The rural elderly are a barely visible population that is, as the adage goes, "out of sight, out of mind." Yet, they are aging along with the rest of America. This group, ruggedly independent but less healthy than their urban counterparts, have fewer community resources to assist them in time of need. Hopefully, by deepening nursing's awareness of these people and their culture, efforts will be enhanced to reach out and find those needing our care.
It has been said that statistics are people with their tears wiped off.1 Because this article deals with statistical facts, I want to set the stage by briefly describing four rural elders in North Carolina, all of whom have one pressing goal: to keep away from what they considered the dehumanizing conditions of nursing homes.1 Picture if you will:
Mrs. F, 68, a smiling, plump black woman dressed in torn shirt and jeans, a scarf around her head, spits tobacco juice at regular intervals, while peeling and cutting apples for stewing. She lives in a dilapidated old trailer, with no running water or bathroom, behind her only son's house. He has 14 children and 21 grandchildren. She receives "some" Social Security.
Mrs. M, 91, is a happy, active and friendly white woman with abundant silky white hair. She has been widowed for 12 years, lives close to two of her children and not far from the other five. Her gracious, two-story house is situated in a grove of oak trees. It is wellappointed with all of the amenities necessary for comfortable living, including washer and dryer. She goes to church every Sunday. She depends on no one for money.
Mr. L, 71, has a broad smile and large, widely spaced teeth showing white in his dark black face. He is six feet tall, and his hair and mustache are just beginning to gray. He owns a very small four-room house heated with an oil circulator. It has an indoor bathroom and a small garden. A former sharecropper and janitor, he gets Social Security and a $15 monthly pension from the place where he used to work. He is used to drinking whiskey. This widower lives alone but wants someone with him.
Mr. C is 67, tall, thin, dejected, and depressed. A deeply religious man, he lives in a nice four-room home with flower and vegetable gardens. He was a successful farmer who spent all of his savings on his wife, who died of cancer five years ago, and his son, who died of lung cancer. His Social Security is spent on his own health bills. He wants to marry and share his home and flowers. Anyone from 40 to 65 years would be great.
Together, these two men and two women, are meant to put faces on the data that are presented in this article.
A 1980 study of seven national magazines determined the frequency with which old people, 65 years of age or more, were pictured in advertisements. The study found that only 5.9% contained a picture of elderly persons.2 Underrepresented by the media, our society's elders have become its most invisible element. Even more forgotten and neglected are those aged Americans who live in our country's vast rural spaces. Even more than their urban counterparts, these citizens fulfill the age-old adage, "out of sight, out of mind."
This article will direct attention on the rural elderly. It will not discuss the prototypes of Scarlett O'Hara's grandparents or other Southern aristocrats. Nor will it refer to closed cohesive religious societies such as the Hutterites and Amish where secure interpersonal relationships, established from childhood, continue until death. Rather, by using aggregate data derived from regional and national sources, it will profile the average North Carolina rural elder of moderate or diminished means, and discuss social and behavioral influences on nutritional status.
The 1980 national census revealed that 25.5 million people 65 years of age and older were living in America; 43% live in rural areas and 60% are women. Among the white population, 38% are rural residents, half of whom live in the South. One-third of the black elderly live in rural areas, almost 90% of them in the South.3 Only 14% of Hispanic elders live in rural areas.4
In North Carolina in 1980, 52% of the entire population was rural. Another 18.5% live in small towns of less than 25,000 population.5 This is over 70% of the state's population, a figure that has not changed since 1970. In the state, 10.3% are 65 years of age or older, compared to 1 1 .2% for the United States as a whole.
