Hughes, A., Watanabe-Galloway, S., Schnell, P., & Soliman, A. (2015) studied the differences in colorectal screening between rural-urban in Nebraska. Their investigation into the reasons behind this gap indicated a few differences, some of which were not of the expected variety. The authors found that rural residents were more likely to believe that colorectal cancer cannot be prevented, and thus they did not feel screening was worthwhile. A higher percentage of rural residents also indicated that cost was a barrier, as well as things like perceived embarrassment, perceived unpleasantness were indicators found more frequently among rural residents. The study indicates that there are definitely some cultural factors that speak to the rural-urban divide. However, they also found that people with a personal doctor had a higher rate of receiving screenings. This indicates that physician density can also play a role – people without a doctor are more likely to not receive advice to get screenings, or referrals, and these factors can definitely result in a lower rate of screening and higher rate of morbidity. An Icelandic study (Haraldsdottir, S., Gudmundsson, S., Thorgeirsson, G., Lund, S. H., & Valdimarsdottir, U. A., 2017) regarding cardiovascular disease arrived at similar conclusions. The authors found that rural areas had a higher prevalence of preventable risk factors. However, they also found that hospital discharges were more frequent in rural areas, and that this might have contributed to higher mortality rates. The underlying causal factors of higher discharge rates were not studied here, but the implication is that shorter hospital stays might be more associated with rural residents, especially if the hospital is not in their community, but may deprive them of the full range of testing that they would have received had their stay been longer.

Amponsah, W. A., Tabi, M. M., & Gibbison, G. A. (2015) looked at cardiovascular disease in rural Georgia. As was the case with the Icelandic study, they found that lifestyle factors contributed to the gap in health outcomes. Rural residents in their study generally had lower socioeconomic status, and lower socioeconomic status is associated with higher rates of cardiovascular disease. This adds to the body of evidence that health disparities between rural and urban residents are at least in part attributed to lifestyle differences.

One of the roles that physicians play is to provide medical advice and guidance for their patients. Bo Nielsen, J., Leppin, A., e Gyrd-Hansen, D., Ejg Jarbøl, D., Søndergaard, J., Veldt Larsen, P., & ... Larsen, P. V. (2017) conducted a study in Denmark to query potential gaps in preventative care as a reason for the rural-urban outcome divide. As in many of the other studies, socioeconomic factors were linked to lifestyle choices that in turn saw increased likelihood of cardiovascular disease. In their study, rural residents were more likely to smoke, have poor diets and abstain from exercise.

Campbell, D. T., Manns, B. J., Weaver, R. G., Hemmelgarn, B. R., King-Shier, K. M., & Sanmartin, C. (2017) conducted a study in Canada that was not specifically linked to the rural-urban question. They found, however, the correlation between lower socioeconomic status and higher rates of cardiovascular disease held in their study. They specifically cited that financial barriers to accessing medications and healthy food as reasons why poorer people faced higher rates of cardiovascular disease. This removes the rural-urban dynamic from the argument, but lends further support to the link between socioeconomic status and higher rates of cardiovascular disease.

In South Carolina, rural residents face further barriers, including several that are not directly linked to socioeconomic status. Some of the barriers identified for them include lack of health insurance, lack of knowledge, misperceptions and fear, and limited accessibility as reasons why rural South Carolinians do not participate in clinical trials (Kim, S., Tanner, A., Friedman, D., Foster, C., & Bergeron, C. (2014). A fairly reasonable argument can be made that these factors could easily apply to other forms of health care as well.

Where other studies looked at lifestyle factors, Allenby, A., Kinsman, L., Tham, R., Symons, J., Jones, M., & Campbell, S. (2016) took a different approach and looked at the quality of care in rural communities, to compare it to the quality of care in urban communities. There is a clear association between targeted preventative activities and practice factors....

In other words, people tend to respond if their doctor tells them that they are at risk, and that they need to make lifestyle changes in order to solve the problem. What the authors found was that "there is substantial room for enhanced cardiovascular prevention throughout rural primary care in Australia, particularly for high-risk patients." Often, only when someone is diagnosed with cardiovascular disease were they receiving lifestyle advice – so preventative care was lacking. The authors did not delve into why this preventative care might be lacking (overworked physicians, patients traveling long distances), leaving those as critical gaps in the literature.
One study that counters many of these findings is Choo, W. K., McGeary, K., Farman, C., Greyling, A., Cross, S. J., & Leslie, S. J. (2014), where the authors found that in rural Scotland the referral rates between rural and urban patients were not significantly different. However, this is one study, and findings applicable in Scotland might not be applicable in another country as health care practices can differ. That said, it is valuable to know that rural location need not inherently pose barriers to care.

Syed, S., Gerber, B., & Sharp, L. (2013) looked at transportation barriers faced by rural residents. They found that transportation barriers were often cited as issues for rural residents by looking at 61 different studies. This form of analysis does not seek to validate the view that transportation is an issue, only that it is cited by patients as an issue. The authors found that the strongest case was for people with lower incomes and the un/underinsured. The former group might find traveling for care to be a legitimate financial burden, the latter group might not be able to pay for care, but claim other reasons why they didn't seek care. It would be interesting to see the particulars of each study – rural residents cannot travel the same distance on average as urban residents for cardiovascular care, but they don't for anything else either. Why would health care be an issue and other things not? There are unanswered questions that require looking at the constituent studies in greater detail.

One of the biggest challenges in cardiovascular care is that the care usually has to be very individual-centric and personal. In particular, preventative care needs to meet these requirements because each person needs their own individual health plan to provide cardiovascular care (Harrington RA and Heidenreich PA, 2015). The rural residents who have the worst outcomes with respect to cardiovascular disease are the ones who face the biggest obstacles – they do not receive the preventative care they need, and they do not receive the individualized care that they need in order to manage their heart health.

The body of research suggests that the biggest issues for rural residents are actually lifestyle, and they are typically related to the overall lower level of incomes in rural areas. Lower socioeconomic status is associated with less healthy lifestyles, and these in turn are associated with greater incidence of cardiovascular disease. The literature also highlights that rural people may not receive the same standard of care, certainly not in terms of preventative medicine, but none of the studies in this literature review delve too deeply as to why this is. Certainly, rural residents must travel further to receive care, but they also seem to seek it out less.

This is one of the peculiarities of eh American studies. Many rural residents have greater shame about health, seek out health care at lower rates, and generally seem less comfortable discussing or dealing with their health issues. Overall, these issues speak perhaps to a greater conservativism, but this is not helpful to health outcomes, especially when coupled with already lower physician density and greater travel times.

Drawing on the literature, finding ways to encourage rural residents to adopt healthier lifestyles seems a starting point. To do this, higher income levels would help, but so would stronger relationships between rural doctors and their patients. The lack of strength is not known, but likely relates to higher transportation barriers, and in the US the lower ability to pay. Many will simply not receive any health care at all.

The literature actually does not examine the issue of specialists. It looks mainly at primary care, and that is related to preventative medicine. But the reality is that there are fewer specialists. This might not impact on morbidity…