Prevalence of heart disease and its associated risk factors in rural residents.
Abstract: Heart disease is the leading cause of death in the United States. Unhealthy lifestyles contribute to the development of heart disease. Rural populations often have disadvantages in achieving good health. This study evaluated the prevalence of heart disease and associated risk factors in rural versus urban residents of Pennsylvania by analyzing the data from the Behavioral Risk Factor Surveillance System. Compared to urban residents, rural residents were found to have a significantly higher prevalence of heart disease, and a greater likelihood of having unhealthy lifestyle behaviors. Health education programs to promote healthy lifestyle choices among rural populations are urgently needed.
Article Type: Survey
Subject: Heart diseases (Development and progression)
Physical fitness
Prevalence studies (Epidemiology)
Medical research
Medicine, Experimental
Authors: Forrest, Kimberly Y.Z.
Hannam, Susan E.
Leeds, Marcy J.
Pub Date: 01/01/2011
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2011 Source Volume: 26 Source Issue: 1
Product: Product Code: 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs
Organization: Government Agency: United States. Centers for Disease Control and Prevention
Geographic: Geographic Scope: Pennsylvania Geographic Code: 1U2PA Pennsylvania
Accession Number: 308741534

Traditionally, living in rural areas is often viewed as the idealized country life--relaxing, active, fresh air, sunshine, and plenty of fresh fruits and vegetables. However, current rural residents in the United States are generally older, poorer, and less healthy [1, 2]. They are more typically beset with an array of obstacles to good health, including a high level of poverty, an inadequate health infrastructure, and limited access to health care [1-6].

Currently, the major health problem and leading cause of death in the United States is heart disease [7]. Besides family history, the occurrence of heart disease is often linked to certain unhealthy lifestyle choices, including a sedentary lifestyle, a poor dietary intake, smoking, and consuming alcohol in excess. Nationally, physical activity levels have been found to be lower in rural residents than in urban residents [8, 9], and both men and women residing in rural communities are more likely to be inactive than their urban counterparts [10]. Inactive lifestyles leading to obesity are becoming a significant problem in many rural areas [1, 11-14]. In the past few decades, trends in smoking have changed. Up until the early nineties, urban residents were much more likely to smoke than rural residents, but during the last two decades this trend has shifted [15, 16]. Currently among smokers, rural residents smoke more frequently than urban residents [14-16]. Although metropolitan counties were found to experience a higher prevalence of heavy and binge drinking than rural counties, trends of an increase in heavy drinking between 1995 and 2003 were sharper in rural counties, nationwide [17]. Rural males are more likely to drink alcohol in excess than urban males [18]. Overall, rural residents of all ages are more likely to engage in risky behaviors due to alcohol consumption when compared to their urban counterparts [19]. Many rural adults have poor diets and do not meet recommended nutrition guidelines. Vitolins and colleagues reported that the majority of older adults in two rural counties in North Carolina did not meet the minimum servings recommended by the Food Guide Pyramid for grains, fruits, vegetables, or dairy [20]. This same group was found to exceed recommended intakes for discretionary calorie servings. Even though poor diets are a concern for both males and females in rural areas, males were found to have worse dietary patterns than females; males tended to consume less fruits, vegetables, cereals high in fiber, and milk, and to consume more sweetened beverages, including soft drinks [21]. Several factors which influence poor dietary habits have been identified among rural residents, including: drinking sweetened soft drinks, consuming super-sized portions, and eating while doing other activities such as driving or watching television [22]. Rural residents with poor dietary intakes also reported more health issues, including hypertension, high blood cholesterol level, and high resting heart rates; all of these concerns could potentially be the consequence of unhealthy dietary choices [23].

Due to the aforementioned risk factors, rural residents in some areas have been reported to have higher rates of heart disease and associated mortality than urban residents [24]. There is a variation in the incidence of heart disease mortality across different geographic areas. The highest rates of mortality from heart disease have been found in rural regions with low population densities and limited access to emergency medical services [3]. Diabetes increases the risk of cardiovascular disease. Two major risk factors for diabetes, as shown by the Third National Health and Nutrition Examination Survey, are being a rural resident and being a minority race [25]. Diabetic patients in rural areas were found to have much worse blood sugar and blood pressure control, which are two of the most important factors leading to diabetic complications, including heart disease [26, 27]. Overweight and obesity are important risk factors for heart disease and diabetes. Obesity has been found to be significantly more common in rural communities than in urban communities in the United States [10]. Between 1994 and 2000, the rate of obesity was found to increase more rapidly in the rural population than in the urban population of the U.S. [28]. Borders and colleagues confirmed the same trend for rural Texas residents [29].

