Overview
Rural communities in comparison to their urban counterpart struggle to generate revenue to support its economic infrastructure, which contribute to limited access of community resources such as healthcare, childcare, and education and training. These challenges are generally the result of school closures; medical practitioners declining to work in rural communities; lower level of educational attainment; increased aging population, while young adults migrate to urban communities; and a decrease of immigrants taking up residence in rural communities (“Strengthening Rural Canada,” n.d.). The latter is demonstrated as immigration increased in urban and metropolitan areas of Ontario by 124% between 2001 and 2011; however, there was only a 2.8% increase within rural populated areas of this region (“Strengthening Rural Canada,” n.d.). While it makes sense that people residing in rural communities can access necessary resources by commuting to neighboring urban and metropolitan hubs, approximately six million represent the total rural population, 3.7 million of which live in areas where strong to moderate commuting is possible in comparison to 2.3 million located in remote rural regions (DesMeules et al., 2006). Consequently, many choose to relocate rather than drive great distances, attributing to the decline in rural populated areas and economic prosperity (DesMeules et al., 2006).
The Canadian economy relies heavily upon the exporting of natural resources from rural regions which allow metropolitan and urban areas to prosper; rural communities on the other hand struggle to survive due to a lack of a skilled workforce, declining populations, and the inability to expand and develop economic infrastructure (Moazzami, 2016). However, additional factors directly associated with a declining economy include (a) extreme weather conditions, (b) climate change, (c) lack of transportation of goods, and (d) Aboriginal population affirming their land and treaty rights which inevitably influence industrial development (“Strengthening Rural Canada,” n.d.). When an economic infrastructure lacks the necessary resources for its residents, lower perceived quality of life can ensue.
Quality of life can be viewed in terms of good health, increased employment opportunities, job security, and access to community resources. When comparing rural communities with that of their urban counterpart, life expectancy is generally lower in rural areas, mortality rates are higher, and chronic health conditions are more prevalent. The resulting cause is generally due to limited healthcare services (i.e., medical specialists) and hazardous occupations (i.e., mining and farming). Barriers also play a vital role in overall quality of life and have traditionally been a factor for many people with disabilities who reside in rural areas. These often include limited public transportation, poor architectural accessibility, unaffordable housing, lack of social and community support, and reduced employment opportunities for PWDs since many rural jobs are generally more physical in nature. Throughout this chapter, we explore the challenges experienced by Canada’s rural regions.
Learning Objectives
- 1.
Understand the demographic characteristics of rural Canada.
- 2.
Understand the economic conditions of rural Canada.
- 3.
Be able to identify the most common occupations, along with the types and size of industry groups in rural Canada.
- 4.
Identify the current health conditions in rural Canada and understand causes for these conditions.
- 5.
Identify strategies for improving service delivery for individuals residing in rural communities.
Introduction
Rural and small towns in Canada is generally made up of diverse communities which continue to play a vital role in the country’s economy through the production of food, clean water and air, affording of natural resources to both urban and rural communities, alternative energy, and strong emphasis toward a reduction in carbon emission (Canadian Rural Revitalization Foundation [CRRF ], 2015). Socioeconomically, culturally, and environmentally, rural Canada consists of two extremes of the distribution – the most affluent and the most disadvantaged (Alasia, 2004). However, geographically, rural Canada constitutes roughly 95% of its country’s landmass and experiences harsh, cold, lengthy winter conditions. Despite these conditions, Canada’s largest gross domestic product lies in the areas of forestry, fishing, mining, quarrying of oil and gas (ranked first), and manufacturing (ranked second). A continuing lack of government support, however, is prompting younger rural citizens to relocate to urban hubs for better opportunities (CRRF, 2015).
Since 1851, approximately nine out of ten Canadians lived in rural areas as the economy was primarily driven by agriculture and natural resources (Moazzami, 2016; Statistics Canada [SC], 2015). With a changing global economy and a decline in food production and farming of natural resources, the proportion of people living in rural areas significantly declined between 1921 and 1931, falling below 50% over the last 160 years (SC, 2015). Between 2000 and 2014, the percentage dropped further from 21% to 18%, and among the “Group of Eight” which accounts for eight countries with approximately 50% of the global gross domestic product, Canada falls among the lowest for percentage of people living in rural regions (World Bank, 2014).
