Off the beaten path: A scoping review of how ‘rural’ is defined by the U.S. government for rural health promotion

Background: Given the recognition that the U.S. government lacks a consensus definition of the word rural, the purpose of this scoping review was to uncover how the federal government defines the term and to establish a nuanced understanding of what criterion is used to designate an area as rural. Methods: Arksey and O’Malley’s framework was used to synthesize, analyze, and summarize the existing literature. A multi-system search was conducted, and articles were screened for eligibility by two independent reviewers using pretested forms. Results: Initially, 929 articles were screened that used the search terms rural and some variation of the word definition. After eliminating all ineligble studies, 49 documents were included in the final analysis. These documents revealed 33 federal definitions of rural. The majority of definitions centered on either population, population density, or urban integration provisions. Additionally, the analysis showed that the literature could be separated into two categories: how rural was defined in a particular industry or for a specific population and the multiple adverse effects of having multiple definitions of rural. Conclusion: The discrepancies found in current classification systems reveal the need for a standardized definition of rural. Ultimately, policies centered on securing health care services for rural populations are impacted by whatever definition of rural is used. Failing to establish a gold standard definition of rural could have harmful consequences to the health and wellbeing of the many people living in rural communities across the U.S.