The elderly, as a group, are not mobile. Recent data report that more than two-fifths of rural elders living in small towns and two-thirds of those living on farms have not moved in 20 years.3 None of our four prototypes have moved from the community where they lived all their lives. However, there is some migration from the North to the South and West for those over age 75. There is some evidence, also, that urban elders are moving to rural areas in increasing numbers. Between 1975 and 1978, 2.1% of older urbanités left a metropolitan area.6
Population Composition, Marital and Family Structure - It is not surprising that there are more women than men, since women continue to outlive men, and more widows than widowers. About one-third of rural elderly women are married, living with their spouses, but half are widows.4 While one-third of rural elderly women live alone, over half live with their families. Very few rural elderly men live alone. Our two male prototypes, although living alone, are searching for wives. Most elderly men are married and still living with their wives. Widowers tend to remarry younger women.
In 1975, nearly four-fifths of rural elderly men lived with their families. Of these, 76.1% were considered the head-of-household. Only half of the women lived with their families and only 8.5% were head of the household.4
It is easy to see the isolation of growing old beyond the city limits affects the women to a much greater degree than it does men.
Housing - Housing is probably the single most important element in the life of an older person, with the possible exception of one's spouse. Yet housing for the rural elderly, viewed in the aggregate, constitutes much of the substandard housing in the United States. Blacks have three times more substandard housing than whites. In 1975, one in every three homes of rural elders had no plumbing; 20% were without telephone; 50% lacked central heating.7 Very few had such niceties as automatic clothes- or dishwashers, or air conditioning, but many did have freezers.
In her handbook on aging, Frances Carp states that 90% of substandard rural and small-town dwellings are in need of federal assistance for rehabilitation. Yet, of the combined resources of the US Department of Housing and Urban Development (HUD) and the Farmer's Home Administration (FHA), only 2% have been directed toward alleviating this dire situation.7
Among our prototypes, one woman lives in a dilapidated trailer with no plumbing. Only one woman, who lives in a large home, has a washing machine. None have air conditioning. Three have freezers.
Fiscal year 1983 loans for repairing or remodeling homes of the elderly carried the same 9.25% interest rate as the previous year. Even though elders may wish to remodel, they are subjected to very stringent credit terms in order to finance home improvements. Against such adversity, few feel motivated to remodel, especially when they foresee living only a few more years. This is regrettable, because in order to create a healthful, comfortable environment in which to pass one's final years, even housing of a decent standard needs certain modifications. Even heating, the elimination of drafts, brighter illumination, grab bars and guard rails both inside the house and out are just a few necessary modifications. Most older homes even need modification to make it easier for elders living alone to prepare and store food.
It is interesting that the French government provides funds for the rehabilitation of homes of their elders. German planners are calling for modernization of substandard housing units so that their elderly can stay at home. The United States has not yet reached this stage of planning.
Defining what is good or bad housing, though, is highly subjective, and not limited to mere physical amenities. For housing to be successful, it must occur within a complex matrix of social support systems and climatic conditions. Transportation, shopping, recreation, medical services, and other facilities must satisfy the individual's needs. Insufficient transportation is perhaps the greatest problem. Because of the great distances that separate them from external activity, the rural old are often confined to their homes. Their families are often incapable, either financially or physically, of assisting with this problem.
Despite the housing difficulties that confront the rural elderly, home ownership is high - between 80% and 90%. In 1977, 70% of black families with an over-65-year-old head-ofhousehold owned their homes. As you recall, Mr. L owns his. Among white families, 84% were home owners. Both of our white prototypes, Mrs. M and Mr. C, own theirs.8 Single elders often live in mobile homes where they can maintain independence, as does our prototype, Mrs. F.
Generally speaking, there is fierce determination to retain separate housing and independence from the extended family for as long as possible. Indeed, prior to the age of 75, much of this independence is realized. Moving in with relatives is interpreted by the rural elderly as visible proof of dependency.
In addition, disposing of property can be a problem. The sale of real estate, which usually includes not just a house, but land and other buildings, is frequently impeded by archaic wills or by the absence of any will. The legal process required to resolve such conflicts becomes prohibitive.