According to the U.S. Census Bureau, Pennsylvania has one of the nation's largest rural populations [30]. Moreover, the rural population has grown faster than the urban population in the past decade in Pennsylvania, while across the United States the trend has been the opposite [31]. On average, Pennsylvania's rural residents are older than its urban residents, and this difference is rapidly increasing. Between 1990 and 2000, the increase in the proportion of rural seniors was double that of urban seniors [31]. Since heart disease is more common among older adults and the incidence of reported unhealthy lifestyles is higher among rural residents, this underscores the need to evaluate the prevalence of heart disease and associated risk factors among rural Pennsylvanians. Therefore, the purpose of this study was to identify if rural Pennsylvanians experience more heart disease than urban Pennsylvanians, and to evaluate risk factors for heart disease among rural Pennsylvanians by analyzing data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS).



The BRFSS is a collaborative project of the Centers for Disease Control and Prevention (CDC) and the U.S. states and territories. The BRFSS, initiated in 1984, is an ongoing data collection program designed to measure behavioral risk factors in the U.S. adult population (18 years of age or older) living in households. The objective of the BRFSS is to monitor preventive health practices and risky behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases in the U.S. adult population [32]. Data collection for the BRFSS is managed by state health departments with guidelines provided by the CDC. A random sample of adults (only one adult per household) is surveyed through a telephone interview. The data collected by state health departments are then transmitted to the CDC for processing at the national level. Compiled BRFSS data files are available at the CDC's website as public domain data. The Institutional Review Board (IRB) of the Centers for Disease Control and Prevention (CDC) approved the BRFSS. Pennsylvania began the BRFSS in 1989, and has continued to collect data every year since its inception. The current study used the 2005 BRFSS data downloaded from the CDC's website, and then created the Pennsylvania data set from the national data file. The survey response rate in Pennsylvania was 45.9% in 2005 [33].


Based on the definition established by the Center for Rural Pennsylvania, a rural county is defined as having a population density of less than 274 persons per square land mile, which is the average population density of Pennsylvania [31]. Based on this definition, 48 (72%) of Pennsylvania's 67 counties are located in rural areas.

Coronary heart disease, heart attack, and stroke were self reported in the BRFSS. The participants were asked if a doctor ever told them that they had experienced angina/coronary heart disease, a heart attack, or a stroke. Hypertension was assessed by self reporting if a doctor had ever told the participants that they had high blood pressure or if they were currently taking any medications for hypertension. Overweight was defined as a body mass index (BMI) of 25 or above, and obesity as a BMI of 30 or above.

Evaluated risk factors included: smoking cigarettes, drinking excessive alcohol, being physically inactive, and consuming insufficient fruits and vegetables. Smoking status was classified as current smokers (smoke everyday or smoke some days) and former smokers. Alcohol drinking was categorized as heavy drinkers (adult men having more than two drinks per day and adult women having more than one drink per day) and binge drinkers (adult men having five or more drinks on one occasion and adult women having four or more drinks on one occasion). Being physically inactive was defined as an adult who did not meet the criterion of 30 or more minutes of moderate physical activity for five or more days per week or vigorous physical activity of 20 or more minutes for three or more days per week, and included adults who had no physical activity. Consuming less than five servings of fruits/ vegetables per day was considered as insufficient. Health status was self-reported as excellent, good, fair and poor.

Age was evaluated by three age groups: 1844, 45-64, and 65 or older. Race was classified as Caucasian, black, Hispanic, and other. Annual family incomes were categorized as < $15,000, $15,000-$24,999, $25,000-$34,999, $35,000-$49,999, and $50,000 or above. Education levels were defined as less than high school, high school graduation, some post secondary education, and college degree or higher.


Two statistical programs were used to analyze data in the current study. The statistical program SAS System for Windows (Release 9.1) (SAS Institute Inc. Cary, NC) was utilized for data management and variable examination, such as sorting data and recoding variables. Due to the complex nature of the survey data from BRFSS, statistical software SUDAAN (Release 9.0.1) (Research Triangle Institute, Research Triangle Park, NC) was used to analyze the data. SUDAAN can account for complex multistage sample designs and sample weights.

