CARE OF CLIENTS IN
URBAN AND RURAL
SETTINGS
Approaches to Defining Rural
and Urban

U. S. Census Bureau
 Office of Management and Budget
(OMB)
 Montana State University Rurality
Index
U.S. Census Bureau (1990)
 Based on population density
 Urban: “one or more places and the
adjacent densely settled surrounding
territory that together have a minimum
population of 50,000 persons”
 Rural: Any area that does not meet the
definition of urban
OMB Classification

Based on the presence of a city or
suburbs and the degree of integration
of that territory with city or suburb

Operationalized in USDA continuum
codes
USDA Continuum Codes - 1
 Metropolitan Counties




0 - Central counties of metropolitan areas with
populations of 1 million or more people
1 - Metropolitan counties on the fringe of
central counties that have populations of 1
million or more people
2 - Metropolitan counties with populations of
250,000 to 1 million people
3 - Counties in metropolitan areas with
populations less than 250,000 people
USDA Continuum Codes - 2
 Non-metropolitan Counties

4 - Urban populations of 20,000 or more people
adjacent to a metropolitan area

5 - Urban populations of 20,000 or more
people, not adjacent to a metropolitan area

6 - Urban populations of 2,500 to 19,999
people adjacent to a metropolitan area
USDA Continuum Codes - 3
 Non-metropolitan Counties

7 - Urban populations of 2,500 to 19,999
people not adjacent to a metropolitan area

8 - Completely rural areas or areas with urban
populations of less than 2,500 people adjacent
to a metropolitan area

9 - Completely rural areas or areas with urban
populations of less than 2,500 people, not
adjacent to a metropolitan area
MSU Rurality Index
 Classifies counties based on

Population density

Distance to health care services
 Classifies residents based on

Distance to health care services only
Frontier

An area or county that has a
population density of less than 7
people per square mile
Characteristics of Rural Nursing
 “The provision of health care by
professional nurses to persons
living in sparsely populated areas”
(Source: Long & Weinert, 1998).
Characteristics of Urban Nursing
 Care of clients who reside in an
urban setting
Concepts of Rural Nursing
Theory






Work beliefs and health beliefs
Isolation and distance
Self-reliance
Lack of anonymity
Insider/outsider status
Old-timer/newcomer
(Source: Long & Weinert, 1998)
Rural Nursing
 Generalist practice
 Expectations of competence in many areas,
expertise in a few
 Expanded scope of practice
 Blurring of disciplinary boundaries
 More intimate knowledge of clients in
multiple types of interactions
Urban Nursing




Greater opportunity for specialization
Narrower scope of practice
More rigid disciplinary boundaries
Less intimate interactions with clients
Biophysical Factors
 Urban
 Higher overall
mortality
 Higher AIDS
mortality
 Lower child
immunization rates
 Higher elder
immunization rates
 Rural
 More elderly
 More children
 Overall higher
morbidity
 Poorer self-reported
health
 Higher injury
mortality
Psychological Factors
 Urban
 Lower suicide
mortality rates
 Equal levels of
stress, but different
sources
 Rural
 Fewer mental
health services
available
 Lower rates of
psychiatric beds
Physical Environmental Factors
 Urban
 Greater influence of
built environment
 Greater exposure to
pollutants, noise
 More energy
efficient
 Lack of housing
 Rural
 Greater influence of
natural environment
 Greater exposure to
pesticides
 Great distances
 Greater potential
for plant/animal
exposures
 Rundown housing
Sociocultural Factors - 1
 Urban
 Greater
heterogeneity
 Social isolation
 Greater mobility
 Exposure to
unconventional
norms
 More agency
services
 Rural
 Greater
homogeneity
 Sustained
interactions
 Traditional gender
roles
 Informal support
networks
Sociocultural Factors - 2
 Urban
 Diffused
responsibility
 Higher crime rates
 Less family support
 More visible
homeless
 Better economic
base for health
 Rural
 Lack of privacy
 Greater poverty
 Fewer single-parent
households
 Lower education
 Lack of OSHA
coverage
Behavioral Factors
 Urban
 More underweight
 More smoking
 More drug and
alcohol use
 Rural
 More obesity
 More smokeless
tobacco use
 Less leisure activity
 More sexual risks
 Less health
promotion behavior
Health System Factors
 Urban
 More services
available
 Higher reimbursement rates
 Greater managed
care availability
 Greater
convenience
 Rural
 Fewer providers
 Great distances to
services
 Less insurance
coverage
 Inappropriate MCO
models
Goals for Care in Urban and
Rural Settings - 1
 Increase access to health care services and
decrease barriers to their use
 Eliminate or modify environmental risk
factors
 Modify social conditions that adversely
affect health
Goals for Care in Urban and
Rural Settings - 2
 Increase clients’ abilities to make informed
health decisions
 Develop systems of care that are population
appropriate
 Develop equitable health care policies that
address the diverse needs of urban and rural
populations
Means for Achieving Goals
Will differ based on:

Population needs

Risk factors involved

Population characteristics (e.g., culture,
age, etc.)
Evaluation of Care in Urban and
Rural Settings
Focuses on:
 Individual client outcomes
 Population outcomes
 Achievement of national objectives