Helmsley Charitable Trust incorporates a focus on older adults in its rural healthcare program, where grants are awarded to improve healthcare access and delivery and to strengthen the healthcare workforce. The Trust has also funded a number of initiatives that employ technology, including remote patient monitoring, to help seniors better manage their health.
The Northland Foundation in northeastern Minnesota is in the third year of a $2.5 million Rural Aging Initiative to strengthen avenues for older adults to age in place. The initiative focuses on assisting communities to better serve older adults and their caregivers, increasing civic engagement and social connectedness among older adults, and honing models for rural assisted living that combine housing and services.
The Kate B. Reynolds Charitable Trust sponsors an award program for individuals and organizations entitled “New Rural: Innovations in Rural Health Award.” The awards are designed to encourage and recognize promising work that has the potential to improve the health status of people living in rural communities in North Carolina and nationally.
Many of the health needs of rural elders are supported by the work of the Bureau of Health Professions’ Geriatrics Workforce Enhancement Program (which includes Geriatric Education Centers). Grants made to 28 states, some with large rural populations, support programs that integrate geriatrics with primary care, maximize patient and family engagement, and transform the healthcare system to meet the needs of the population.
The physician shortage in rural areas has been well documented, but the delivery of health care to rural elders can be enhanced in states where advanced practice nurses are allowed to practice without a doctor’s oversight (21 states to date). The Robert Wood Johnson Foundation is supporting the Future of Nursing: Campaign for Action with AARP’s Center to Champion Nursing in America to help remove outdated statutory barriers and build a “Culture of Health” in every community.
It is difficult to identify those topics that are in the greatest need of more attention from funders, because even those that have been the focus of research, demonstration projects, or program funding initiatives by foundation and government sources are not adequately understood or addressed.
Listed below are a range of general topics in need of further research on unmet needs; model program development, evaluation and dissemination; and policies to bring more resources to rural areas:
- basic and medical transportation alternatives;
- health promotion and disease prevention;
- alcohol and drug abuse prevention and treatment;
- nutrition education and obesity prevention and treatment;
- expansion of home health and mental health services;
- increased access to critical access hospitals;
- use of telehealth and other technologies to monitor health status; and
- long-term care options that utilize rural community strengths and available resources.
Noted below are four general priorities that would lead to an increased understanding of these topics:
- Develop a national online data bank to collect and disseminate research on rural aging needs; information on program models, initiatives and best practices; and strategies to leverage limited resources through collaborative approaches to service planning and provision.
Information on rural aging is scattered and uncoordinated at the federal and state level. Many initiatives are carried out at the state or local level and are often not rigorously evaluated.
One exception that could serve as a model is the National Resource Center on Rural Aging that was supported by the Administration on Aging from 1988-1991. This center collected and disseminated state-of-the art research and program information nationally on a variety of topics such as transportation, nutrition, and family caregiving via hard copy. However, the author is unaware of any contemporary version of such a program. Another possible model would be the effort by led the National Council on Aging titled “National Study of Health and Supportive Services in the Aging Network, 2000-2001” that included descriptions of professionally evaluated programs.
A number of professional organizations in aging have maintained interest groups on rural aging such as the Gerontological Society of America’s “Rural Interest Group” which focuses on research, and the National Council on Aging which provides webinars and other information relevant to rural aging issues. Some organizations focus on and advocate for rural health issues in general such as the National Rural Health Association. However, none of these organizations has the resources necessary to achieve the goal noted above.
2. Identify, evaluate, and disseminate information on programs that effectively recruit, educate, train, and retain professionals involved in service provision to rural elders.
Barriers to these actions are fairly well documented and nearly every state with significant numbers of rural elders has at least piloted rural practitioner training and retention programs that impact older populations, but their success and institutionalization is not known.
One example of a program designed to enhance the knowledge of aging professionals in rural areas is that conducted in upstate New York by the Ithaca College Gerontology Institute. Supported by funding from the Bureau of Health Professions to the Finger Lakes Geriatric Education Center, this program has provided on-site as well as web-based education sessions on locally identified topics to a wide range of social and health service professionals for almost 20 years. In 2007, this program conducted a New York Statewide Rural Gerontology Summit that brought together consumers, providers, politicians, agency heads, and policy experts to identify solutions to problems facing rural elders. However, as is the case with many such well-intentioned initiatives, a lack of resources and political will limited the implementation of its recommendations.
3. Increase the amount of information on rural aging included (and required) in professional schools such as medicine, social work, and the allied health professions, with an emphasis on multi- and interdisciplinary education and professional competencies necessary for successful rural practice.
Unfortunately, many health and social service professionals working with older adults have little specialized education or training in gerontology or geriatrics and even less in the unique issues they face in rural communities. However, curriculums and programs in rural social work and nursing do exist and could be used to inform wider initiatives in rural aging education.
4. Investigate the impact of emerging trends on rural elders and service planners and providers.
A discussion of areas in need of greater attention must be viewed not only in terms of today’s older rural population, but with an eye to the impact of future changes that will likely occur. These include:
- increased rural demographic diversity,
- the epidemic of drug abuse among rural young adults,
- increasing resource gaps between haves and have-nots at the individual and community level,
- greater consolidation in health care systems and specialized medical services in more populated areas, and
- increased availability of technology as a means to address health issues.
Aging in Rural Places: Policies, Programs, and Professional Practice by Kristina M. Hash, Elaine J. Jurkowski and John A. Krout, Springer Publishing Co., 2015.
Rural Aging in 21st Century America, Nina Glasgow and E. Helen Berry, Eds., Springer Publishing Co., 2013.
“Rural America at a Glance: 2015 edition,” Economic Research Service, U.S. Department of Agriculture, 2015.
Service Delivery to Rural Older Adults: Research, Policy and Practice, R. Turner Goins and John A. Krout, Eds., Springer Publishing Co., 2006.
Social Work in Rural Communities by Leon Ginsberg, Council on Social Work Education, 2011.
Organizations and Online Resource Libraries
Rural Health Information Hub: formerly the Rural Assistance Center; provides extensive information, tools, and resources.
Housing Assistance Council: a national nonprofit organization that helps build homes and communities across rural America.
National Association for Rural Mental Health: a membership organization for professionals and consumers that serves the field of rural mental health.
Center for Rural Affairs: a policy and advocacy group for rural Americans.
National Rural Health Association: provides leadership on rural health issues through advocacy, communications, education, and research.
HRSA, Federal Office of Rural Health Policy: resources on rural health and health policy.