«RURAL VETERANS: INVISIBLE HEROES, SPECIAL PEOPLE, SPECIAL ISSUES* HILDA R. HEADY ATLAS RESEARCH PART I: WHY A SPECIAL ISSUE ON RURAL VETERANS This ...»
Journal of Rural Social Sciences, 26(3), 2011, pp. 1–13.
Copyright © by the Southern Rural Sociological Association
INVISIBLE HEROES, SPECIAL PEOPLE, SPECIAL ISSUES*
HILDA R. HEADY
PART I: WHY A SPECIAL ISSUE ON RURAL VETERANSThis special issue of the Journal of Rural Social Sciences (JRSS) seeks to introduce and explore the topic of rural veterans, their characteristics and demographics, the challenges they face in accessing health and mental health care in rural America, and the efforts being made to serve and assess this special population through research-based studies and analyses. The issue will begin to fill the gaps in the literature and augment our knowledge on the issues faced by rural veterans and their families. It is our hope that this issue will stimulate discourse among a wide range of thought leaders engaged in service, policy, and research on needed policy and practices to better address rural veterans’ challenges.
There are four primary reasons why this special issue is useful and relevant to many areas of science and practice concerning rural veterans: (1) it is the first ever peer-reviewed journal issue dedicated solely to the issues faced by rural veterans and those who care for them; (2) it is an attempt to highlight the gaps in our current research and policy work; (3) it is an attempt to challenge researchers and policy makers to view these issues across many disciplines, as our authors represent a wide range of social science and health science fields; and (4) it is time to provide a singular focus on these issues.
Overview of Rural America Rural Americans are blessed and challenged by social, cultural, economic, and geographic differences from their urban counterparts. These differences can simultaneously contribute to rural health disparities and provide solutions to closing the service gap. The population living in rural areas constitutes one of the largest underserved U.S. population groups. Rural residents are more likely to: be elderly, be from a lower socioeconomic status, be uninsured, report fair or poor health, suffer from chronic disease, and have higher mortality rates associated with * Please direct all comments to: Hilda R. Heady, 968 Ashton Place, Morgantown, West Virginia 26508-6874, firstname.lastname@example.org, (304) 288-9003 1
2 JOURNAL OF RURAL SOCIAL SCIENCESchronic disease (Braden and Beauregard 1994; Eberhardt and Pamuk 2004).
Simultaneously, rural residents are more likely to serve in the military, maintain strong family ties, live in communities with lower crime rates, and work in high risk occupations. Rural residents are also less likely than their urban counterparts to visit a primary or ambulatory care provider, contributing to lower rates of preventive services and higher rates of potentially avoidable hospitalizations (Laditka, Laditka, and Probst 2009; NACHC 2009). Furthermore, an enduring feature of the U.S. health care landscape is the uneven distribution and relative shortage of rural health care providers, where only 9 percent of the physician workforce is available to serve 20 percent of the total U.S. population (HHS HRSA 2010). As a result, nearly one-third of all rural counties contain Health Professional Shortage Areas (HPSAs), and there are twice as many rural HPSAs as there are urban ones (Probst et al. 2004).
Rural and Minority Military Service Rural and minority Americans serve in the military at disproportionately higher rates than are represented in the general population. Rural Americans often join the military at higher rates than non-rural Americans: while only 20 percent of Americans live in rural areas, roughly half of all military recruits come from small towns and rural areas compared with 14 percent from major urban cities (DOD 2008; Heady 2007). When analyzing active duty military components in terms of race and ethnicity, the U.S. military is quite diverse. Black, Native Hawaiian and Pacific Islander, and American Indian and Alaskan Native racial minority groups are often overrepresented among active duty enlisted personnel in all military components (Army, Navy, Marines, and Air Force) when compared with relevant civilian comparison group populations (DOD 2008). For example, blacks are often overrepresented in military components, making up roughly 20 percent of all active duty enlisted personnel, but only 13 percent of the civilian comparison group (DOD 2008). Hispanics considered an ethnic rather than a racial group, are often underrepresented, making up 11.6 percent of active duty enlisted personnel while accounting for nearly 18 percent of the comparable civilian population (DOD 2008).1
Consequently, due to their high rates of military service rural and minority Americans also represent a substantial proportion of the U.S. veteran population.
Approximately 41 percent of veterans (3.3 million) enrolled in the Department of Veterans Affairs (VA) health care system live in rural or highly rural areas of the country, with the majority living in the southern or central portions of the country (VA ORH 2011). Of the 21.8 million veterans identified in the Census Bureau’s American Community Survey in 2010, approximately 19 percent (more than four million) identified themselves as racial minorities and 7 percent (1.6 million) were female (U.S. Census Bureau2011).
Whether motivated by tradition and values, the need for education and job skills, or economic concerns, rural and minority Americans respond to the call to war at higher rates than their counterparts. However, there are serious gaps in our research on the motivations influencing rural and minority populations’ decision to enlist. The research that is available focuses primarily on material factors such as educational benefits and improved economic opportunity. This research ignores the influence of personal and social values on decision making, such as the value of service to others a characteristic attributed to rural and some minority populations (Heady 2007). When faced with the decision to enter the military, especially in war time, it seems reasonable that possessing a value of service to others could more easily facilitate this decision. However, the literature is critically limited in the areas of minority and rural populations and how their values and culture relate to military service.
