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A new study looked at the rates of heart disease in rural areas. John Fedele/Getty Images
  • An observational study reports that adults in the United States who live in rural areas have a 19% overall higher risk of developing heart failure compared to adults who live in urban areas.
  • Black men who live in rural areas of the United States have a 34% higher risk of developing heart failure than their urban counterparts.
  • Black women had an 18% higher risk compared to Black women in urban areas.
  • White women living in rural areas had a 22% increased risk of heart failure compared to white women in urban areas.

In 2020 about 46 million people in the United States, about 14% of the population, lived in rural areas, according to the U.S. Department of Agriculture.

Rural and urban deaths per 100,000 population were about equal in the 1980s, but by 2016 there were about 135 excess deaths per 100,000 in rural areas compared to urban ones, according to a 2019 study.

Individuals living in rural areas are more likely than those in urban areas to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke, according to the U.S. Centers for Disease Control and Prevention.

A variety of factors likely put people who live in rural areas at higher risk; according to the U.S. Food and Drug Administration. Those factors include less access to grocery stores and medical care as well as higher rates of poverty

A large, observational study published in the journal JAMA Cardiology by researchers at the National Heart, Lung, and Blood Institute (NHLBI), a part of the National Institutes of Health, and Vanderbilt University Medical Center in Tennessee, reports that U.S. adults living in rural areas have a 19% overall higher risk of developing heart failure compared to adults living in urban areas.

The researchers say their study is the first to look at the link between living in rural America and first-time cases of heart failure.

Dr. Véronique Roger, the study’s corresponding author and a senior investigator with the Epidemiology and Community Health Branch in NHLBI’s Division of Intramural Research, told Medical News Today she had previously worked with a team that studied heart failure among rural areas of Minnesota — a population that was about 95% white.

“So, we were interested in looking at the intersectionality between rurality and race,” she said.

The researchers studied 27,115 adults who participated in the Southern Community Cohort Study (SCCS).

Beginning in 2002, researchers working on that study enrolled participants from Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.

About 86% of those individuals were recruited from community health centers that care for medically underserved populations.

Of the participants selected from the SCCS for this study: about 20% lived in rural areas. Only participants who identified as Black or non-Hispanic white were included in this study because, as the researchers explain in their paper, there were too few participants from other racial and ethnic groups.

About 69% of the selected participants were Black. The median age of participants was 54. Only participants who did not report having heart failure at the beginning of the study were selected.

Researchers reported rural participants had slightly higher body mass indexes and slightly higher rates of hypertension, diabetes, coronary disease, and hyperlipidemia than their urban counterparts.

Rural residents had similar rates of stroke to their urban peers and lower rates of depression.

Diet and exercise was similar among the two populations.

Rural residents were less likely to be current smokers and they were more likely to be married and have less formal education.

From the start of the study to a median 13 year follow-up, participants experienced 7,542 heart failure incidents.

Heart failure occurs when the heart does not pump blood throughout the body as well as it should. Symptoms include shortness of breath during daily activities or trouble breathing when lying down.

Of the heart failure incidents, 1,865 occurred in rural residents while 5,677 occurred among urban residents.

After adjusting their analysis for factors such as age, sex, and race as well as cardiovascular risk factors, health behaviors and socioeconomic factors, the researchers reported that adults living in rural areas have an 19% overall higher risk of developing heart failure compared to their urban peers.

The risk of heart failure was highest in rural Black men. This group had a 34% higher risk of heart failure than their urban counterparts.

Women were also at a higher risk. Compared to women living in urban settings, rural Black and white women had an 18% and 22% higher risk of heart failure.

“We addressed, as much as we could, things that we thought could be playing a role in our observation,” said Roger. “We expected that… we would find such a difference, but we did not expect the magnitude of the difference that we saw.”

Keisha Ray, an assistant professor of bioethics and medical humanities at McGovern Medical School at UTHealth Houston in Texas, wasn’t surprised to see women and Black men faced higher risk of heart failure in rural areas.

“It is consistent with what health disparities scholars have consistently maintained —discrimination like racism and sexism touches all parts of Black people’s lives and women’s lives,” she told Medical News Today. “Racism also influences access to the resources people need for proper heart health like access to healthy foods, access to recreation, proper income and housing, and access to preventive health care.”

Health practitioners often fail to take women seriously because of misogyny, Ray added.

“Women are often not believed when they complain of illness or their poor health is dismissed and downplayed,” she said. “This can affect how quickly they receive life-saving care.”

Dr. Yu-Ming Ni, a cardiologist at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in California, told Medical News Today this study confirms that “people with less access to care generally don’t do as well.”

Ni pointed out that the bulk of the participants in this study were seen at community health centers.

“There are people in rural communities that have even less access to care,” he said. “They may not even have a landline, let alone a cell signal. And so, these people are going to be hard to reach and being able to ensure that they’re well cared for is extremely challenging.”

Dr. Brad Serwer, the chief medical officer of CardioSolution, told Medical News Today that “the widening disparity of health care in rural America” is a serious issue.

“Geographically disadvantaged regions have longer response times for emergency medical services… have less access to medical care, and have longer wait times to see specialists,” he said.

Hospitals are closing in rural areas at higher rates because of financial struggles, Serwer noted.

“Increasing access to care and improving the quality of health care in rural America is paramount,” he said.

Ni pointed out that a study that looked at people who live in rural areas in other parts of the United States could turn out differently from this one, which looked at participants who lived in rural areas of the South.

Roger agreed.

With the people she studied in rural Minnesota for instance, “rurality is associated with some adverse outcomes, but probably for very different reasons than in the rural South,” she said.

In their paper, the researchers stress that it’s not well understood whether these inequities reflect a higher incidence of heart failure in rural areas.

More work needs to be done, said Roger.

“We didn’t have the data to ask that question about, ‘OK, yeah, it’s in rural areas, but is it mediated, if you will, by systemic racism, or access to health care, or availability of health care, because in some of those rural areas, health care facilities are just, by definition, they’re more distant than if you live in an urban area, and if you add on top of that maybe barriers to transportation, etc.,” Roger said.

“So I think it’s important to understand and underscore… some of the future studies that need to be done would be to understand exactly what rurality encompasses in terms of some of these… social determinants of health that can travel with rurality,” she added.