Issues/Resources for Persons with TBI in Rural Areas

Individuals with TBI from rural areas experience unique difficulties related to limited resources, limited access to appropriately trained health professionals, limited transportation, and limited employment opportunities.

Landscape with tractor tilling large fieldDefining Rural versus Urban Areas

The US Census Bureau defines rural as “densely settled areas with a population of 2,500 to 49,999 (

What is the incidence of disability and TBI in the rural US and Missouri?

Between 19.8% and 25% of US residents live in rural areas, equaling an estimated 60 million individuals (a number which exceeds the population of the United Kingdom, Spain, Italy, or France).

It is estimated that 8.5 million individuals with disabilities live in rural America.

31.92% of Missourians live in rural counties (28th most rural state in the US).

According to the Disability Statistics Center, following are the rates of disability for residents of the following geographic areas:

  • Rural = 24% disability rate
  • Urban = 15.4% disability rate
  • Suburban = 13.7% disability rate

General Disability (i.e., non-TBI) Issues Specific to Rural Areas

  • Death rates for traffic accidents in the most rural counties are over twice as high as rates in metropolitan areas.
  • Death rates in the most rural counties are 50% higher than in suburban areas, and rural seniors have a 10% higher death rate than urban seniors.
  • In some regions, suicide rates among men are 80% higher in the most rural counties than in large metro counties.
  • Health risk factors are also higher in rural areas, with 8% higher adolescent smoking rates, 5-6% higher adult smoking rates, and 7% higher obesity rates than in urban or suburban areas.
  • Rural residents are less likely to have health insurance and are less likely to receive preventive health services than their urban counterparts.
    • This lack of preventive care is blamed for hospitalization rates in rural areas that are over 35% higher than in urban counties.
  • Rural residents also have 6-7% higher rates of activity restriction due to health conditions compared to suburban areas.
  • Nearly 75 percent of rural areas are classified as “medically underserved”.
  • The National Health Service Corps, whose mission is to serve rural citizens, is only able to meet approximately 15% of primary care, 7% of dental, and 6% of mental health needs of persons in underserved areas.
  • Rural clients have fewer local educational resources and opportunities available to them to support achievement of personal goals.
  • An estimated 31% of the nation’s children attend rural schools, and 13.8% of these rural children live in poverty (Rural School & Community Trust, 2003).
  • Students from rural communities are more likely to drop out of high school than urban students (National Center for Education Statistics, 1998).
  • The average instructional expenditure per student in rural communities is among the lowest at $3,518, compared to $4,086 in large metropolitan areas (National Center for Education Statistics, 1999).

Rural Americans are at greater risk for chronic illness, disability, and loss of independence, higher hospitalization-related health care costs, and reduced productivity.

Accessibility Difficulties for Individuals with TBI in Rural Areas

  • Distance to facilities
  • Limited transportation opportunities
  • Increased poverty levels
  • Lack of health professionals trained in TBI
  • Difficulties recruiting health professionals to rural areas
  • Higher unemployment rates
  • Fewer employment opportunities

Secondary Health Conditions in Persons with Disabilities/TBI in Rural Areas

  • More chronic health conditions
  • Worse self-reported health
  • Higher levels of overall impairments in daily activities
  • Poorer prognosis than urban counterparts
  • Persons with TBI in rural Iowa were more than twice as likely to be in poor health and dependent on others than those in more populated counties.
  • Women with TBI in rural areas reported more significant problems relative to their urban counterparts in terms of finances, accessing service providers and systems, transportation, obtaining information, and coordinating services.

Difficulties Related to Increased Distance from Services

  • The further rehabilitation programs are from rural residents’ homes, the less likely they are to receive rehabilitation services.
  • There are very limited public transportation opportunities for individuals in rural areas, and particularly those who live outside city limits.
  • For those rural areas with public transportation, most vehicles are past their life expectancy and more than half (i.e., 60%) are not wheelchair accessible.

What role does poverty play in TBI outcomes in rural areas?

  • Poverty rates are higher for persons in rural areas.
  • 14.3% of rural residents lived below the poverty level in 1999, compare to 11.2% of the urban population

Rehabilitation Professionals Working in Rural Areas

  • 55% of U.S. counties have no psychologists, social workers, or psychiatrists in practice.
  • Over 70% of all federally designated Mental Health Service Provider Shortage Areas are in rural communities.

