Rural Data June 21st, 2017

Figure 1.1. Population densities of metropolitan, micropolitan (large rural), and rural counties in North Dakota. According to the 2015 census estimate, North Dakota is slightly less rural than was determined following the 2010 census. The metropolitan population has increased as has the number of counties so designated. Now six counties are classified as metropolitan (Burleigh, Cass, Grand Forks, Morton, Oliver, and Sioux). The metropolitan population accounts for 49% of the state’s population. In the 2010 census, metropolitan accounted for four counties and 49% of the population. Oliver and Sioux counties were added to the Bismarck metro area. As in 2010, there are seven counties (24% of the population) classified as micropolitan. Rural as a percentage of population has declined from 29% to 26%, and the number of rural counties has declined from 39 to 37. According to the 2015 census estimate, North Dakota is slightly less rural than was determined following the 2010 census. The metropolitan population has increased as has the number of counties so designated. Now six counties are classified as metropolitan (Burleigh, Cass, Grand Forks, Morton, Oliver, and Sioux). The metropolitan population accounts for 49% of the state’s population. In the 2010 census, metropolitan accounted for four counties and 49% of the population. Oliver and Sioux counties were added to the Bismarck metro area. As in 2010, there are seven counties (24% of the population) classified as micropolitan. Rural as a percentage of population has declined from 29% to 26%, and the number of rural counties has declined from 39 to 37.   Figure 1.1. Population densities of metropolitan, micropolitan (large rural), and rural counties in North Dakota. Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

Figure 1.4. Average age of North Dakota residents from 1980 to 2010 by metropolitan, micropolitan (large rural), and rural counties The average age for the state has increased from 33 years in 1980 to over 37 years in 2010 (about two years every 10-year census). This trend is projected to increase as the baby boomer population ages. Rural North Dakotans are older than either micropolitan or metropolitan North Dakotans. This was true in all four census periods (1980, 1990, 2000, and 2010). The average age for the state has increased from 33 years in 1980 to over 37 years in 2010 (about two years every 10-year census). This trend is projected to increase as the baby boomer population ages. Rural North Dakotans are older than either micropolitan or metropolitan North Dakotans. This was true in all four census periods (1980, 1990, 2000, and 2010). Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

Figure 1.17. Population in North Dakota from 1900 to 2015 by metropolitan, micropolitan (large rural), and rural counties Rural population decreased from 1930 to 2010 but has remained stable since then. Since 1990, metropolitan population has been higher than rural population. Population in rural North Dakota counties was up to three times as high as metropolitan or micropolitan populations into the 1940s. Then a sharp increase in metropolitan populations and decrease in rural populations caused the rural counties’ populations to become less than the metropolitan counties by the 1980s. . Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

  Figure 1.19 Net number of in- and out-migrations for metropolitan, micropolitan (large rural) and rural North Dakota. Metropolitan areas have highest in-migration, averaging 5,552 people a year. Rural areas out-migrate an average of 907 people a year. Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

5.6% - 12.5% 12.6% - 19.8% 19.9% - 27.0% 27.1% - 34.2% 5.2% - 12.5% 12.6% - 19.8% 19.9%-27.0% 27.1% - 34.2% Figure 1.13. Percentage of 1980 population aged 65 and older. Figure 1.15. Percentage of 2000 population aged 65 and older. McIntosh County is over 27% older adults. • McIntosh, Nelson, Sheridan, Wells, Logan, and Emmons counties are over 27% older adults. 5.2% - 12.5% 12.6% - 19.8% 19.9% - 27.0% 27.1% - 34.2% Figures 1.13–1.16 show the progression of population change for people age 65 and older at four census periods (1980, 1990, 2000, and 2010). There has been a continual increase in the proportion of older adults in the rural counties. In 2010, the eight counties with 27% or more of their population age 65 or older were all rural; in fact, they are some of the most remote counties because all are classified as frontier

