Letter to the Field No. 2
by James A. Ciarlo, PhD, John H. Wackwitz, PhD, Morton O. Wagenfeld, PhD, Dennis F. Mohatt, MA
The Frontier Mental Health Services Resource Network, under a contract with the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, was created to gather, analyze and disseminate information about mental health and substance abuse needs and services in "isolated rural areas" in the US. These isolated rural areas, defined for purposes of this contract as having fewer than 7 persons per square mile, are very nearly identical with what has been termed "frontier rural areas" by a number of scholars and federal agencies. For this reason, and because almost all of these areas are found in the western states and Alaska, we have adopted the term "frontier rural area" to better identify those rural areas with which this project is concerned. This paper discusses how to identify this type of rural area in existing mental health literature and research studies, and discusses both some common and some unique physical, socio-demographic, and economic characteristics of these frontier rural areas.
The word "frontier" itself conjures up a special set of images for most of us. Indeed, historians (e.g., Turner, 1993; Webb, 1952) have argued the frontier shaped American character. One associates the frontier with such terms as pioneers, hunters, trappers, ranchers, and Indians. While the frontier of historic imagination no longer exists, the frontier does live on in the western US and Alaska. It is protected from large-scale settlement by harsh climate, difficult terrain, lack of water, distance from metropolitan areas, lack of exploitable resources, and various access restrictions on large federal land tracts (Duncan, 1993; Popper, 1986). As one might expect, providing any type of human services to this rural population presents formidable geographic, cultural, and human resource problems.
As the following sections will discuss, distinguishing frontier rural areas from other "rural" areas in research and literature can also be a challenge. Rural areas share the common characteristics of comparatively few people living in the area, limited access to large cities (and sometimes even to smaller towns), and considerable traveling distances to "market areas" for either work or everyday-living activities. They exist along a continuum, however, from more rural to less rural and vary extensively based on the following factors (Hewitt, 1989):
Over the years, public agencies and researchers have used combinations of these factors to define "rural" and designate geographic areas as "rural".
The areas described as "rural" by these different groups can vary significantly depending on how the factors are used in their definition. Obviously, different conclusions about "rural" populations and the delivery of mental health services to them may also be reached depending on the definition used. Meaningful discussion of frontier areas and their mental health services issues clearly requires differentiating "frontier" and "rural" from one another, as well as from other areas or populations.
The particular definitions discussed below have been selected largely from the different ways mental health-oriented researchers and writers have defined "rural" in their work. It in no way purports to be a definitive review. Instead, our focus is to bring greater clarity to the mental health-oriented tasks that comprise the mission of this Frontier Mental Health Services Resource Network.
The Nonmetropolitan County as "Rural." This by-exclusion method of designating "rural" counties has been used frequently over the past two decades by medical and mental health writers. It is based on the concept of living either within or outside the "market" area of a central place, typically a large city. The Office of Budget Management (OMB) defines these central places, called Metropolitan Areas (MAs)**, as having either a city with more than 50,000 residents or a Census Bureau defined urbanized area and a total population of at least 100,000. The county or counties that include an MA and any outlying counties that are part of the same large market area with daily in-commuting for work and commercial activity are called metropolitan (metro). All counties not classified as metropolitan are by definition nonmetropolitan (nonmetro) (Bureau of the Census, 1990; GAO, 1993). An extremely large number of counties throughout the US are "rural" based on this nonmetro classification (see Fig. 1).
(** Metropolitan areas are further classified into free-standing Metropolitan Statistical Areas (MSAs) or Consolidated (multiple) Metropolitan Statistical Areas (CMSAs) based on their location with respect to other MAs.)
If we consider just the total number of persons living in these nonmetro counties, some of the midwestern and southern large-population states (e.g., Illinois, Pennsylvania, Texas, and Alabama) have the largest nonmetro populations. However, if one considers the proportion of nonmetro residents in a state, the states with the highest percentages of nonmetro residents tend to be those more commonly thought of as "rural"-for example, Maine, Montana, Iowa, Arizona, and Alaska (see Fig. 2).
Many health- and especially mental health-oriented data sets involve this nonmetro definition of rural, since a great deal of important health-related and economic data is collected in the US by county. So-called "rural" data can thus be obtained, and compared with data for "urban" areas, by simply dividing any set of counties into these metro/nonmetro categories. This classification scheme, because of its ease of use, can obviously have substantial policy implications for rural mental health, including the granting of funds to these areas.
