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Environmental Health Issues in Rural Communities.


The objective of this study was to examine the beliefs of rural health care providers concerning the environmental health issues challenging their communities. A national survey of rural health care providers (RHCPs) was undertaken to identify their perceptions of the environmental health issues facing their constituents. Follow-up telephone interviews obtained additional information about environmental health problems in selected rural communities. In valid surveys received from 384 RHCPs, groundwater pollution and surface-water pollution ranked as the top two concerns, followed by pesticide misuse and soil erosion. Groundwater and surface water are traditionally concerns of rural communities, as those communities are almost exclusively served by well water. Pesticides and soil erosion are logical second-tier rankings. Agriculture, the primary activity in rural areas, involves the heavy use of pesticides. Soil erosion, particularly in difficult planting and growing years, also can adversely affect environmental quality through water pollution as well as air pollution via wind borne particles. More than half of the respondents reported that environmental problems are or have been a cause of health problems in their Communities. Those respondents also were likely to attach greater importance to each environmental problem listed. The respondents who were personally interviewed by telephone indicated that water pollution is the most important environmental issue in their rural communities. Odors, visible air pollution, nonvisible air pollution, and noise pollution were ranked less important.


A number of studies have been conducted to assess the environmental and quality-of-life issues that affect urban areas of the United States. Fewer studies have been conducted to assess the environmental health concerns of rural communities. In 1995, scientists at the Environmental and Occupational Health Sciences Institute (EOHSI) agreed to work cooperatively with the leadership of the Rural Coalition, based in Washington, D.C., to develop a proposal on environmental justice. The proposal obtained support from the National Institute of Environmental Health Sciences (NIEHS). As part of this research effort, a survey instrument was developed to assess the major environmental health issues facing America's rural communities.


Rural health care providers (RHCPs) were selected as the target group for a nationwide survey. To reach this group, membership mailing labels were obtained from the National Rural Health Association (NRHA) (N = 2,248). Since not all members of the National Rural Health Association are health care providers, and it was impossible to determine from the mailing list who did or did not provide these services, it was decided that the questionnaire would be mailed to all NRHA members.

The survey, which directly addressed RHCPs, was constructed so that nonproviders would not be able to answer many of the questions. This sampling technique allowed for targeting of a large number of RHCPs, but it did not allow for the calculation of an accurate response rate because there was no true denominator. In addition, the sampling technique did not allow the authors to determine the representativeness of the sample. It did, however, allow for the presentation of descriptive statistics about the environmental health concerns of RHCPs who responded to the survey.

All surveys were coded by census region (Northeast, Midwest, South, and West) since there are differences among U.S. regions in proportions of racial and ethnic groups, agricultural products, certain health outcomes, and lifestyle habits. Because these differences could confound the results, census region was used as a control variable in the analysis.

The Instrument

A survey instrument was developed to measure several types of information. Page 1 listed the 21 health objectives from Healthy People 2000 (U.S. Department of Health and Human Services, 1991), with Likert scales (an equal-interval survey scale ranging from 1 to 5) for each objective. The scale asked RHCPs to rate how important each health objective was for their community, with 1 as "not at all important" and 5 as "most important." A second

Likert scale asked about the amenability of each health objective to change, with 1 as "likely to change" and 5 as "unlikely to change." This scale had been used in previous studies and had already been tested for reliability and validity, including for studies in which health personnel were respondents (Greenberg, Schneider, & Martell, 1995; Greenberg, Schneider, Duncan, & Moskowitz, 1998; Schneider, Greenberg, & Choi, 1993; Schneider, Robson, Greenberg, & Saunders, 2000).

Page 2 of the questionnaire asked about potential problems in the provision of health care to the RHCP's community resulting from changes in funding and legislation at the local, state, and federal levels (concern variables). Responses to questions on pages 1 and 2 have been reported elsewhere (Schneider, Greenberg, & Moskowitz, 2000).

Page 3 asked respondents to answer a list of questions about environmental health problems in their communities. Specifically, 10 environmental problems were listed, a Likert scale (1 to 5) was again provided, and the respondents were asked to indicate the importance of each environmental problem for their communities. If an environmental problem was of concern to a community, a follow-up question asked whether it was a recent concern or a longstanding one. Finally, for each environmental concern listed, respondents were asked if they thought the concern was a problem unique to their community, or if they thought it was a problem for other rural communities as well.