Description of Rural Canadian Population
Population across urban and rural provinces and territories
Population | Urban | Rural | Urban % | Rural % | |
|---|---|---|---|---|---|
Canada | 33,476,688 | 27,147,274 | 6,329,414 | 81 | 19 |
Newfoundland and Labrador | 514,536 | 305,566 | 208,970 | 59 | 41 |
Nova Scotia | 921,727 | 521,338 | 400,389 | 57 | 43 |
New Brunswick | 751,171 | 394,479 | 356,692 | 53 | 48 |
Quebec | 7,903,001 | 6,368,270 | 1,534,731 | 81 | 19 |
Ontario | 12,851,821 | 11,045,785 | 1,806,036 | 86 | 14 |
Manitoba | 1,208,268 | 874,714 | 333,554 | 72 | 28 |
Saskatchewan | 1,033,381 | 689,983 | 343,398 | 67 | 33 |
Alberta | 3,645,257 | 3,030,402 | 614,855 | 83 | 17 |
British Columbia | 4,400,057 | 3,790,694 | 609,363 | 86 | 14 |
Yukon | 33,897 | 20,562 | 13,335 | 61 | 39 |
Northwest Territories | 73,368 | 39,938 | 33,430 | 54 | 46 |
Nunavut | 31,906 | 15,377 | 16,529 | 48 | 52 |
Early Adulthood
Between 2001 and 2011, urban populated areas increased by 15.13%, while rural regions declined in population by 7.34% (Moazzami, 2016). One of the primary factors for a decline in rural populations has been the result of migrating of youths (29 years of age and younger). For instance, the single most significant factor for a decline in economic conditions within rural communities in Ontario has been the result of 20–30% of youths migrating to urban hubs, particularly Aboriginals who are receiving greater government funding in the cities. Although Canada’s government has identified the need for retaining their younger population to improve the current state of the rural economy, many are unhappy with residing in rural communities. This has been attributed to the negative views younger adults have of rural and small towns and the perception that urban living is equated to monetary success, higher social status, and educational opportunities (Malatest, 2002). Malatest found 55% of rural youths indicated they planned on relocating to an urban hub, and for those who currently resided in a urban community, only 37% planned on returning to a rural region. However, the aforementioned factors are not solely the cause for youths migrating to metropolitan and urban communities. Particularly, many rural areas have experienced a significant rate of school closure often necessitating families to either commute or relocate to urban hubs, and access to post-secondary education and trainings is often less accessible in rural regions (Malatest, 2002). For those who remain in rural and small town areas, there is often little choice as a result of decreased finances, caring for aging family members with a chronic illness and/or disability, uncertainty of the future, and maintaining job security.
In another study of outward migration of young people from rural communities, MacBride (2013) found key factors used to make migration decision were influenced by a lack of attention to matters that impact youth. MacBride found the key factors and possible points for action include the need for more relevant guidance for rural youth in high school and, later in life, community development strategies that focus on young adults and increased government attention and consultation on rural youth issues . In exploring strategies for rural youth retention, Lui (2015) found strategies in the county or town were mainly focused on four themes: education and training, career opportunities, youth engagement, and local community development. To strengthen youth retention approaches, Lui proposed five recommendations: (a) establishing a youth council, (b) encouraging collaboration to implement plans for county level programs, (c) connecting with youth in high school and before they leave for post-secondary education, (d) creating short-term job opportunities, and (e) promoting county culture and lifestyle and amenities.
An additional factor impacting rural economies is the educational attainment of this group. Malatest (2002) conducted a study of 1091 young adults between the ages of 20–29 years and found only 22% were attending school. For individuals aged 25 to 29 years, only 11% were attending school on a full-time or part-time basis. According to Gilmore (2010), young adults who do not complete high school are especially vulnerable to unemployment, and when they are employed, they work longer hours for less pay than high school graduates. Furthermore, not completing high school is a risk factor for poverty for young adults (British Columbia Teachers’ Federation, 2013). As will be discussed further within the rural workforce section of this chapter, when a community has deficiencies in a qualified and skilled workforce , opportunities for economic prosperity can pass by.
Later Adulthood
The senior population consisting of persons aged 65 years and older is vastly outgrowing all other age groups, and by 2026, one in five Canadians (9.8 million) will be 65 years of age or older (Division of Aging and Seniors [DAS], 2002). As of 2008, this group accounted for 15% of the rural population, 13% of urban populations, and 33% of disability rates (Dandy & Bollman, 2008). Women form the majority of Canadian seniors by 56%, and considering women have a greater lifespan than men, 46% of women are widowed in comparison to 12.7% of males (Dandy & Bollman, 2008). Overall, however, the aging population has poorer health and is underserved for healthcare services than that of their urban counterpart while maintaining to play a viable role within rural Canada’s workforce (DAS, 2002). Nonetheless, as they continue to outgrow other age groups and with the youth relocating to urban hubs, they are often left with the responsibility to care for older family members while generating a source of income. Subsequently, they experience an array of challenges either through ageism, increased pressure to care for others while needing to care for themselves, and common barriers (i.e., lack of available transportation) associated with rural living. As rural regions are left with a high proportion of older adults, we explore this group in greater detail in proceeding sections of this chapter.
As previously discussed, younger aged adults are migrating to urban communities for better opportunities. Hence, support for seniors is often limited, and as a result, they commonly seek employment or prefer to remain employed to care for themselves and/or other aging family members. More than one person out of five in the labor force of rural areas is aged between 55 and 64 years (Martel & Malenfant, 2006). However, as a result of limited job options in rural regions, low educational attainment, and age, aging adults often work in hazardous occupations (i.e., farming) which increase the probability of injury and/or disability. For individuals who work as farmers (women and men), the economic conditions in the agricultural industry can vary and ultimately affect the age at which one retires from these arduous jobs (Keating, Swindle, & Fletcher, 2011). For those choosing to retire, the aging population in rural communities has rated the retirement income substantially lower than those who retire in urban communities (Keating et al., 2001). Subsequently, the barriers to employment and lack of workplace pensions have created rural poverty for this population. Among nonfarming older men and women, they encounter difficulties when resource industries prefer hiring individuals of predominately younger age and thus experience high rates of unemployment and poverty. As a result of these factors, the overall aging population experiences a 30% unemployment rate and a low annual income of $19,162 (Dandy & Bollman, 2008).
Aboriginals
The Aboriginal people represent 4% of the total national population and are growing at a substantially faster rate in comparison to the rest of Canada (Canadian Rural Revitalization Foundation, 2015). Within rural nonmetropolitan adjacent regions, Aboriginal people represent 6% of the population and 34% within rural northern regions and are expected to remain a fundamental factor in rural demography (Bollman, 2007). Aboriginals, also known as Indigenous Canadians, comprise three groups: First Nations (North American Indian), Métis or Inuit, and Treaty Indian or a Registered Indian (O’Donnell & Wallace, 2011). And contingent upon the group, their primary place of residence differs. Approximately 45% of Registered Indians live on the reserve, non-status Indians (75%) and Métis (71%) live in urban areas, and 56% of Inuit reside in rural communities and small towns (Aboriginal Affairs and Northern Development Canada, 2013). In comparison to the national average, Aboriginals have higher poverty rates, mortality rates, suicide rates, lower life expectancy, decreased employment rates, higher percentages of chronic and communicable diseases, and poorer educational opportunities (Assembly of First Nations, 2011). Based on the aforementioned inequalities experienced by the Aboriginal population, they continue to assert their treaty and land rights to improve the quality of life for their people, a primary driver for influencing Canada’s rural economic conditions (State of Rural Canada, 2015).
Canadian Rural Economy
Apart from effective counseling (e.g., empathy, unconditional positive regard, good listening skills, etc.) and a collaborative effort between a counselor and consumer, a thorough understanding of the economic conditions of the community for which a rehabilitation counselor operates under is fundamental for successful employment outcomes. As such, we explore the following: (a) occupations and industry groups, (b) size of industry, and (c) the rural workforce.
Occupations and Industry Groups
Rural employment by industry group
Industry group | % of total rural employment |
|---|---|
Primary industry (agriculture, forestry, fishing, hunting, mining, oil and gas extraction) | 18% |
Construction | 12% |
Manufacturing | 5% |
Distributive services (wholesale trade, transportation and warehousing, and information and cultural industries) | 23% |
Producer services (finance and insurance; real estate and rental leasing; professional, scientific, and technical services; management of companies and enterprises; and administrative and support) | 15% |
Social and personal services (education, healthcare and social assistance, arts, entertainment and recreation, and public administration) | 27% |
Industry Size
The role and function of vocational rehabilitation counselors (VRCs ) extend far beyond general counseling skills; they entail detailed knowledge of the economy as previously discussed and the size of industries that operate within the region for which we provide job placement services. The latter, however, is often dependent upon the areas in which we offer services. For example, it is common knowledge that job opportunities are more prevalent in metropolitan areas; therefore, whether companies employ 200 or more personnel may be of little use to a VRC. Conversely, rural areas are often limited with employment opportunities, and thus, VRCs must be thoroughly versed in all aspects of the economic characteristics of their region. To illustrate this point, let us consider the following demographic statistics. In 2007, 22% of businesses located in rural communities were estimated to have 371 firms for every 10,000 residents in comparison to large urban districts with 331 firms for every 10,000, (Rothwell, 2007). What is of particular importance is the size of the firms which greatly differ from one another. Twenty-percent of businesses in rural sectors generally have 1 to 4 employees, whereas 10% of urban businesses employ 200 or more personnel (Rothwell, 2007). Thus, employment opportunities in rural regions are vastly outnumbered by their urban counterpart which often results in residents choosing to commute and oftentimes relocate to urban centers for work (Moazzami, 2016). With this in mind, we turn our attention to the labor force demographics as rural communities often lack the necessary skilled workers as a result of the aforementioned cause for relocating to urban hubs.
Rural Workforce
In 2006, rural communities in Canada had higher high school dropout rates (16.4%) which were nearly twice the rate of urban communities (9.2%) and had lower percentages of residents with only some post-secondary education; and among the Organisation for Economic Co-operation and Development (OECD) which consists of 35 countries committed to democracy and the market economy, they have the largest and poorest rural-urban gap with regard to education and workforce (Canada Council on Learning, 2006). The importance of a community’s workforce is essential to sustainability, yet when a community has deficiencies in a qualified and skilled workforce, opportunities for economic advancement can pass by. For example, Magnusson and Alasia (2004) conducted a study to assess for workforce comparisons between rural and urban communities and found unskilled employment opportunities were predominately found in rural regions in comparison to urban areas where greater proportions of high skilled occupations existed. Hence, low educational attainment and an unskilled workforce inevitably determine the proportion of employment opportunities. Furthermore, with rural communities aspiring to evolve and improve economic conditions in a changing global economy (i.e., technological advances in alternative energy), a society lacking a workforce with qualified skill sets and knowledge will ultimately create barriers and impede rural development. To overcome this challenge, the “integration of new learning technologies into a rural human capital development strategy” is a recommended initiative to enhance a community’s workforce (Canadian Rural Revitalization Foundation, 2015, p. 5). However, unless rural regions make significant strides toward the advancement of education and employment opportunities, opting to relocate often becomes the viable choice.
Health Conditions of Rural Canadians
Asthma
Arthritis
High blood pressure
Diabetes
Heart disease
Stroke
Pulmonary disease
Cancer
Crohn’s disease
Thyroid condition
Eating disorders
Glaucoma
Colitis
Epilepsy
Alzheimer’s
Schizophrenia
Mood disorders
Anxiety disorders
Aging citizens of rural populated regions experience an even higher incidence of chronic health conditions. The Division of Aging and Seniors (2002) conducted a study to assess for medical conditions among Canadian seniors. Results revealed 52% of respondents perceived their health to be favorable which ranged from good (12%), very good (28%), and excellent (12%); however, more than 80% had a chronic medical condition . These conditions included (a) arthritis and rheumatism, (b) high blood pressure, (c) allergies, (d) back problems, (e) chronic heart problems, (f) cataracts, and (g) diabetes. Furthermore, 21% had a chronic disability as a result of falls or labor-intensive employment injuries . Such injuries were also reported a key concern among older adults with women 60% more likely to sustain an injury than men, with the primary cause being a fall.
In Canada, access to healthcare reflects the strong social value of equality (i.e., “distribution of services to those in need for the common good and health of all residents”); however, people residing in rural and remote areas do not experience such equality (Browne, n.d., p. 1). According to Browne, major factors that contribute to inequities in access to health services of resident living in rural and remote regions of Canada include geographic barriers, limited availability of healthcare personnel and services, hospital downsizing, and cultural differences. In response to the challenges facing healthcare delivery in rural areas, rural-oriented education programs and clinical experience for medical and nursing students are recognized as an effective means of training and retaining graduates in rural areas. In addition, telehealth has the potential to improve both the health and the healthcare of people living in rural Canada (Herbert, 2007).
To assess for health disparities between urban, metropolitan, and rural populated areas, Shields and Tremblay (2002) found metropolitan areas had increasingly higher positive health outcomes in comparison to rural communities. Canada’s largest cities (Toronto, Montreal, and Vancouver) and those with populations exceeding 500,000 tended to be among the healthiest in the country as smoking, drinking rates, and obesity were lower than the national average and rural populated areas. Moreover, increased life expectancy is favorable in urban and metropolitan areas. For example, Richmond, British Columbia’s average life expectancy is 81.5 years. Conversely, socioeconomic conditions among rural Canadians (e.g., lower educational attainment and low income) were found to be positively correlated to unhealthy living (DesMeules et al., 2006). Similarly, geographically rural remote regions with significantly greater distances to urban or metropolitan areas have the lowest life expectancy and highest rates of smoking, drinking, and obesity in the country. Aboriginal Canadians living in the remote North have particularly higher rates of these conditions substance abuse and suicide.
Determinants of Chronic Health Conditions and Disability
Determinants of rural health have been directly linked to hazardous occupations such as fishing, mining, farming, forestry, and meatpacking industries. These occupations contribute to high accident rates, work-related diseases, and early retirement (Laurent, 2002). Although work conditions for miners have improved considerably, exposure to silica and radiation has resulted in silicosis and lung cancer (Shields & Tremblay, 2002). Unfortunately, mining conditions also contribute to obstructive pulmonary diseases and cancer of the bowel, stomach, bone, bladder, and pancreas (Laurent, 2002).
Within the farming/agriculture industry , standard day-to-day operations are often facilitated through the owner (i.e., self-employed farmer), and as such, lack of health and safety regulations is not enforced and thus exacerbates chronic health conditions (Pong, 2002). Pong lists the following as contributing factors of injuries, deaths, and farming-related diseases : (a) farmers tend to work in isolation; (b) average farm size has increased four times over the last 20 years resulting in longer distances to local services and neighbors; (c) children and older adults are often present at worksite; (d) farmers are exposed to harmful chemicals; and (e) farmers experience high levels of stress due to the competitive global market. Kubik and Moore (2005), for example, found that 57% of woman farmworkers felt sad or depressed, had trouble relaxing, and felt anxious and 67% reported difficulty in sleeping; financial problems accounted for 45% of the stress experienced followed by harvest and seeding (17%), extensive work (9.5%), harsh weather conditions (5.2%), uncertainty (4.9%), and family disagreements (4.3%).
Another cause for concern among residents and local governing officials involves an insufficient healthcare workforce (Pong, 2002). The rate of medical practitioners choosing to work in Canada’s rural areas continues to be problematic and in need of stronger efforts in recruitment and retention. The University of Ottawa, for example, during one time period produced 50 medical doctors; however, only 6 or 12% chose to practice in rural areas (Laurent, 2002). Key determining factors for declining to work in these communities included social isolation, decreased pay, and longer hours with less support (Laurent, 2002). When a community is unable to meet the healthcare needs of its residents, poorer health outcomes are likely to ensue. As a case in point, when residents are required to commute 75 miles or more to see a physician , they often miss appointments or choose not to seek medical care. With chronic health conditions, injuries, and disabilities affecting this population, support services are critical for improved quality of life. Nonetheless, demographics (i.e., isolated from community resources), depletion of natural resources, high unemployment, the aging population, poor economic development, and inadequate municipal infrastructure are all factors which contribute to the health and well-being of rural Canadians (Cruise & Griffiths, 1999).
Disability and Perceived Barriers
Aging population in rural Canada and perceived barriers
Theme | Barriers |
|---|---|
Outdoor spaces and buildings | Poor accessibility to and within public buildings (i.e., wheelchair ramps); poor quality sidewalks, curbs, and crosswalks; lack of accessible washrooms |
Transportation | Lack of transportation (no buses or taxis); increased expense to travel outside of community; lack of accessibility; and lack of information about transportation options |
Housing | Unaffordable; inaccessible housing (i.e., narrow hallways); and shortage of assisted living facilities |
Respect and social inclusion | Ageism; abuse; and mobility- or health-related issues leading to isolation |
Communication and information | Lack of awareness of existing programs; difficulty toward finding access to government programs; vision- and hearing-related difficulties; outdated information about events; and poor access to cable, radio, or broadband services |
Employment opportunities | Transportation challenges and lack of opportunity for and/or barriers to paid employment |
Community support and health services | Lack of healthcare professionals; insufficient home care services; high cost home modifications for those with disabilities; and difficulty traveling long distances for medical appointments |
Similarly, Veltman, Stewart, Tardif, and Branigan (2001) found 38.8% of individuals with disabilities had difficulties keeping a medical appointment due to lack of transportation services , 32.3% were unable to access their doctor’s office, 38.3% were unable to access the medical equipment during their doctor’s visit, and 22.9% could not gain access to a washroom. Surprisingly however, the research was not conducted in a rural region set in Canada but rather the largest metropolitan area, Toronto. As discussed throughout the text, rural and urban areas remain vastly different with barriers most commonly occurring within rural and small town communities. For instance, lack of transportation, employment opportunities, community support and health services, housing, architectural accessibility, and communication and information are barriers affecting all PWDs toward living fully integrated and independent lives .
Implications for Rehabilitation Counselors
When providing services for people with disabilities (PWDs) , several considerations must be implemented for a collaborative and meaningful relationship to occur. For instance, as this group identified transportation as a common barrier, they become limited toward seeking employment opportunities and making general appointments with healthcare professionals. Consequently, if a rehabilitation counselor operates within an urban community which borders a rural town, commuting may be a preferred option to hurdle the challenge of obtaining transportation means by the client. Additional recommendations include (a) offering educational services to improve health, well-being, and independence, (b) facilitating inclusion of older adults in social activities to promote independence and enhance quality of life, and (c) strengthening supportive environments within rural communities (DAS, 2002).
Counselors should also not assume that since Canada has universal healthcare, all their clients’ healthcare needs are being met. One of the commonly noted problems with universal healthcare is that there is often a long waiting period for diagnostic and operative procedures. Unless one’s health condition is life-threatening, many Canadians often have waiting periods of months or years depending on where they reside. These difficulties are compounded for rural residents.
Rehabilitation counselors are also faced with the extremely difficult task of finding employment for PWDs who live in rural settings. Although the vast majority of Canadian citizens live within 100 miles of the American border and reside in urban areas with the requisite services of any major city, those with disabilities in rural areas and especially the Aboriginal population face numerous barriers as noted earlier. Travel to urban centers for social services and medical care during what typically is 6 or 7 months of winter and severe climate conditions is often prohibitive for those with chronic illness and disability to make the journey. Employment opportunities in these areas are not only scarce, but the jobs themselves are most often physically laborious ones that most with disabilities are unable to perform. Those younger individuals with disabilities often migrate to larger cities for the more highly skilled jobs. Aboriginals who choose to move to urban areas are also often faced with discrimination from Caucasians who perceive Aboriginals to be freeloading off government money (Irmo Marini, personal communication September 14, 2016). When working with Aboriginals on employment issues, rehabilitation counselors must be both aware of and acknowledge this discrimination exists and advocate on behalf of Aboriginals to ensure social justice and their human rights are met.
Summary
Although Canada ranks 12 of 201 (US ranks 39 in comparison) in life expectancy rates (World Population Prospects, 2015) and enjoys universal healthcare, it is not without its problems for Canadians with disabilities and those living in rural areas. The harsh winter conditions and limited or no quality healthcare in many parts of rural Canada often leave those with disabilities vulnerable and left to their own devices. Many choose to go without needed healthcare and ultimately become more ill and succumb to a higher mortality rate. Rehabilitation counselors in Canada must think outside the box as far as assisting rural Canadians with disabilities in obtaining adequate healthcare and in their employment efforts, particularly Aboriginals who may also endure even more discrimination. Rural dwellers in most modern societies face isolation, higher incidence of suicide, depression, stigma toward seeking mental health treatment, substance abuse, poorer healthcare, and chronic health conditions (Smith, Thorngren, & Christopher, 2016). Availability and accessibility to healthcare, social services, and related services are often the greatest barriers for rural residents to obtain treatment.