The PROC CROSSTAB procedure in SUDAAN was utilized for univariate analysis, including the description of the study population and assessment of bivariate associations. Prevalence rates were calculated by dividing the number of persons with an event of interest by the total number of survey participants in the same group. Differences in prevalence rates were evaluated for statistical significance using the chi-square test, which is available in SUDAAN. Ninety-five percent confidence intervals (95% CI) were provided for all prevalence rates. The PROC LOGISTIC procedure in SUDAAN was employed in multivariate analyses to identify independent correlates of heart disease, which combined coronary heart disease and heart attack. Taylor series linearization methods were used for variance estimation. Odds ratios (OR) and 95% CI for odds ratios were provided. The significance level was set at 0.05. All analyses used weighted data to adjust for non-response and non-coverage of the survey, so that the results were representative of the population of Pennsylvania. These adjustments were made by applying the examined sample weight variable provided by the CDC. Weighted prevalence rate estimates were reported.


A total of 13,378 Pennsylvania residents participated in the 2005 BRFSS. Table 1 describes, by rural versus urban status, the study population that represented Pennsylvania's non-institutionalized civilians who were 18 years or older. Overall, nearly 5% more females than males participated in the study. About 20% of the study population was aged 65 years or older, which was similar between rural and urban residents. Almost 85% of the study population was Caucasian, with 7.9% black, 3.2% Hispanic, and 4.4% other races. Rural areas had a higher proportion of Caucasian residents than urban areas (93.2% vs. 81.1%). Rural residents were more likely to be from low income families defined as having an annual income of less than $35,000. Rural residents were less likely to graduate from college than urban residents (20.5% vs. 33.1%). Based on the 2005 BRFSS data, 37.2% of the Pennsylvanian population resided in a rural area, and 62.8% lived in an urban area.

Common health conditions were compared between rural and urban Pennsylvania residents in Table 2. Compared to urban residents, rural residents had a significantly higher prevalence rate of heart disease (5.9% vs. 4.6%, p-value = 0.02) and heart attack (5.2% vs. 4.2%, p-value = 0.05). Although the differences were not statistically significant, rural residents were more likely to experience high cholesterol level, overweight, obesity, and self-reported poor health status. Risk factors, including smoking cigarettes, drinking excessive alcohol, being physically inactive, and consuming inadequate fruits and vegetables, were also compared between rural and urban Pennsylvania residents in Table 2. Rural residents had a significantly higher current smoking rate than urban residents (25.4% vs. 22.6%, p-value = 0.02). The majority of the smokers smoked every day. Slightly more rural residents reported being binge drinkers (17.3% vs. 15.2%, p-value = 0.06) than urban residents. Physical activity was measured as not meeting recommendations (including either insufficient or no physical activity) and as no physical activity at all. The differences of these physical activity measures were not statistically significant between rural and urban residents. The proportion meeting the recommendation of consuming five or more servings of fruits and vegetables per day was very low in both the rural and urban populations. However, there still were significantly more rural residents than urban residents who consumed less than five servings of fruits and vegetables per day (80.0% vs. 73.8%, p-value < 0.001).

In the multivariate analysis, coronary heart disease and having a heart attack were combined into any heart disease as the dependent variable. Variables that were available to the multivariate model selection were the factors that were significantly associated with heart disease in the univariate analysis, including rural status, age, gender, race, family annual income, being overweight, smoking, binge drinking, and consuming less than five servings of fruits and vegetables per day. Table 3 presents the results of the multivariate analysis. Being a rural resident, male gender, 65 years of age or older, overweight, family annual income less than $35,000 were found to be independently significantly associated with heart disease. Being a minority, binge drinking, and consuming less than five servings of fruits and vegetables per day were also associated with an increased risk of heart disease, but these associations were not statistically significant. After adjusting for age and other variables in the model, males had a 1.99 times higher risk of heart disease than females. Overweight individuals had a 1.80 times higher risk of heart disease than normal weight individuals. After controlling for all the independent variables in the model, being a rural resident was still a significant independent risk factor which was linked to a 32% increased chance of heart disease (p-value = 0.0094).


This study evaluated heart disease and its associated risk factors among rural residents and compared that with urban residents in Pennsylvania using the BRFSS data. We found that heart disease was significantly more common in rural Pennsylvanians than in urban Pennsylvanians. Besides the traditional risk factors for heart disease, such as older age, male gender, and overweight, being a rural resident was a significant independent risk factor associated with heart disease occurrence.