On the back of the survey, the RHCPs were asked to estimate the populations of the communities they served. In an effort to estimate rurality, the survey also asked how far the community served was from a city of 50,000 or more. Finally, the survey asked whether respondents would agree to be interviewed and, if they responded yes, asked them to provide name, address, telephone number, and the best time to call. A one-time mailing of the survey instrument went to all 2,248 members of NRHA. As surveys were returned, the responses were entered into a database, and the data were checked for errors.

Statistical Analysis

The percentage of responses was calculated for the total sample and for each of the U.S. census regions. For each of the 21 health objectives, mean responses were calculated for both importance and amenability to change. The resulting means were then used to calculate ranks for both variables. The scores for each of the 21 questions were added to form cumulative "importance" and "amenability" scales. Higher aggregate scores on these two variables indicate more importance and more amenability to change. Cronbach's alpha was used to ascertain the reliability of using the aggregate 21 items as a single scale. Both scales were judged to be valid (0.86 and 0.87 for importance and amenability, respectively).

Next, sums were calculated for the reasons each respondent gave for selected objectives becoming less amenable to change his or her jurisdiction. For example, the number of times reduction of federal support was mentioned by a respondent became the sum for that variable for that respondent. Descriptive statistics were calculated for the concern questions by region and for the total sample. The responses were aggregated to form a cumulative "concern" score (Cronbach's alpha 0.65).

Means and ranked responses were calculated for the environmental problems in respondents' communities (from a Likert scale in which 1 = not important and 5 = most important). Differences in means were examined with respect to the following characteristics of respondents: scores on importance and amenability of public health objectives (aggregate variables from Page 1 of the survey), concern about changes in public-health legislation and funding (an aggregate variable from Page 2 of the survey), opinion about whether environmental problems were or had been a cause of health problems in the community (dichotomous variable from Page 3 of the survey), rurality of respondent's community (distance to a mid-sized city), and region.

Of the respondents who signed the statement on the back of the survey indicating a willingness to be interviewed, researchers were able to contact 17 who agreed to participate. The interviews were successfully carried out by a single interviewer over the course of a two-month period. Open-ended questions included queries about changes in community demographics, changes in population health, changes in the provision of health care and other services, changes in the local economy, and concerns about environmental health issues.


A total of 384 valid responses were received from the 2,248 surveys mailed. Thirty-nine surveys were eliminated because they had targeted inappropriate individuals. One survey was returned with the coding destroyed, so it could not be assigned to a census region. The returned surveys yielded an estimated response rate of 17 percent, an underestimate of the true response rate because of the overrepresentation of individuals who were members of NRHA but who were not RHCPs. Estimated response rates varied little by census region, with 32 responses received from the 211 surveys sent to the Northeast (15 percent), 127 from the 802 sent to the South (15 percent), 133 from the 690 sent to the Midwest (19 percent), and 92 from the 509 sent to the West (18 percent).

Although the sample was not a random one, it did represent 384 rural health care providers with opinions on a topic about which they clearly had expertise--the health of their rural constituents and the influence the environment might be having in their communities. The sample also reflected that a large number of RHCPs were concerned enough about environ mental health issues to respond to a lengthy survey. Three hundred and forty-nine respondents claimed to serve populations with a median size of 18,000. The mode, perhaps a better indicator of population served, was 5,000. Twenty-two percent of respondents served communities located within 25 miles of a mid-sized city (50,000 or more); 23 percent served communities within 25 to 49 miles, 24 percent served communities within 50 to 74 miles, nine percent served communities within 75 to 99 miles, and 22 percent served communities 100 miles or more from a mid-sized city. In other words, 55 percent had to travel more than 50 miles to reach a mid-sized city.

Environmental Health Issues

For each of the potential environmental health problems listed on the questionnaire, Table 1 shows how respondents ranked the importance of the problem, giving the mean response for each problem. Examining the data according to the variables' importance, amenability and concern yielded no statistically significant differences. That is, respondents who were more likely to be concerned with public-health problems in general and cuts in their budgets in particular were not more likely to indicate environmental health problems in their communities. When responses for environmental health problems were examined by region, it was found that erosion was more likely to be mentioned in the Midwest and the West; odors, visible pollution, and nonvisible air pollution were more likely to be mentioned in the West; surface-water pollution was more likely to be mentioned in the South; and groundwater pollution was more likely to be mentioned in the North. Rurality was not a good predictor of responses, but noise was more likely to be noted as an environmental issue by those living less than 50 miles from a medium-sized city than by those living farther away (p = .014).