Rural Areas by Census Definition. A related definition, but one that can be used for not only counties but also smaller (e.g., census tracts) and larger (e.g., regions, states) geographic areas, is the Census Bureau's definition of rural versus urban/urbanized areas. This definition is based on the concepts of place size and population density. "Urbanized" areas include a central city and the surrounding densely settled regions with a total population of 50,000 or more persons and a density of greater than 1000 persons/sq.mi. "Urban" areas include these large urbanized areas and places (mostly towns) outside urbanized areas having more than 2,500 people. Again, rural is defined by exclusion; all areas not designated as urban (that is, places of under 2,500 or areas with no places) are considered "rural" (Bureau of the Census, 1990; GAO, 1993). A large number of rural areas by this definition can also be found throughout the US.
Again, however, states with large total populations also tend to be the states with the largest "rural" populations by this definition (e.g., New York, California, Pennsylvania, Illinois). When considering the ratio of rural to total population, however, those states with more than half their population living in "rural" areas are again those commonly spoken of as rural-Maine, West Virginia, Alabama, and the two Dakotas (see Fig. 3). Notice that Alaska's population is less than 50% rural, reflecting the concentration of its people into its coastal cities and towns.
This population density/place size-oriented definition of "rural" does not seem to have caught on as much with health and mental health researchers as has the nonmetro/metro county definition; many fewer uses of it are found in the literature. Yet, in many cases it can be more useful than the OMB-based nonmetro designation, since it stresses the relative isolation and dispersion characteristics of an area.
Combinations and Cross/Classifications of Metro/Nonmetro and Rural/Urban Definitions. While both the Census and the OMB definitions lead to an estimate of a "rural" US population of around 25%, the areas defined can be quite different. Many people living in nonmetropolitan "rural" counties may actually live in urban areas (towns and cities with 2,500-50,000 people) according to the census definition. Conversely, within an MA and its associated metro counties, there are many rural areas where most or all residents live outside the densely populated urbanized area or towns of larger than 2,500 population. This situation occurs more commonly in the West, where counties are generally larger. The boundaries of these large counties are less likely to match up with urban and suburban developments, thus creating pockets of rural living within metro counties. Hence, when the county is used as the geographic unit in question, accurate designation of an area as "rural" is more difficult in the West than in other regions of the US.
To understand the magnitude of these cross-classification differences, in 1980 about 14% of the population of US metropolitan counties (all within MAs) actually lived in rural areas by the census definition. Furthermore, about 38% of nonmetropolitan county populations in fact lived in urban areas. Because of this large percentage of urban persons, nonmetro data for "rural" events or characteristics must always be interpreted with extreme caution.
Some rural-oriented research has made use of this cross-classification of areas by metro/nonmetro and urban/rural definitions, focusing on the four types of areas thus defined. For example, Ciarlo and Tweed (1992) have shown that there are significant differences in "need for mental health/substance abuse services" between the four types of areas, especially with respect to metro but rural "exurban" regions (lowest in need) and nonmetro but urban areas (fairly similar to cities in percentage of persons needing mental health services). These two areas are again different from the other two more "consistent" regions (metro and urban "cities", nonmetro and rural "non-towns").
Frontier Rural. The type of rural area of primary interest to this project is that designated as "isolated" or "frontier." Frontier areas have usually been defined exclusively by low population density, most often fewer than 6 (sometimes 7) persons per square mile (Popper, 1986; NRHA, 1994; GAO, 1993). The consequences of this more restricted definition of rural are striking. Applied to US counties, an upper limit of 6 persons per square mile reduces the number of rural counties by the nonmetro definition from 2,357 using 1980 census data to roughly 400 frontier rural counties (Popper, 1986; Hewitt, 1989; NRHA, 1994)--a reduction of 83% in the list of nonmetro counties. This restriction to only low-density frontier rural areas removes from discussion many nonmetropolitan "rural" counties having sizable towns or small cities. However, using density alone as a defining factor can also be deceiving, especially in large western counties. An extremely large county land mass may mask the existence of higher density urban populations by unrepresentatively low county-wide density figures.
In contrast to the nonmetropolitan (OMB) and rural (Census) definitions, essentially all frontier counties are in western states (including Alaska), lying West of a north-south line running from the middle of North Dakota through the middle of Texas (see Fig. 4). They are characterized by considerable distances from central places, by poor access to market areas, and by people's relative isolation from each other in large geographic areas-some of the cardinal characteristics of a "rural" area. Even some of the higher-population western states have substantial numbers of such counties within their borders; for example, about half (31) of Colorado's 63 counties had 6 or fewer persons per square mile in 1990. For less populous states like North Dakota and Wyoming, the proportion of frontier counties is even higher
The "frontier" definition is central to this project. The focus of activities will be primarily on the western frontier counties shown in Figure 4, plus a few nonmetro counties with somewhat higher density.