A study of predominantly rural white Pennsylvanians made in 1961 and repeated in 1971 found that the least acceptable alternative to independent living was residing with a sibling or child.9 The elders preferred living in nursing homes or retirement centers. Considering the accumulating evidence that most disadvantaged elders do not want to live with a concentration of their peers, such as in nursing homes and retirement centers, this is quite an assertion. Most elderly Americans, however, want to live near a child. In fact, most do. Their major means of contact is the telephone. Our rural North Carolina prototypes all live near, but not with, their children, with the exception of one whose only child is dead.
There are major differences, however, between black and white families. Black families are more apt to have young children with them. The extended family pattern of providing informal foster care and adoption services to children is prevalent among blacks.8 In fact, the norm of intergenerational reciprocity is still strong all over the United States.
Income - According to a recent article in the Wall Street Journal, 25% of American elders remain below or just above the government's designated poverty income of $4,400 a year. Worst off are blacks and single or widowed women over 70. As reported, we are just giving them enough so they starve better.10
A 1977 Census study found that 20% of men over the age of 65 still worked, compared to 8.3% of women. By age 70, the elderly work force had decreased so that only 15% were working.4 The trends were about the same for both black and white.
One current trend is toward extending one's working life in order to supplement meager income. Dirt farmers in North Carolina ease gradually into retirement. Despite the current high level of unemployment and the traditional retirement age of 65, many ablebodied elders continue to work and to seek work beyond that age.
Record level inflation has disproportionately affected elders' fixed incomes. Their heating bills have been the chief problem in the last two or three years. However, a 1978 study shows that over 90% of the elderly consider their incomes adequate. Only one-fourth admitted any financial difficulty.6 Most feel, as do our four prototypes, that no matter how badly off they are, they are better off than their parents had been.
The 1980 census statistics show that income levels are below the poverty level in 8% of all white families and 28.9% of all black families. Contributing to the rising poverty rate over the past ten years has been the increase in families supported by women, because women's incomes tend to be 45% lower than men's.11
The income of the elderly blacks appears to be only one-half (52%) as large as that for all races, and is worse for families headed by women. Over one-third of black, female, elderly heads of household have incomes below the poverty level. Altogether, three to four times more elderly blacks are poverty stricken than others.11
Although poverty is still more common among the urban elderly, it is nonetheless a severe problem for those who live in rural areas. Among the white population, 39% of those over age 72 live in poverty. Among blacks, 53.4% are in this category.
Social security benefits are received by about 92% of all elderly people.4 Black elders often have, in addition, their earnings and supplementary benefits. White families often have dividends and pensions. The poverty of rural elders, especially that of blacks, is so grave that even the nominal expense of Medicare may be beyond their means.
Transportation - The Administration on Aging and the US Department of Transportation have attempted, despite insufficient operating assistance, to meet the transportation needs of the rural elderly. In communities with populations of less than 2,500, public transportation is extremely scarce, serving about 12% of such areas. Taxi service is even scarcer and less efficient.12
The problem of rural immobility is further complicated by the special transportation needs of the disabled, the typical lack of telephone with which to request such transportation, and the chronic inability of lower-income clients to pay for specific and costly transportation services. Many rural elders have some kind of automobile, but are unable to drive. Others rely on friends and relatives to chauffer them, or else pay exorbitantly for taxis. Those who must give up driving because of failing health or because of prohibitive maintenance costs often become housebound if family and friends do not come to their aid.
US News and World Report recently published an article on bus deregulation. The big scheduled carriers, especially Greyhound, are abandoning rural stops en masse. Both it and its competitor, Trail ways, are boosting fares as much as 25%. Every month, Mr. H, 93, and his 68-year-old wife board a Greyhound bus in front of their home in Walton, West Virginia, for the 35-mile journey to Charleston for medical care. They do not own a car. "I reckon we'll just have to sit here unless we can get someone to take us to Charleston," says Mrs. H.13
Health Status- Almost 50% of rural Americans live in medically underserved areas.14 In 1977, there were more than three times as many doctors per capita in cities than in rural areas. For every 100,000 people, there were 56 physicians in rural districts and 170 in metropolitan centers.15 In contrast to this disproportion of manpower, hospital beds were almost equally distributed. For every 100,000 people, there were 4.1 beds in rural areas and 5.0 beds in urban settings.15
As the rate of mortality declines for the elderly, the number of frail elders increases. These are the people who make the heaviest demands on our health care resources. During the 1976-78 National Health Interview Survey, rural elders reported 15% fewer physician visits than the urban elderly, averaging six visits per year. Another 13.9% reported having made no visit to a physician at all during the previous two years.15 Proportionally fewer rural whites than blacks saw a doctor.
A further finding of the survey was that rural elderly were 27% more likely to have experienced an episode requiring hospital care than urban elderly. During the two-year period in question, 29.2% of rural elders had a hospital episode as compared to 23.6 percent of urban elders. Of the rural population, 30% of white elders had been hospitalized, even though they saw physicians less often. Only 21 .4% of black elders had a hospital episode.15
In terms of perceived health or illness, 38.3% of the rural elderly report only fair to poor health.15 The proportion is greater among all black people, and increases with decreasing urbanization-between 1976 and 1978, 56.2% reported fair to poor health.15 This survey indicates that over half of the black rural elderly and nearly 37% of the white elderly report poor health.
There are considerable obstacles in obtaining health care in rural areas. As a result, rural residents are less likely to have preventive care, more likely to spend more than 30 minutes traveling to a physician visit, and more likely to experience longer waits once there. Clearly, their greater need for medical care is indicated if only by the fact that rural people in general, and the elderly in particular, are less healthy than those living in the city. The Surgeon General has established a goal to reduce elders' disability days due to chronic or acute disease from an average 41.9 days per year to less than 30 days per year by 1990.
Biomarkers are physical and behavioral changes that occur at predictable times during the aging process. Some biomarkers in humans are hearing, vision, cardiovascular changes, bone loss, sleep variations, and alteration in glucose tolerance and the body's immune functions. Thus far, dietary restriction is the only intervention that repeatedly alters the rate of aging in experimental mammals.
In 1952, McCoy reported on two rat sisters. One, the last survivor of the normally fed control group, was old, feeble, and decrepit, and died after 964 days. Her sister, fed on a very low calorie diet, showed little sign of aging. She lived 1,320 days, equivalent to 132 years.16
Social Support Systems - Along with deteriorating health and financial solvency, social support resources tend to dwindle with age. Friends and relatives die, divorce and move away, leaving in their wake a strong sense of discontinuity.
Ofstein and Acuff have reported that the disengaged, socially isolated elderly are prone to low self-esteem, and thus are a high-risk suicide cohort.17 Because isolation limits their ability to communicate suicide intent, suicide attempts of the elderly are four times more fatal than for other groups.
Nevertheless, friendship and morale are remarkably high in rural areas. Data show that the elderly stay highly involved in social and community activities. Church membership and participation, for example, is important. Brothers and sisters now play an enhanced role in their social lives. They remain in close contact with friends and neighbors, and there is a general sense of cohesiveness in the community. Neighbors can be relied upon in a crisis.6 Visiting and talking with friends are preferred leisure-time activities.
Rural elders state that much of their life satisfaction depends on the ability to live independently, a sense of being wanted and cared for by their loved ones, meaningful work, and perhaps a few small luxuries.
When asked what their problems are, they report the following:
* Not enough money
* Not feeling needed
* Fear of crime
* Poor health
* Not enough medical care
* Not enough to do to keep busy
* Not enough friends
* Not enough clothes18
Social and Behavioral Influences on Nutritional Status - Food preferences and habits of people do not change easily. Nutritionists are very aware that knowledge of the local foodways is essential to the success of any nutrition counselor in providing better care. They are passed down by one generation to the next. Dr. Mary Ann Bass, dietitian with Nutrition Services in Knox ville, Tennessee writes that foodways are the activities involved in the selection, procurement, distribution, storage, manipulation and consumption of food, as well as the disposal of inedible portions and human waste.19 Each region has its own culture.
