Rural, Remote, and Resilient: How to Build Better Outcomes Outside of America’s Cities

Alan Morgan’s wish list for rural America begins with such a fundamental ask, it’s easy to wonder why it belongs on a list of hopes and not realities.

“Access to basic primary care,” he said. “That’s really first and foremost.”

Next up is 24/7 emergency room service, followed by obstetrics services. Morgan, the CEO of the National Rural Health Association, sees these as not just lifesaving measures but also society-sustaining ones.

“Those three things really ensure the future of rural America,” he said. 

More than 60 million people live outside cities in the United States, and those residents face higher rates of obesity, diabetes, heart disease, and suicide. There’s no single cause for the effects, but experts point to environmental differences, workforce shortages, and education gaps as some of the most likely reasons for health disparities.

The unique elements of rural America that contribute to poor public health require a unique approach to solutions. As experts in assessment, development, and assurance—as well as members of these particular communities—rural public health professionals are perhaps best positioned to lead the way. How can they collaborate creatively within these regions and combat dwindling resources to foster better outcomes for their neighbors?

What Are the Public Health Outcomes in Rural and Frontier America? 

Healthy People 2020 defines social determinants of health (SDOH) as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” 

Examples include the availability of clinical services, educational quality, transportation options, and social support systems—all of which can be assets or barriers to quality public health outcomes.

SDOH are often a root explanation for health disparities between rural and urban America. For example, 152 rural communities lost obstetrics services from 2011 to 2018, meaning women seeking prenatal care had to drive up to an additional 60 minutes more than before. The decline in services corresponded with increases in births outside of hospitals and preterm births. 

Urban environments experience their own particular results: About half of people in cities around the world are breathing air that doesn’t meet air quality recommendations, as indicated in a 2014 Ambient Air Pollution report from the World Health Organization (PDF, 215 KB).

But in non-metro areas, outcomes are generally falling behind that of their metro counterparts. A CDC report on obesity prevalence shows that 34.2% of adults in rural America have a body mass index (BMI) categorized as obese, compared to 28.7% in urban areas. The Rural Data Explorer from Rural Health Information Hub shows that Americans in rural areas are also more likely to be diagnosed with diabetes and be physically inactive. 

Bar graph showing health disparities between United States metro and non-metro areas

In non-metro areas, 26.6% of residents are physically inactive, compared to 21.5% in metro areas. Rural residents are also more likely to experience obesity and live shorter lives. Heart disease, cancer, stroke, and recent psychological stress are more prevalent in non-metro areas.

Go to a tabular version of data at the bottom of the page describing health disparities between metro and non-metro areas in the United States.

How Can Rural Communities Foster Better Health Outcomes?

The sense of community in rural areas is strong and fosters collaboration. Hospitals, primary care providers, and community leaders know they need to work together as resources are stripped away.

More than 440 nursing homes closed or merged in rural areas during the past decade. Since 2010, nearly 90 rural hospitals shut their doors. What frontier areas lack in numbers, they must make up for in the establishment of strong systems—and experts say they are working hard to do just that.

According to the Health Resources and Services Administration (HRSA) Designated Health Professional Shortage Areas Statistics (PDF, 162 KB):

59%
of primary health shortages occur in rural spaces.

3,890
providers are needed to close the gap in care.

“There are incredible networks and incredible people constantly looking at these issues and advocating for rural mental health needs,” said Jennifer Christman, president of the National Association for Rural Mental Health.

Morgan said many significant healthcare innovations originated in rural America. Telehealth, patient navigators, community health workers, and dental health therapists are a few examples of progress stemming from the rural search for solutions.

But there are challenges in the social norms of these communities: The stigmatization of mental health is a powerful barrier to care. The belief that “I should not need help” was cited as the most common reason for not seeking mental healthcare in a study of older adults in rural spaces, as reported by Next Avenue.

“In rural areas, if there is only one mental health provider, many people may not go because the whole community would know,” Christman said. “If a person has been struggling to find the needed care, that person may give up on the process all together.”

Five Strategies for Public Health in Rural America

Public health professionals, community leaders, and individuals can foster better health outcomes in frontier spaces with these five strategies.

1

Look on the Inside, Teach to the Outside

The workforce shortage in rural communities is one of the challenges most consistently repeated among experts. The solution isn’t as simple as sending recent graduates out to frontier America. Instead, these regions need professionals who choose to work there, stay, and become competent in the cultural needs and norms of rural communities.

Invest in rural recruitment and residency. Finding culturally proficient and long-term professionals starts at home. The National Rural Recruitment and Retention Center (3RNet) is a network of nonprofits aimed at finding and placing healthcare professionals in rural communities. Communities can also include career-focused events at high-schools to help students who are interested in health learn more about giving back. Existing practices and organizations can reach out to local universities about residency placements.

Establish a network of community health workers. Community health workers are liaisons between patients and the world around them. They assist with transportation, education, outreach, and more. Most importantly, they are peers of the members of the community they work with.

Train new professionals in rural cultural competency. Set up programs to educate new health professionals not just on rural communities but also one the specifics of your community. What is unique about your population and its outcomes and barriers?