Rehabilitation Professionals in Missouri

There are significantly fewer health professionals and services for persons with TBI in rural versus urban Missouri. Given ~32% of Missourians live in rural areas, an appropriate expectation is for 32% of health care providers and services to also be in rural Missouri. However, this study found:

  • Only 13% of medical doctors practice in rural Missouri.
  • Only 7% of rehabilitation physicians (i.e., physiatrists) practice in rural Missouri.
  • Only 20% of physician assistants practice in rural Missouri.
  • Only 19% of physical therapists practice in rural Missouri.
  • Only 16% of occupational therapists practice in rural Missouri.
  • Only 18% of occupational therapy assistants practice in rural Missouri.
  • Only 13% of speech pathologists practice in rural Missouri.
  • Only 23% of registered nurses practice in rural Missouri.
  • Only 24% of advanced practice nurses practice in rural Missouri.
  • Only 13% of psychologists practice in rural Missouri.
  • Only 14% of psychiatrists practice in rural Missouri.
  • Only 13% of social workers practice in rural Missouri.
  • Only 21% of professional counselors practice in rural Missouri.
  • Only 25% of rehabilitation hospitals are located in rural Missouri.
  • Only 17% of brain injury support groups are located in rural Missouri.

However, on the positive side:

  • 42% of osteopathic physicians (i.e., D.O.s) practice in rural Missouri.
  • 30% of physical therapy assistants practice in rural Missouri.
  • 44% of licensed practical nurses practice in rural Missouri.
  • 42% of state Vocational Rehabilitation offices are in rural Missouri.
  • 50% of hospitals are located in rural Missouri.
  • 50% of skilled nursing facilities are located in rural Missouri.
  • 56% of independent living centers are located in rural Missouri.

Are there differences in employment outcomes for persons with TBI in rural areas?

Studies have been conducted in Missouri to determine if persons with TBI experience differences in employment outcomes in rural versus urban areas. Specifically, 78 clients of the Missouri Division of Vocational Rehabilitation (DVR) were followed from time of referral to DVR until case closure. The results indicated the following:

  • Few if any differences were found between the groups in demographics (i.e., more African Americans in urban areas), injury severity (i.e., more rural residents had multiple TBIs), or neuropsychological test scores.
  • However, individuals from urban areas received significantly more services than clients from rural areas, including:
    • More maintenance funds (46% vs. 21%).
    • More transportation services (36% vs. 11%).
    • More on-the-job training (28% vs. 7%).
    • More funds spent on them ($1,816 vs. $1,242).
  • Additionally, more individuals from urban areas were successfully employed at VR case closure compared to rural areas (24% vs. 7%).
  • Conclusion: Individuals with TBI from rural and urban settings have generally similar demographic, injury severity, and neuropsychological abilities; however, they appear to differ in terms of vocational outcomes and number of VR services received, possibly related to limited availability of resources in rural areas.

Increasing Mental Health Services in Rural Areas

Research completed at the University of Missouri demonstrated the potential for telehealth technologies to improve the accessibility of mental health services to persons with TBI in rural areas.

  • 70 general mental health professionals (i.e., psychologists, social workers, counselors) completed training in TBI over the internet, and then were referred individuals with TBI for services. The results indicated:
    • Clinicians showed gains in knowledge regarding TBI.
    • Clients rated trained providers higher than untrained providers.
  • Conclusion: Telehealth training allows clinicians to receive support in their rural communities, reduces clinician isolation, creates a network of generalists with working knowledge of specialty conditions, and promotes high-quality behavioral health services for rural clients.

A similar study was conducted to determine if persons with TBI in rural Missouri found telehealth-based interviews for neuropsychological services to be of similar effectiveness as in-person interviews. The results indicated the following:

  • Telehealth clients were more likely to want to repeat their experiences.
  • Psychologists liked telehealth-based interviews less than in-person interviews.
  • Telehealth services saved DVR in financial costs (e.g., client travel expenses).
  • Telehealth services saved psychologists travel costs.

Specific resources for persons with TBI in rural areas.

Rural Psych is an online resources center rural behavioral health that is maintained by the American Psychological Association (APA)

The National Advisory Committee on Rural Health and Human Services provides general information about health services available to rural residents.

The University of Montana provides general information about disability issues in rural areas (

Information about general resources for persons with disabilities in rural areas is available at the following website:

Purdue University provides information regarding resources available to the caretakers of individuals with disabilities in rural areas.

Information on Housing Issues for persons with disabilities in rural areas can be found at the following website: