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from the printed version of the chartbook

Children in rural areas face particular risks to their health and well being. Rural children are more likely to live in poor families,1 are more vulnerable to death from injuries,2 and are more likely to use tobacco than their counterparts in urban areas.3 Rural families also face particular challenges in gaining access to health care, as they often have to travel greater distances to use health services.4 In 2010, 2,052 non-metropolitan (including rural and frontier) counties in the United States, 704 were designated as Health Professional Shortage Areas (HPSAs) for primary care, 467 were considered HPSAs for dental care, and 521 were designated as HPSAs for mental health services. In addition, 1,505 entire counties were considered Medically Underserved Areas by the Federal Government.5

Discrepancies in health status and health risks may be attributable both to children’s geographic location as well as to the demographic characteristics of the children and families who live in rural areas. Where these differences do exist, they can give program planners and policymakers important information with which to target services and interventions.

The National Survey of Children’s Heath (NSCH) provides a unique resource with which to analyze the health status, health care use, activities, and family and community environments experienced by children in rural and urban areas. The NSCH was designed to measure the health and well-being of children from birth through age 17 in the United States while taking into account the environments in which they grow and develop. Conducted for the second time in 2007, the survey collected information from parents on their children’s health, including oral, physical, and mental health, health care use and insurance status, and social activities and well-being. Aspects of the child’s environment that were assessed in the survey include family structure, poverty level, parental health and well-being, and community surroundings. The survey was supported and developed by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) and was conducted by the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).

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How Locations Were Defined

Children were classified as residing in an urban area, a large rural area, or a small or isolated rural area, based on their ZIP code, the size of the city or town, and the commuting pattern in the area. Urban areas include metropolitan areas and surrounding towns from which commuters flow into an urban area, including suburban and less densely populated areas. Large rural areas include large towns (“micropolitan” areas) with populations of 10,000 to 49,999 persons and their surrounding areas. Small or isolated rural areas include small towns with populations of 2,500 to 9,999 persons and their surrounding areas.6 Thus, it is important to recognize that the geographic categories used here describe the location’s commuting pattern and proximity to a city or large town, not necessarily the population density of the child’s home town.

The map [image below] shows how these three types of areas are distributed across the United States. Of the 73.7 million children in the U.S., 60.2 million live in urban areas, 6.7 million live in large rural areas, and 6.8 million live in small or isolated rural areas.

rural and metro areas of the United States

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Findings of the Survey

Urban and rural children differ in their demographic characteristics, which, in combination with geographic factors, can affect their health status and health risks. Children in rural areas are more likely to be poor than those in urban areas. Of those who live in small or isolated rural areas, 23.3 percent have household incomes below the Federal poverty level (FPL), as do 23.7 percent of children in large rural areas. Of children living in urban areas, 17.4 percent have household incomes below the FPL. Rural children are also more likely to be non-Hispanic White. Among children in urban areas, just over half (53.0 percent) are White, compared to two-thirds (67.1 percent) of those in large rural areas and nearly three-quarters (73.8 percent) of those in small rural towns.

Children’s overall health status does not vary substantially by location; approximately 84 percent of children are reported by their parents to be in excellent or very good health, regardless of where they live. (This percentage was slightly lower, about 80 percent, among older children in rural areas.) Children’s oral health was equally consistent across locations; while not quite as good as physical well-being, the percentage of children reported to have excellent or very good oral health ranged from 69.0 to 71.1 percent.

Children living in large rural areas are slightly more likely than those in small rural or urban areas to have chronic conditions, including physical conditions and emotional, behavioral, and developmental conditions. Nearly one-quarter (24.9 percent) of children in large rural areas had at least one of 16 chronic conditions asked about in the survey, compared to approximately 22 percent of children in other locations. Thirteen percent of children in large rural areas were reported to have at least one of 7 emotional, behavioral, or developmental conditions (attention deficit disorder/attention deficit hyperactivity disorder [ADD/ADHD], anxiety, autism spectrum disorder, depression, developmental delay, oppositional defiant disorder [ODD] or conduct disorder, or Courgette Syndrome), compared to 11.1 percent of children in large rural or urban areas.

Across locations, approximately 90 percent of children currently have health insurance. Children living in rural areas are more likely to have public insurance, such as Medicaid or CHIP, and urban children are more likely to be privately insured. Some children have insurance that does not fully meet their needs, because it doesn’t cover the services a child needs, allow access to needed providers, or it requires burdensome out-of-pocket payments. Older children (ages 12-17) in small rural areas were the most likely to have insurance that was not adequate (30.1 percent).

Rural children face specific health risks. For example, children from birth through age 5 in rural areas care less likely than urban children ever to be fed breast milk: 77.0 percent of urban children were ever breastfed, compared to 67.6 percent of children in large rural areas and 69.8 percent of those in small rural communities. Children living in rural areas are also more likely than urban children to be overweight or obese. More than one-third of rural children aged 10-17 met the criteria for overweight or obesity (having a BMI at or above the 85th percentile for their age and sex) — 34.6 percent of children in large rural areas and 35.2 percent of those in small rural areas — compared to 30.9 percent of urban children. In addition, children in rural areas are more likely than urban children to live with someone who smokes. One third (33.1 percent) of children in large rural areas and 35.0 percent of those in small rural areas lived with smoker, compared to 24.4 percent of urban children.

Children in rural areas experience other risks to their educational and social well-being as well. Children in rural areas are more likely to repeat a grade in school; 12.6 percent of school-aged children in large rural areas and 13.5 percent in small rural areas (including 17.4 percent of boys) have repeated a grade, compared to 10.0 percent of urban children. Rural children are also more likely to spend more than an hour each weekday watching television or videos: 60.9 percent of children in large rural areas did so, compared to 53.0 percent of children in small rural areas and 53.9 percent of urban children.

In other cases, rural children—especially those living in small rural areas—appear to be well protected on measures of connectedness to their families and communities. The percentage of children who shared a meal with their families everyday in the past week was highest in small rural areas, where 50.7 percent of children did so, and parents of children in small rural areas were the least likely to report usually or always feeling parenting stress. The percentage of children who attend religious services once a week or more is highest in small rural areas (57.5 percent). Children in small rural areas are also the most likely to participate in physical activity everyday (34.7 percent).

Rural communities themselves appear to provide health benefits for their residents as well. Children in rural areas are more likely than urban children to live in safe and supportive communities, as reported by their parents. However, they are less likely to have access to amenities such as community or recreation centers or parks or playgrounds than their urban counterparts.

This book presents information about the health and health care of children by location and by major demographic characteristics such as age, sex, race and ethnicity, and household income as compared to the FPL. Unless otherwise noted, all graphs provide information on all children from birth through age 17. Children were classified by race and ethnicity in seven categories: non-Hispanic White, non-Hispanic Black, Hispanic (in homes where English is the primary spoken language), Hispanic (in homes where Spanish is the primary spoken language), non-Hispanic American Indian/Alaska Native (alone or in combination with other races), multiracial, and single races other than those listed above. All comparisons presented in the text of this chartbook are statistically significant at the .05 level; however, unless otherwise specified, other differences presented in the graphs have not been tested for significance and should be interpreted with caution.

A few limitations of the survey should be noted. All information presented here is based on parental reports and was not independently verified. In addition, the analyses in this book are simple tabulations; they do not use complex analytic techniques and do not control for demographic or other factors that may influence the differences among populations.

The Technical Appendices [About the Survey] at the end of this book presents information about the survey methodology and sample. For more in-depth information about the survey and its findings, other resources are available. For more detailed analyses of the survey’s findings, the Data Resource Center (DRC) on Child and Adolescent Health web site provides online access to the survey data. The interactive data query feature allows users to create their own tables and to compare survey results at the national and state levels and by relevant subgroups such as age, race/ethnicity, and income. The Child & Adolescent Health Measurement Initiative (CAHMI) leads the DRC in partnership with state and family leaders, including numerous Title V leaders, Family Voices, other family organizations and public and private sector child health data experts. It is sponsored by the Maternal and Child Health Bureau within the Health Resources and Services Administration. More complex analyses can be conducted using the public use data set available from the National Center for Health Statistics at:

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1 U.S. Census Bureau, 2008 American Community Survey. Table C17001, accessed through American Factfinder.

2 Cherry DC, Huggins B, Gilmore K. Children’s heath in the rural environment. Pediatric Clinics of North America 54(2007): 121-133.

3 Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. (2009) Monitoring the Future: National Survey Results on Drug Use, 1975-2008. (NIH Publication No. 09-7402.) Bethesda, MD: National Institute on Drug Abuse.

4 Probst JC, Laditka SH, Wang J-Y, Johnson AO. Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey. BMC Health Serv Res2007 Mar 9;7-40.

5 Health Resources and Services Administration, Geospatial Data Warehouse.

6 University of Washington Rural Health Research Center. RUCA Data: Code Definitions Version 2.0.