Introduction

Children in rural areas face particular risks to their health and well-being. Children who live outside of metropolitan areas are more likely to live in poor families,¹ have higher mortality rates,² and are more likely to use tobacco³ than their counterparts in urban areas. Rural families must travel greater distances to use health services; 452 non-metropolitan and frontier counties are designated as Health Professional Shortage Areas for primary care, and 1,409 entire counties are considered Medically Underserved Areas by the Federal government.⁴

The National Survey of Children’s Health (NSCH) presents a unique resource with which to analyze the health status, health care use, and risk factors experienced by children in rural areas in the context of their families and communities. The NSCH was designed to measure the health and well-being of children from birth to age 17 in the United States while taking into account the environment in which they grow and develop. Conducted for the first time in 2003, the survey collected information from parents about their children’s health, including oral, physical and mental health, health care utilization and insurance status, and social well-being. Aspects of the child’s environment that were assessed in the survey include family structure, poverty level, parental health and habits, 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, National Center for Health Statistics (NCHS).

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How Locations Were Defined

Children were classified according to their residence in an “urban focused” area, a large rural area, or a small or isolated rural area, based on the size of the city or town and the commuting pattern in the area. Urban-focused areas include metropolitan areas and surrounding towns from which commuters flow to an urban area; large rural areas include large towns (“micropolitan” areas) with populations of 10,000 to 49,999 persons and their surrounding areas; and small or isolated rural areas include small towns with populations of 2,500 to 9,999 persons and their surrounding areas. The map on page 6 shows how these three types of areas are distributed across the United States. Of the 72.7 million children in the U.S., 58.2 million live in urban-focused areas, 7.2 million live in large rural areas, and 7.3 million live in small rural or isolated areas.

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Findings of the Survey

Children in rural areas are more likely to be poor than those in urban-focused areas: of children in small or isolated areas, 22.9 percent have family incomes below the Federal poverty level, as do 19.8 percent of those in large rural areas; this compares to 17.0 percent of children in urbanfocused areas. Rural children are also more likely to be non-Hispanic White. Among children in urban areas, 57.2 percent are White, compared to 73.3 percent of children in large rural areas and 76.2 percent of children in small rural towns.

The NSCH found that children’s 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 their urban or rural status. However, rural children do face specific health risks. Children in both large and small rural areas are significantly less likely to be breastfed for at least 6 months, as the American Academy of Pediatrics recommends: 40.5 percent of children in urban-focused areas are breastfed for 6 months or more, compared to 31.7 percent of children in large rural areas and 31.4 percent of children in small rural communities. In addition, rural children are more likely to live in households where someone smokes. More than one-third of children in rural areas (37.0 percent of children in large rural areas and 38.1 percent of children in small rural or isolated areas) live in households with a smoker, compared to 27.5 percent of urban children.

Rural children may experience other risks to their well-being as well. School-aged children in large and small rural areas are more likely than urban children to have repeated a grade: 13.1 percent of children aged 6-17 in large rural areas and 13.3 percent of children in small or isolated rural areas have repeated a grade, compared to 10.8 percent of children in urban-focused areas. Rural children, especially those in small or isolated areas, are also more likely to stay home alone. Among 6- to 11-year-olds in small or isolated rural communities, 18.7 percent are reported to have spent any time caring for themselves, without the supervision of an adult or older child in the past week, compared to 16.1 percent of children in large rural areas and 15.6 percent of children in urban-focused areas.

In some cases, the effect of living in rural areas is particularly pronounced for specific subpopulations. For example, low-income children in rural areas are at higher risk of missing 11 or more days of school due to illness and to have moderate or severe social-emotional difficulties than children of the same income level in urban-focused areas or higher-income children in rural areas. Some risk factors are especially prevalent among specific racial/ethnic groups: compared to their urban counterparts, American Indian/Alaska Native children in small rural areas are twice as likely to be overweight, non-Hispanic White children in rural areas are more likely to experience gaps in health insurance, and rural non-Hispanic Black children are less likely to be breastfed for at least 6 months.

Living in rural areas also has health benefits for children. A higher percentage of children in rural communities are reported by their parents to be safe in their neighborhoods (90.2 percent of children in small or isolated and 86.9 percent of children in large rural areas are usually or always safe in their neighborhoods, compared to 82.6 percent of children in urban-focused areas). Rural children are also more likely to exercise regularly: 75.3 percent of children in small rural and 73.9 percent in large rural areas are reported to exercise regularly, compared to 70.4 percent of children in urban areas.

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 family income. Unless otherwise noted, all graphs provide information on children from birth to age 17. Children were classified by race and ethnicity in six categories: non-Hispanic White, non-Hispanic Black, Hispanic, non- Hispanic American Indian/Alaska Native (alone or in combination with other races), other single races, and other combined races.

The Technical Appendix of this chartbook presents important information about the survey sample and methodology. For more detailed analyses of the survey results, the Data Resource Center on Child and Adolescent Health (DRC) Web site, which is sponsored by the Health Resources and Services Administration’s Maternal and Child Health Bureau. It provides online access to the survey data. The interactive data query feature allows users to create their own customized tables and to compare survey results at the National and State level, and by relevant subgroups such as age, race and ethnicity, and family income.

More complex analyses of the data can be conducted using the public use data set available from the National Center for Health Statistics.

1 United States Department of Agriculture, Economic Research Service. Rural Children at a Glance. Economic Information Bulletin Number 1, March 2005.

2 Eberhardt MS, Ingram DD, Makuc DM, et al. Urban and Rural Health Chartbook. Health, United States, 2001. Hyattsville, Maryland: National Center for Health Statistics. 2001.

3 Johnston LD, O’Malley PM, Backman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use, 1975-2004: Volume I, Secondary School Students. NIH Publication No. 05-5727. Bethesda, Maryland: National Institute on Drug Abuse, 2005.

4 Health Resources and Services Administration, HRSA Geospatial Data Warehouse. http://datawarehouse.hrsa.gov