Figure 1.6 Poverty in North Dakota by rural, micropolitan, (large rural), and metropolitan areas.   Any person or family whose income falls below a threshold set by the federal Office of Management and Budget (OMB) is considered poor. In 2014, for a family of two this was $15,379 and for a family of four it was $24,008. In 2014, 11% of North Dakota residents were in poverty (U.S. had 14.8% in poverty) and lived in all regions of North Dakota. Poverty has risen from 8.5% to 14.9% in metropolitan areas since 2000, and in rural areas it decreased from 12% to 11.3%. The poverty rate from 2000 to 2012 was higher in rural North Dakota than either micropolitan (large rural) or metropolitan areas.  Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf Poverty in North Dakota counties has ranged from 6.7% to 41.4% from 2000 to 2014. Three counties in North Dakota have more than 20% of their population in poverty and have been classified under federal guidelines as persistent poverty counties: Rolette County (poverty rate in 2014 of 31.6%), Benson County (29.9%), and Sioux County (33.6%).9 These three counties have a significant American Indian population. A persistent poverty county is one in which 20% or more of the population was in poverty in three consecutive census periods (currently 1990, 2000, and 2010). Six counties in North Dakota have more than 15% in poverty.There are 26 counties with poverty rates less than 10%, based on 2014 data. In 2010, there were 14 counties. Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

         Binge drinking has declined slightly in rural and micropolitan areas, but increased for the metropolitan areas. Males binge drink more than females, and it is a phenomenon associated more with the younger (under 40) age group. Adults in North Dakota tend to drink more than found nationally. Over the past decade, smoking has decreased in metropolitan populations but has remained essentially unchanged elsewhere across North Dakota. This trend is seen in both men and women, although men continue to smoke in greater frequency than women (see Figure 2.2). Nevertheless, the gap between the two groups is narrowing over time.   Source: University of North Dakota School of Medicine and Health Sciences Advisory Council. (2017). Fourth Biennial Report: Health Issues for the State of North Dakota 2017. Retrieved from http://www.med.und.edu/biennial-report/_files/docs/ fourth-biennial-report.pdf

AARP Livability Index Stats Score of 57 for entire state with lowest areas being Health (41) and Neighborhood (42) Neighborhood ranks low due to lack of jobs accessible within a 45-minute commute; lack of mass transit Health ranks low due to rates of smoking and obesity as well as proximity to places to exercise Fargo scores 63, Bismarck 67 on this Index as compared to these more rural areas: Crosby 56 (extreme NW), Lidgerwood 54 (extreme SE), Rhame 60 (extreme SW) and Pembina 57 (extreme NE)

Healthy People 2020 Stats for ND (% change between 2007 and 2012) Colon cancer death rates have dropped 5.2% (down 1.6% nationally) Prostate CA death rate down 1.4% (down 3% nationally) New cases of invasive colorectal CA down 6% (down 7% nationally) Rate of adult diabetic patients who perform home blood glucose monitoring increased 2.7% compared to only 1% nationally Per capita water usage (environmental health) down 12% in ND, 10% nationally 36.3% of adolescents in ND participate in daily Physical Education, Nationally only 29.8% which is a decrease from 33% and below the target of 36.6% in 2020

Healthy People 2020 Stats for ND (% change between 2007 and 2012)--continued New cases of gonorrhea in females aged 15-44 have increased from 68.2/100k to 149.1/100k and continue to trend up, while the target is a decrease to 259.1 nationally and has begun to trend down ND has had no congenital syphilis cases since 2009, while the national rate is 11.6/100k live births Percent of adolescents who perceive there is great risk from binge drinking has decreased slightly in ND to 34.3% and about 2% nationally to 39.7, target was an increase to 44%

Rural Healthy People 2020 Little change since 2010 Access to health care (including emergency services, primary care, and insurance) was identified as the highest priority, followed by: 2) nutrition and weight status 3) diabetes 4) mental health and mental disorders 5) substance abuse 6) heart disease and stroke 7) physical activity and health 8) older adults 9) maternal infant and child health 10) tobacco use