Overall, 54 percent of respondents (n = 206) thought environmental problems were or had been a cause of health problems in their community. Respondents who indicated that environmental problems were or had been a cause of health problems in their communities were likely to choose higher Likert-scale numbers for each environmental problem listed. That is, they gave higher means for each of the environmental problems listed on the questionnaire compared with respondents who did not think there were environmental health problems in their communities (p [less than] .01). Respondents' perceptions about whether the environmental problems were of recent or longstanding concern are given in Table 2. For each issue covered in the survey, Table 3 reports the number of respondents who thought the issue was unique to their community and the number who thought it affected other communities as well as their own.

The Interviews

While one-third of respondents indicated a willingness to be interviewed, many could not commit to the open-ended format and indeterminate time block requested. Telephone appointments were made for open-ended interviews, and 17 were completed, ranging from 15 minutes to over an hour in length. Interviews were conducted in Illinois, Indiana, Kentucky, Michigan, Missouri, New Mexico, New York, Nevada, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Washington, and West Virginia.

The interviews elicited comments and expressions of concern about the health of respondents' communities, and many of those concerns were region-specific (e.g., about agriculture, forestry, or mining). The major themes raised, however, did not relate to environmental disease or environmental health threats; the most commonly cited concern was about tobacco and alcohol issues, especially for adults and youth. Several respondents specifically cited the high use of both substances by young, single mothers. They attributed this substance use and abuse problem to low socioeconomic status and the lack of other activities in the rural areas. A second theme that emerged, from more than half of the interviews, was the treatment of individuals with HIV/AIDS. Rural communities by their nature are conservative. It is difficult for individuals in a small and remote area to maintain confidentiality, and those who are identified with HIV/AIDS suffer from social ostracism as well as from health problems.

A third theme that emerged in the interviews was a lack of medical resources and health care providers in rural communities at all levels. Many rural areas lack doctors, dentists, nurses, and other medical professionals. Several of the older, established RHCPs commented on low compensation as a problem for recruitment of new health professionals. They themselves had many times received eggs, milk, or potatoes in lieu of payment for their services. These providers recognized that newly graduating professionals, often with significant loan obligations, would find it difficult to survive on the wages paid in these rural communities. Without state or federal intervention to help increase compensation, the shortage of RHCPs is likely to continue.

The environmental issues (air pollution, pesticides, water pollution, soil erosion, noise, and odors) did not elicit the same level of concern as the traditional health care issues (alcohol, drugs, and lack of services). The RHCPs viewed environmental health problems as just part of a rather bleak future they envisioned for many rural communities, and they ranked these problems as secondary to the more pressing, acute problems facing health care.


Water pollution, of both groundwater and surface water, was a major concern of the RHCPs who responded to the survey. Drinking-water supplies in many rural communities test positive for pesticides and fertilizers. In areas with dairy farming, water quality issues affect not only the human population, but also the live stock population. Another major concern of respondents was pesticide misuse. Farmers and farm workers may be exposed to pesticides directly through application to crops or live stock; farmers tend to have higher rates then the general population of certain cancers, including leukemia, non-Hodgkin's lymphoma, multiple myeloma, skin cancer, soft-tissue sarcoma, and cancers of the lip, prostate, and brain (Ward, Zahm, & Blair, 1999). In addition, rural residents who are not actively engaged in farming operations are environmentally exposed to pesticides and other agricultural chemicals simply by living in proximity to agricultural land. An agricultural community that uses these materials may experience long-term adverse health effects.

Odors, visible air pollution, and noise pollution were of some concern to respondents, but those issues were less likely to be viewed as recent or longstanding concerns than were the issues of water pollution, pesticides, and soil erosion. Occupationally related illnesses were of greater concern to respondents than were environmental health issues. Of most concern were traditional health care problems--that is, drug and alcohol use and abuse, and access to services.