One article examining the motivations for serving in the National Guard (Griffith 2008) found that personal values play a role in the recruitment and retention of soldiers. Those intrinsic values are associated with assisting and protecting others, loyalty to completing goals, and feeling obligations to others. While those specific values relate to rural and minority values and culture, the article did not specifically consider rural values or rural communities. The study concluded that soldiers who joined for intrinsic reasons were more committed to reserve military service, influenced by social context (such as family and friends in the unit), and perceived themselves as more combat ready than those who joined for other, often economic reasons. Other studies have analyzed factors influencing enlistment into the military, which again may apply to rural populations, but have not specifically focused on rural values and culture. These studies have shown that the institutional and cultural presence of the military within an area significantly influences the decision to join the military. Therefore, the presence of military family members, such as grandparents, parents, or siblings; military bases; military
4 JOURNAL OF RURAL SOCIAL SCIENCESpersonnel; veterans; and military-related institutions increase the propensity to enlist (Cebula, Menon, and Menon 2008; Kleykamp 2006; Segal et al. 1999).
Furthermore, Cebula et al. (2008) found that the military is a vehicle for upward social and economic mobility. The same study found that youth from states where a higher percentage of the population is without health insurance coverage show a higher tendency to enlist, but the authors concluded that there was insignificant prior research to support this finding, and that further research would need to be conducted to make any conclusions regarding this association.
Rates of military service among rural populations remain relatively unchanged when analyzing the impact of both the discontinuation of the draft and enlistment following 9/11. Changes in the recruitment-to-population ratio after 9/11 show that large increases (of greater than 10 percentage points) occurred in Iowa, Wisconsin, Kansas, Washington, Arizona, Indiana, Oregon, Nebraska, Colorado, Minnesota, and North Carolina (Kane 2005). While rates of military service have remained relatively unchanged, information from the Department of Defense (DOD) in 2005 demonstrated that a significant proportion of service members killed in action in Iraq and Afghanistan were from small towns and rural areas (Battles 2005). Using DOD casualty figures updated through February 12, 2005, 42.9 percent of the service members killed in action during Operation Iraqi Freedom (OIF) and 43.9 percent of the service members killed in action during Operation Enduring Freedom (OEF) originate from rural cities and towns with populations below 20,000 (Battles 2005). However, according to the U.S. Census Bureau in 2005, only 22.5 percent of Americans live in towns with populations at or below 20,000 (Battles 2005). These data enforce the importance of rural and minority populations in military service.
Rural and Minority Veterans Research on the health care status and needs of rural veterans compared with their urban counterparts is growing, but there are still many issues, topics, and specialty populations that remain undeveloped. Current data on enrolled rural veterans suggest that, as compared with urban veterans, rural veterans are often older, have greater physical and mental co-morbidities, have lower physical and mental quality-of-life scores, and reside further away from VA and non-VA health care facilities (Weeks et al. 2006). While the data indicate that the rural veteran population experiences a higher burden of disease, they have a lower utilization rate of VA health care services than urban veterans. Rural populations face unique access RURAL VETERANS 5 barriers including cost, travel distance, travel time, and weather that limit rural veterans’ ability to utilize care (Booz Allen Hamilton 2008).
However, most of these data focus upon rural veterans enrolled in the VA health care system. The VA Veteran Rural Health Advisory Committee (VRHAC 2009) suggests that there are insufficient data regarding non-enrolled rural veterans. Data on this population could reflect both the adequacy of outreach efforts conducted by the VA and the health status of those veterans not utilizing VA services. These data could provide a more comprehensive picture of the health issues and barriers to care facing all rural veterans, not merely those already enrolled in the VA health care system. In addition, data suggest that the demographic composition of the rural veteran population is changing. Minorities serve in the U.S. military at higher rates than their representation in the U.S. population (Heady 2007) and population estimates from the VA suggest that the percentage of minority veterans, including African Americans, Hispanics, and female veterans, is on the rise (VA NCVAS 2010). Similarly, as the military continues to draw recruits from rural areas, the rural veteran population potentially will get younger. Currently, most of the male enrolled rural veterans are between the ages of 55 and 64 (VRHAC 2009). In contrast, almost half of all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans residing in rural areas are under the age of 35 (VRHAC 2009).
These demographic shifts will result in changes in the types of services requested and utilized. Therefore, more focused research on the unique health care needs and access patterns of these populations is necessary to enrich the field of rural and minority veteran health care.
Impetus for Change In November 1997, I suggested to my rural health colleagues in a policy board meeting of the National Rural Health Association (NRHA) that we develop a policy statement on rural veterans and their needs. While I had hoped for an immediate and passionate response, I discovered that many were not aware of the needs of this group I termed “invisible heroes”: invisible because the public is unaware of their disproportionate rate of military service, and heroes because of their deeply personal decision to serve. Fortunately, two colleagues who were Vietnam veterans came up to me following that meeting and agreed that there was a need for such a policy paper and volunteered to help. What ensued was a highly frustrating experience as I researched the literature for existing research and policy statements regarding rural veterans and found almost nothing specific to this issue. My first search efforts on any material concerning rural veterans uncovered proceedings of congressional