As mentioned earlier, rural areas in the US, including frontier, are widely diverse and vary along a continuum from most urban-like to most isolated rural. Researchers have found the preceding simplistic definitions do not always adequately describe or differentiate the diversity. Therefore, further classification schemes or typologies have been proposed which use more factors and categories to define rural areas.
ERS County Typology. The Economic Research Service (ERS) of the US Department of Agriculture (USDA) has developed a classification of nonmetropolitan areas based on type of economy and socioeconomic characteristics of the population (Bender et al., 1985). Eleven (11) types of nonmetropolitan counties, six "economic" and five "policy," are defined. The developers argued that the classification provides a useful perspective for policy analyses and "reflects the extremely diverse economic and social structure of rural America" (Cook & Mizer, 1994).
The six distinct, mutually exclusive types of counties identified based on economy were: farming-dependent, government-dependent, manufacturing-dependent, mining-dependent, services-dependent and non-specialized. This typology scheme also classifies nonmetro counties by five policy criteria; retirement-destination, Federal lands, persistent poverty, commuting, and transfers-dependent (Cook & Mizer, 1994).
Defining the Continuum: An Example. Another non-binary typology of "rural" areas has been devised using 1990 Colorado county data (Wackwitz, 1994). Colorado's 63 counties are diverse on several dimensions. Counties range in population density from less than 1 to over 3,000 persons per square mile. The state contains 1 multi-county MA of greater than 1 million inhabitants, several smaller multi-county MAs, and at the other extreme, two counties each having a population of less than 1,000. This diversity provided the opportunity to develop a typology more representative of the frontier/rural/urban continuum than any of the binary definitions reviewed above. Nonetheless, it is as an illustrative, rather than definitive, scheme for viewing rurality in western-state counties; further typological work of this kind is one of the important activities of this project.
The following population distribution variables were used:
A cluster analytic procedure produced 9 groupings of counties that could be considered more similar to one another than to counties in other groups:
Differences among the subtypes of the Frontier, Rural and Urban types are primarily attributable to differences in the total population and distance variables.
Before generalizing any rural data to a specific frontier rural region, it is important to determine the definition of rural used. Nonmetro and even rural (by census definition) areas may be significantly different in important characteristics from a western frontier area. In future work being done here, further refinement of all rural definitions, including frontier, will hopefully aid in the understanding of, and better mental health service to, these isolated areas.
Even using the broadest definition of frontier (less than 7 persons/sq. mi.), frontier areas share many characteristics and are significantly different from other rural and urban areas. How different are frontier areas from the rest of rural America or the US? Duncan (1993), a journalist, suggested that they differ in kind, not just degree:
Breshears (1993) has deftly encapsulated the meaning of frontier and how it is different:
Isolation. The frontier constitutes less than 1 percent of the population, but a prodigious forty-five percent of the total US land mass (Popper, 1986). Its greatest defining characteristic is its isolation. Some appreciation of the sparseness of settlement can be seen in the fact that the average population density/square mile of land for the US is 72.9. For the 10 frontier states, it ranges from 34.6 for New Mexico to barely 1 for Alaska. Norris (1993) has captured this well:
In commenting on the large distances between population centers, Kevin Quint (1995, personal communication), the director of the Churchill Council on Alcohol and Other Drugs in Nevada, noted:
This isolation often results in long trips, both inside and outside the county and state, for basic needs. An example of this is the panhandle region of Nebraska, a typical western frontier area in the northwest region of the state. Here residents routinely travel 120 miles one-way to Cheyenne, Wyoming for everything from groceries to health care. Cheyenne is the center of trade and commerce for this Nebraska region.
Economy. It has been discussed elsewhere (e.g., Wagenfeld et al., 1994) that rural areas in general tend to be economically unstable and that this may have an impact on the mental health of its residents. This is even more true for the frontier. There is little manufacturing; the major sources of income are tourism, ranching, farming, logging, and mineral extraction.