Although rural residents experience similar patterns of heart disease and its associated risk factors as urban residents in Pennsylvania, when compared to urban residents, rural residents displayed more unhealthy lifestyle behaviors known to contribute to an increased risk of developing heart disease. Rural residents were more likely to smoke, drink alcohol excessively, and consume an unhealthy diet. These results confirm the findings from other studies [14-16,18, 21]. However, after taking rural status into account, these risk factors were not independently associated with heart disease, and the effects of these risk factors on heart disease were replaced by socioeconomic status, as measured by family annual income. This finding suggests that rural status reflects a cluster of risk factors for heart disease, and individuals with poor lifestyle behaviors tend to have these risk factors grouped together, and not just in isolation. Socioeconomic status has been shown to be linked with cardiovascular disease risk factors in other study populations, and to have contributed to increased heart disease specific mortality [34, 35]. In our study, rural status and socioeconomic status were independent correlates for heart disease occurrence. Thus, the risk of developing heart disease is not completely explained by unhealthy lifestyle behaviors among rural residents. The disparities between different socioeconomic levels could result in individuals having varied levels of knowledge related to heart disease prevention, access to primary health care, and treatment quality. It is long recognized that people with low socioeconomic status in the community have higher rates of death, disability, and illness [36]. This pattern has been observed throughout the world, regardless of whether the major causes of death were from infectious diseases or non-infectious diseases, and despite how socioeconomic status was measured [37]. Low socioeconomic status during childhood and adulthood frequently continues into older adulthood. In an aging society, the effect of socioeconomic status disparities on health status is particularly striking in relationship to heart disease; morbidity and mortality rates from cardiovascular disease have been found to be higher in individuals of lower socioeconomic status as defined by education, occupational position, or income [38, 39].

A major strength of this study was the use of population-based data from the BRFSS. Over many years, the content of the survey questions, questionnaire design, data collection, procedures, interviewing techniques, and data processing have been carefully developed to improve the BRFSS data quality [32]. Several limitations are recognized in the current study. First of all, the data are collected using telephone surveys. Individuals who live in households without a residential telephone are not included. Therefore, the BRFSS might exclude certain segments of the population who are of lower socioeconomic status, or whose households only use cellular phones. Secondly, the survey is based on non-institutionalized populations and excludes persons residing elsewhere, such as nursing homes or long-term care facilities. Thus, the prevalence of heart disease could be underestimated. Thirdly, the BRFSS data are self-reported by the respondents, which can be subject to recall bias.

Modifications and improvements in unhealthy lifestyle behaviors in rural residents will most likely result in significant reductions of heart disease. Health education about healthy lifestyle choices among rural populations is urgently needed and deserves special attention. It is necessary to develop health promotion programs which target rural residents with low socioeconomic status to help individuals change their unhealthy behaviors, and to enable them to increase control over and improve their health. Low socioeconomic status should be regarded as a risk factor for heart disease in line with other traditional risk factors, and policy makers should be aware of this when planning social and healthcare provisions. At a community level, promoting social justice, political reform, and economic development in rural areas can certainly improve access to rural health services, thus helping to decrease heart disease morbidity and mortality and improve health status among rural residents.


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Kimberly Y.Z. Forrest, PhD

Susan E. Hannam, HSD

Marcy J. Leeds, Ed.D

Kimberly Y.Z. Forrest, PhD, is affiliated with the College of Health, Environment and Science, Slippery Rock University of Pennsylvania, Slippery Rock, Pennsylvania, Susan E. Hannam, HSD, is affiliated with the College of Health, Environment and Science, Slippery Rock University of Pennsylvania, Slippery Rock, Pennsylvania, Marcy J. Leeds, Ed.D, is affiliated with the College of Health, Environment and Science, Slippery Rock University of Pennsylvania, Slippery Rock, Pennsylvania. Corresponding Author: Kimberly Y.Z. Forrest, PhD, Department of Public Health and Social Work, College of Health, Environment and Science, Slippery Rock University of Pennsylvania, 1 Morrow Way, Slippery Rock, PA 16057, USA, Phone: 724 738-2258, Fax: 724 738-4032, Email:
Table 1. Demographic Characteristics of the Pennsylvanian
Participants in the 2005 BRFSS

                             ALL            Rural          Urban
                            n (%)           n (%)          n (%)
                         ([section])     ([section])    ([section])

