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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 and 30 contained findings relevant to a rural definition of health (see Figure 1). Of the latter 30 studies, 6 included an urban comparison group (see Table 1). The remaining 24 articles did not include a comparison group. Few studies compared rural and urban definitions of health directly.
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Figure 1.
PRISMA diagram of literature review process.
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. In a study to examine factors influencing individual capacity to manage coronary artery disease risk, both gender and culture (rural vs urban) were identified. 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. 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. 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.
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. 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. Attitudes of rural and urban residents toward seeking medical care were similar in the Harju et al. study, 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.
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". 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. 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. 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. 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.
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