Economic downturns have begun earlier in frontier areas than in the rest of the country. For much of the Plains, the Great Depression began over a decade earlier. By 1925, Montana had experienced 214 bank failures and the average value of ranch land had dropped by half. During the Depression, the proportion of farm families on relief was highest in many of these states. The infamous Dust Bowl, the result of misguided agricultural policies, came to the Plains earlier than the rest of the Midwest. The more recent farm crisis of the 1980s was also felt more acutely in this area. Many of these points can also be made about the petroleum industry. The single industrial base of these areas makes earning a consistent living more difficult, and one of the consequences is frequent migration (NRHA, 1994).
If the industrial base is depressed or collapses, an inevitable chain reaction occurs. Businesses dependent on these industries experience reverses, public services shrink or disappear, and the quality of life suffers (Popper & Popper, 1987). In addition, distance from metropolitan centers and low population density have made frontier areas attractive for practice bombing ranges, missile sites and nuclear waste dumps. In their zeal for economic stability, communities have actively sought these more questionable opportunities (Norris, 1993).
Rural and Frontier Values. Are the values of rural and frontier residents different from those of their urban counterparts? A pervasive view-firmly entrenched in literature and the mass media-holds that rural persons have values that set them apart from their urban counterparts. There is considerable disagreement on this point in the professional literature. On the one hand, several authors (e.g., Bachrach, 1977; Berry & Davis, 1978; Blouch, 1982; Cowan, 1979; Coward et al., 1983; Flax et al., 1979; Kenkel, 1986; Wagenfeld & Wagenfeld, 1981) have suggested that rural values, in contrast to urban, stress self-reliance, conservatism, a distrust of outsiders, religion, work-orientation, familism, individualism and fatalism.
On the other hand, Cordes (1990) dismissed as a myth the notion that the knowledge, attitudes, and beliefs of rural people are substantially different from those of urban residents. Cordes suggested the systems of interstate highways, television and other mass media have largely ended the isolation of rural areas. Similarly, Melton (1983) suggested that the evidence in support of rural/urban value differences is-at best-weak and anecdotal.
In sum, it is likely that rural/urban value differences-if they exist-are not as great as they might have been at some point in the past. Also, it is not clear whether these differences reflect actual community differences or differences in demographic or socioeconomic composition of the communities.
If we take the position that contemporary rural/urban value differences have been exaggerated, can the same be said of frontier rural differences? In other words, how different are the values of frontier residents? Empirical data on this point are scarce. Duncan (1993), a journalist who traveled extensively through the most remote frontier counties (less than 2 persons/square mile) observed that "...in addition to reflecting the violent past that they share, the residents of the sparse places confront life with a fatalism less common in the rest of urban/suburban America." Norris (1993), in describing the western Dakotas, presented several examples of clannishness, a sense of inferiority, and mistrust of outsiders.
Nevada, heavily dependent on gambling, in many ways is a special case:
Poverty. Finally, in presenting this background on rural and frontier America, it is necessary to mention the issue of poverty. Poverty in rural areas has been described as "invisible" (Harrington, 1962) because these areas are off the beaten track. A number of recent publications have dealt with the demographic, socioeconomic and psychosocial consequences of poverty in rural areas. Summarizing recent data on rural poverty (O'Hare & Curry-White, 1992; Porter, 1989; GAO, 1993):
Nonmetro counties with the greatest poverty can be found in two general areas: the South and Appalachia, and in western frontier counties. These counties make up the bottom 25% of counties when ranked by per capita income. Frontier counties are particularity vulnerable to boom and bust cycles and economically unstable industries such as tourism, farming and mineral extraction. Both of these factors complicate the economic situation of frontier counties and can lead to increased poverty.
Going beyond demography and economics, Janet Fitchen, an anthropologist, has written about the problems of poverty in rural areas and the implications for mental health (1981, 1986, 1990, 1991). She has argued that rural poverty is a persistent and self-perpetuating problem that involves intertwining historical, economic, social, cultural, and psychological factors.
Frontier rural areas, distinguished primarily by low population density and great isolation, exist at the furthest end of the urban/rural continuum. Understanding and serving their mental health needs requires distinguishing them from the large number of rural communities closer to the urban end of the continuum. As most health and demographic data exist in the simplified binary classifications of metro/nonmetro and rural/urban, this task can be challenging. It will, however, be pursued by the Frontier Mental Health Services Resource Network. Findings from this "knowledge synthesis" project will hopefully lead to better understanding of the mental health and substance abuse issues in these previously largely neglected areas, and later to ensure adequate provision of sorely needed mental health and substance abuse services. Adequately defining and describing these areas and their mental health needs will be our initial tasks in this effort.
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Frontier Mental Health Resource Network