2

Mitigate Distance as a Barrier to Care

Lack of public transportation in rural communities makes it difficult to travel, especially for people with disabilities. Limited transportation options and lengthening drive times to rural hospitals affect people seeking emergency care, but the geographic spread and realities of frontier living affect all aspects of health.

The nearest dentist, grocery store, and gym can be 30 minutes away and in opposite directions. This creates a choice for residents: Which of these services do they need most right now?

Create ride-sharing programs. Services like Uber and Lyft aren’t always an option in remote places, but strong volunteer networks can work as a suitable replacement with coordination. Use RHIHub’s ride-sharing model to create your own program.

Let the system work for you. If reaching your local provider is a nagging barrier to care, find your nearest telehealth provider. You can check with your health insurance to inquire about included transportation options, which some companies will provide at no additional cost.

Volunteer to drive others on your own. Want to help your neighbors in your spare time? Volunteer to transport others to their appointments with the National Volunteer Transportation Center.

3

Build a Better Environment

The built environment is the physical space we create and operate within (PDF, 152 KB): public transportation, expressways, and other major infrastructure are examples. But other components that urban communities take for granted don’t always exist in rural spaces: Parks, sidewalks, street lights, and paths all facilitate safer activity, and their absence can keep people from finding the motivation to exercise—only 20% of rural residents are “regular walkers.”

Start a community garden. Discussed often for urban spaces because of a lack of greenery, community gardens can be useful for those surrounded by land, too. Start one near a central, routinely visited location like a church or school using this community garden checklist.

Build a running path or walking loop. Consider using connecting properties (with owner consent) to build a running or walking loop that motivates people to exercise.

Finish your streets. Work with local officials to widen road shoulders for safe bicycling and walking. Adding street lights, crosswalks, and new signage can make transportation easier for people in meaningful ways. Check out the National Complete Streets Coalition’s guide on rural communities (PDF, 2.2 MB) for more information.

4

Create Opportunities to Learn From Each Other

With a rate of 17.32 in every 100,000 individuals, Americans in rural communities are more likely to die by suicide than those in urban settings, according to data from a CDC Morbidity and Mortality Weekly Report. But a professional support system can be harder to find. Non-metro counties have one psychiatrist per 100,000 people—one-third the proportion in metro counties, as indicated by the Rural Health Research Center.

Additionally, health literacy is lower in rural populations, and lower health literacy can contribute to negative health outcomes.

Use support groups to listen and learn. While support groups are not a direct replacement for professional treatment, their impact can be vital and lifesaving. Use the World Health Organization’s peer-to-peer support group model to create a system in your community.

Start nutrition and cooking classes. You don’t need an expert chef or registered dietitian to learn how to cook. Gather neighbors together weekly, and ask each to bring their favorite healthy recipe and teach others how to cook it. The exchange of good ideas with peers can be more useful than standardized advice.

Incorporate new learning opportunities into schools. Bring in local leaders and experts to health and gym classes at school and include public health information throughout lessons. Organizations like 4-H have curriculum on agriculture, fitness, and health literacy that can be implemented.

5

Collaborate Across Institutions

With limited resources and escalating outcomes, the need to work together is paramount.

“Whether it's the hospital working with the school system in conjunction with law enforcement and education—it’s about partnering together to address community challenges,” Morgan said.

Reinvent your local gym. Cater your small-town gym to the needs of your residents: Use personal trainers to increase education, and offer flexible contracts. Don’t have a gym? Partner with schools to create an “open gym,” provide track hours, and organize walking groups.

Use creative spaces. Local spaces that are natural gathering spots for the community are inherently great places to collaborate. Places of worship, where people tend to visit routinely, can be used to host classes and serve healthy meals after services.

Create your own system. Come up with an entirely new method. Every community is different, and every idea can grow into something bigger over time. A local farmers market that uses a barter system can go from two stands to 10, and a resident-taught fitness class can go from three members to 30.


The following section includes tabular data from the graphics in this post.

Health Disparities in Metro and Non-Metro CountiesReturn to link

Percentage of Residents in Non-Metro and Metro Counties (2013)
Indicator Percentage of Residents in Metro Counties Percentage of Residents in Non-Metro Counties
Diagnosed With Diabetes 9.7 11.5
Experiencing Obesity 27.0 31.6
Physically Inactive 21.5 26.6
Difference of People in Non-Metro and Metro Areas Per 100,000 (2016)
Indicator People in Metro Counties Per 100,000 People in Non-Metro Counties Per 100,000 Difference
Death From Overdose 16.2 15.4 + 0.8 Metro
With Heart Disease 10.2 13.2 + 3 Non-Metro
With Cancer 6.1 6.5 + 0.4 Non-Metro
Experienced Stroke 2.5 3.1 + 0.6 Non-Metro
Experienced Serious Psychological Distress in the Past 30 Days 3.3 5.1 + 1.8 Non-Metro

Citation for this content: The MPH online program from Baylor University's Robbins College of Health and Human Sciences.