Rural/Urban Status      13,378 (100.0)   5879 (37.2)    7499 (62.8)
  Male                   4957 (47.6)     2197 (47.3)    2760 (47.9)
  Female                 8421 (52.4)     3682 (52.8)    4739 (52.1)
Age (years)
  18-44                  4711 (46.4)     2044 (46.3)    2667 (46.5)
  45-64                  5142 (33.5)     2255 (33.4)    2887 (33.5)
  65 or older            3525 (20.1)     1580 (20.3)    1945 (20.0)
  Caucasian              11189 (84.6)    5488 (93.2)   5701 (81.1) *
  Black                   1357 (7.9)      112 (2.3)     1245 (11.3)
  Hispanic                255 (3.2)       79 (2.5)       176 (3.7)
  Other                   421 (4.4)       71 (2.0)       200 (4.0)
Annual Family Income
  < $15,000               1681 (9.5)     806 (11.8)     875 (8.2) *
  $15,000-$24,999        2430 (16.7)     1173 (19.7)    1257 (15.0)
  $25,000-$34,999        1661 (13.5)     812 (15.9)     849 (12.2)
  $35,000-$49,999        1955 (17.7)     869 (19.5)     1086 (16.7)
  $50,000 or more        3745 (42.5)     1351 (33.2)    2394 (47.9)
Level of Education
  < High School           1380 (9.6)     668 (10.5)     712 (9.1) *
  High School            5466 (39.0)     2757 (45.9)    2709 (34.9)
  Some Post Secondary    2920 (23.0)     1238 (23.1)    1682 (21.5)
  College or Higher      3587 (28.4)     1207 (20.5)    2380 (33.1)

([section]) % is based on weighted data adjusted for study design,
non- response, and stratification.

* Chi-square p-value < 0.05 for the difference between rural and
urban residents.

Table 2. Comparisons of Prevalence Rates (%) of
Health Conditions and Risk Factors between Rural
and Urban Pennsylvania Populations, 2005 BRFSS

Health              Rural           Urban
Conditions      & ([section])   & ([section])
                  (95% CI)        (95% CI)
                      n               n

Heart Disease        5.9            4.6 *
                  (5.1-6.9)       (4.1-5.3)
                     369             428
Heart Attack         5.2            4.2 *
                  (4.4-6.2)       (3.6-4.8)
                     369             349
Stroke               2.1             2.7
                  (1.7-2.7)       (2.2-3.2)
                     202             248
Hypertension        26.7            27.4
                 (25.1-28.5)     (26.0-28.9)
                    1964            2454
High Blood          37.5            36.7
Cholesterol      (35.4-40.0)     (35.0-38.4)
                    1967            2439
Diabetes             8.4             8.0
                  (7.4-9.5)       (7.2-8.8)
                     642             732

 Risk Factors        Rural           Urban
                 & ([section])   & ([section])
                   (95% CI)        (95% CI)
                       n               n

Overweight           62.7            61.3
                  (60.5-64.9)     (59.6-63.0)
                     3698            4469
Obesity              26.6            24.5*
                  (24.7-28.5)     (23.1-26.0)
                     1616            1899
Poor Health           4.5             3.3
Status             (3.8-5.4)       (2.9-3.9)
                      365             369
Current Smoker       25.4           22.6 *
                  (23.6-27.4)     (21.1-24.2)
                     1362            1649
Smoke Everyday       19.8           16.8 *
                  (18.1-21.7)     (15.5-18.3)
                     1058            1237
Former Smoker        24.3            26.0
                  (22.7-26.0)     (24.7-27.4)
                     1553            2098

([section]) % is based on weighted data
adjusted for study design, non-response, and

* Chi-square p-value < 0.05 and ** P-value <
0.01 for the difference between rural and urban

Table 3. Multivariate Model for Heart Disease among, Pennsylvanians,
2005 BRFSS

Factors Associated with Heart Disease          OR           95% CI

Age (for every year increase)                 1.06         1.05-1.07
Residential Area
  Urban                                 1.00 (reference)
  Rural                                       1.32         1.08-1.62
  Female                                1.00 (reference)
  Male                                        1.99         1.60-2.46
  Caucasian                             1.00 (reference)
  Minority                                    1.22         0.86-1.71
Family Annual Income
  < $35,000                             1.00 (reference)
  [greater than or equal                      1.72         1.39-2.12
    to] $35,000
  No                                    1.00 (reference)
  Yes                                         1.80         1.44-2.26
  No                                    1.00 (reference)
  Yes                                         1.31         0.99-1.74
Binge Drinking
  No                                    1.00 (reference)
  Yes                                         1.26         0.85-1.88
[greater than or equal to]
  5 Servings Fruits and
  Vegetables Per Day
  Yes                                   1.00 (reference)
  No                                          1.13         0.90-1.42
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