Of the 384 RHCP respondents, the majority ranked water pollution as one of the most important environmental health issues for their communities. Pesticide misuse and soil erosion followed in perceived importance. These results reflect the agricultural and other industrial activities typical in rural areas (e.g., mining and forestry). Environmental problems such as odors, air pollution, and noise pollution were ranked lower in importance. The completed surveys, as well as the subset of interviews, reflected a much greater concern about traditional health issues-like alcohol abuse, drug abuse, and access to care-than about environmental health issues. This finding corresponds to the findings of similar research done in urban areas (Greenberg, Schneider, & Martell, 1995).

Acknowledgements: The authors thank the Environmental and Occupational Health Sciences Institute for supporting this research. They also thank Dr. Michael Greenberg for his comments on the manuscript.

Corresponding Author: Dr. Mark Robson, Executive Director, Environmental and Occupational Health Sciences Institute, 170 Frelinghuysen Road, Piscataway, NJ 08854. Email: [less than][greater than].


Greenberg, M., Schneider, D., Duncan, L., & Moskowitz, J. (1998, August). Putting the public back in public health. New Jersey Medicine, 45-50.

Greenberg, M., Schneider, D., & Martell, J. (1995). Health promotion priorities of economically stressed cities. Journal of Health Care for the Poor and Underserved, 6, 10-22.

Schneider, D., Greenberg, M., & Choi, D. (1993). Black leaders' perceptions of the year 2000 public health goals for black Americans. American Journal of Public Health, 83, 1171-1173.

Schneider, D., Greenberg, M.R., & Moskowitz, J. (2000, February). Impact of health care and welfare changes on U.S. cities and their most stressed residents (Working Paper No. 14). New Brunswick, NJ: National Center for Neighborhood and Brownfields Redevelopment.

Schneider, D., Robson, M., Greenberg, M., & Saunders, H. (2000). Impacts of health and welfare policy changes on rural America. Journal of Social Medicine, 3, 1-12.

U.S. Department of Health and Human Services. (1991). Healthy people 2000: National health promotion and disease prevention objectives (PHS 91-50212). Washington, DC: Author.

Ward, M.H., Zahm, S.H., & Blair, A. (1999). Pesticides and cancer risk: Clues from epidemiology studies of farmers and the general population. Pesticides, People and Nature, 1(1), 25-32.
Mean and Ranked Responses of Rural Health Care Providers About the
Importance of Environmental Health Issues for Their Communities (N =
Environmental Health Issue Mean Response (SD [a]) Rank
 (I = not important,
 5 = most important)
Groundwater pollution 3.62 (1.19) 1
Surface-water pollution 3.39 (1.21) 2
Pesticide misuse 3.29 (1.23) 3
Soil erosion 3.19 (1.23) 4
Pollution of water impounds 2.84 (1.21) 5
Nonvisible air pollution 2.66 (1.23) 6
Chemical spills 2.66 (1.32) 6
Odors 2.40 (1.26) 8
Visible air pollution 2.33 (1.31) 9
Noise pollution 2.15 (1.13) 10
(a.)Standard deviation.
Identifying Environmental Health Issues as Recent or Longstanding
Problems--Number of Respondents, by Issue (N = 384)
Environmental Health Issue A Recent Concern A Longstanding Concern
Groundwater pollution 82 184
Surface-water pollution 82 181
Pesticide misuse 49 187
Soil erosion 39 192
Pollution of water impounds 54 106
Nonvisible air pollution 45 98
Chemical spills 75 85
Odors 35 67
Visible air pollution 28 77
Noise pollution 45 38
Seeing Issues as Unique to the Community or as Affecting Other Rural
Communities--Number of Respondents, by Issue (N = 384)
Environmental Health Issue Issue Is Unique Issue Affects Other
 for My Community Rural Communities
Groundwater pollution 25 177
Surface-water pollution 21 164
Pesticide misuse 11 166
Soil erosion 22 151
Pollution of water impounds 11 124
Nonvisible air pollution 26 116
Chemical spills 20 125
Odors 32 110
Visible air pollution 16 112
Noise pollution 16 84
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Article Details
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Author:Schneider, Dona
Publication:Journal of Environmental Health
Geographic Code:1USA
Date:Jun 1, 2001
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