The austerity of rural living has fostered ruggedness, independence, and self-reliance. Some families raise most of their own food, and vary or supplement it with food obtained by hunting, fishing, and gathering wild plants. Therefore, a low income has less effect on nutritional status of rural elders than that of their urban counterparts.
In some counties, there are rolling grocery stores. These usually are converted school buses stocked with mostly canned and staple foods. Fresh fruit, lettuce, and cabbage are available in winter. The driver often carries purchases into the homes of elders and sometimes lets people ride to other destinations. They carry foods for special events such as Christmas and will special order for people. Families tend to buy most of their food at the beginning of the month at a grocery store in the county seat, but trade items for food at the country stores toward the end of the month.
A great variety of edible items are accepted as food, depending on the culture and region.
People, as they age, become only more of what they were. Their personality, habits, and preferences become more ingrained. Social and behavioral factors determine what we eat. What we eat makes us become what we are.
- 1. Salber E: Don't Send Me Flowers When l' m Dead. Durham. NC, Duke University Press, 1983, ? xxv.
- 2. Gantz W, Gartenberg HM, Rainbow CK: Approaching invisibility: the portrayal of the elderly in magazine advertisements. Journal of Communication 1980; 30(0:56-60.
- 3. Byerts TO, Howell SC, Pastalan LA (eds): Environmental Context of Aging: Life-styles, Environmental Quality and Living Arrangements. New York, Garland STPM Press, 1979.
- 4. U.S. Bureau of Census: Demographic aspects of aging and the older population in the United Staes, in Sourcebook on Aging, ed 2. Chicago, Marquis Academic Media, 1979, ? 225.
- 5. Number of inhabitants. North Carolina. i980 Census of Population. Washington, DC, US Department of Commerce, Bureau of the Census; 1982, pp 35-50.
- 6. Lee GR, Lassey ML: Rural-urban differences among the elderly: economic, social and subjective factors. Journal of Social Issues 1980; 36(2):62-74.
- 7. Carp FM: Housing and living arrangements of older people, in Binstock RH, Shanas E (eds): Handbook of Aging and the Social Sciences. New York, Van Nostrand Reinhold Co., 1976, ? 250.
- 8. Hill R: A demographic profile of the black elderly, in US Bureau of Census: Sourcebook on Aging. Chicago, Marquis Academic Media, 1979.
- 9. Powers EA, Keith P, Goudy WJ: Family relationships and friendships among the rural aged, in Byerts TO, et al: Environmental Context of Aging: Life-styles, Environmental Quality, and Living Arrangements. New York, Garland STPM Press, 1979.
- 10. The aging mode gains in the 1970s, outpacing the rest of the population. Wall Street Journal February 17, 1983.
- 11. Increase in families supported by women raises poverty rate. The Wall Street Journal September 24, 1982, p. 14.
- 12. McKelvey DG: Transportation issues and problems of the rural elderly. In Golant SM: Location and Environment of the Elderly Population. New York: John Wiley and Sons, 1979, pp. 135-140.
- 13. Now that the brakes are off the bus industry. U.S. News and World Report. April 18, 1983, p. 87.
- 14. 1981 White House Conference on Aging: Rural Mini-Conference Report. Washington, DC, Green Thumb. Inc.. 1981, p. 15.
- 15. U.S. Department of Health and Human Services, Public Health Services: Health: United States i981. publication (PHS) 82-1232, Hyattsville, MD, National Center for Health Services Research, 1981, p. 55.
- 16 . Morgan RF: Interventions in Applied Gerontology. Dubuque, IA, Kendall-Hunt Publishing Co., 1981, p. viii.
- 17. Ofstein DH, Acuff FG: Durkheim and disengagement: a causal model of aging suicide. Free Inquiry in Creative Sociology 1979; 7(2):108-lll, 117.
- 18. Oberleder M: Avoid the Aging Trap. Washington, DC, Acropolis Books, Ltd., 1982, p. 180.
- 19. Bass MA: Dietetic Currents 1983; 10(2):7.