Resources http://www.ruralhealthinfo.org/topics/rural-human-services “Addressing the social determinants of health through the provision of human services has the potential to help control healthcare costs and attain a more efficient healthcare system. Ensuring that patients who use the healthcare system frequently, such as those with chronic conditions, have their other needs met may lessen the stressors that contribute to their chronic conditions, reduce the amount of healthcare resources they require, and reduce unnecessary hospital readmissions. This would free up healthcare providers to address the needs of other patients and also to focus more on preventive care and population health. “

Links to the Rural Community Rural healthcare providers and facilities can assist patients with finding human services to meet their basic needs through “prescribing” benefit programs, providing referrals, or coordinating services with human services providers. Likewise, rural human services providers may find working with healthcare providers is an effective way to identify unaddressed human service needs. Connecting human services to healthcare can help make limited resources go further and leverage the close-knit nature of rural communities.

RHIhub This guide focuses on a wide-range of human services that impact healthcare, including: Income supports like Temporary Assistance to Needy Families (TANF) and Earned Income Tax Credits (EITC) Weatherization and energy assistance Housing Job training Child welfare programs, including child care, adoption and foster care Access to healthy food and to transportation also impact health. These issues are covered separately in RHIhub's other topic guides: Food and Hunger Transportation to Support Rural Healthcare Source: RHIhub

Frequently asked Rural Health Questions How is the provision of human services different in rural areas? What are benefits to the rural healthcare system of helping address the social determinants of health? Can activities related to this help meet ACA requirements for addressing community health needs? How can rural healthcare providers help their patients access needed social supports? What programs have been designed to do this? What types of funding are available for coordinating with human services and providing human services benefit enrollment in a healthcare setting? What are some of the barriers to integrating human services with healthcare in a rural setting? Source: RHIhub

How does the availability of human services for rural residents impact their health? Human services can play an important role in low-income rural residents' health status. Access to support services and networks gives individuals a chance to improve their well-being, reducing stress that can adversely impact health, and allows them more time and resources to better care for their own health and the health of their families. The need for human services is great in many rural communities. According to the 2011 report, Federal Tax Policies and Low-Income Rural Households, the poverty rate is higher in rural areas (15.1%) compared to urban areas (12.9%). Source: RHIhub

Human services that can have an impact on a rural residents health status include: Income supports such as Temporary Assistance to Needy Families (TANF) and the Earned Income Tax Credits (EITC) Supplemental Nutrition Assistance Program (SNAP) Weatherization and energy assistance Affordable housing Job training Child welfare programs including child care, adoption and foster care Transportation

Dynamics of Economic Well-Being: Participation in Government Programs, 2009–2012: Who Gets Assistance?, A May 2015 U.S. Census Bureau report, Dynamics of Economic Well-Being: Participation in Government Programs, 2009–2012: Who Gets Assistance?, shows that non-metropolitan participation in six national assistance programs is higher than for the nation as a whole:

Rural Health Inequities This guide focuses on the health inequities that rural residents experience, discussing the impact of and documenting rural differences related to: Income, employment, and poverty Educational attainment and literacy Race/ethnicity Sexual orientation/gender identity Health literacy Adequate community infrastructure, which can ensure public safety, allow access to media, and promote wellness Environmental health, including water quality, air quality, and pollution Access to safe and healthy homes, including issues related to energy costs and weatherization needs, lead-based paint, and other safety issues Access to safe and affordable transportation, which can impact both job access and healthcare access. Unsafe transportation, such as vehicles in poor condition, may increase risk of injury. Access to healthy and affordable food Access to healthcare services Two related guides are available to learn about the impacts of health inequities (see Rural Health Disparities) and ways to address these inequities to improve health (see Human Services to Support Rural Healthcare). Source:RHIhub