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Creating Health and Equity in Rural Communities

By Phil Bors on October 20th, 2021


Youth 360 participants and Wasilla High School students (Wasilla, Alaska)


For far too long, residents, leaders, and public health professionals from rural communities have been excluded from our national conversations despite the fact that most U.S. counties are “non-metro,” and roughly 20% of the U.S. population lives outside urban and suburban settings.

The U.S. Census Bureau defines rural as not being part of an urbanized area. Look at the U.S. map and notice how vast expanses of our land area appear to be mostly rural, with only pinpoints and small blotches representing large and small cities. Furthermore, while rural places share common characteristics, such as geographic isolation, they are also as different as any two communities can be. For example, residents living in mountainous, sub-Arctic Alaska face significantly different transportation challenges than rural communities in the South Carolina Low Country.

Therefore, to explore the assets and obstacles facing rural communities, as well as opportunities for action, Healthy Places by Design facilitated a recent webinar1 — hosted by the National Association of Chronic Disease Directors (NACDD) and Centers for Disease Control and Prevention (CDC). The learning session, which is the basis of this blog, promoted a more nuanced understanding of rural communities and featured promising examples for increasing social connectedness, enhancing safe places for physical activity, and improving nutrition security. 

Trends in Rural Health

People living in rural communities face obstacles to accessing health care similar to those faced in urban and suburban areas. But for rural communities, these challenges are compounded by geography and limited resources. For example, if a person loses their driver’s license due to a substance abuse condition, alternative transportation options (e.g., public transit) are often nonexistent, further jeopardizing employment and access to treatment. The Rural Health Information Hub describes the following health care barriers: distance and transportation; health workforce shortages; insurance coverage; broadband access; health literacy; and social stigma and privacy concerns. CDC data indicate higher excess chronic and injury deaths in rural communities as well as higher behavioral risk factors such as cigarette smoking and physical inactivity.2 Early in the pandemic, rural communities had lower death rates due to COVID-19. Sadly, this trend reversed in 2021, with rural residents now experiencing the lowest vaccination rates and highest burden of cumulative deaths.3

Opportunities and Bright Spots

Despite troubling patterns of health disparities, economic inequity and geographic isolation, rural communities are also naturally beautiful places with experienced, committed, and creative organizers and community leaders. In addition to the abundance of beautiful open spaces and access to unspoiled natural environments, rural community members often take pride in their community and experience a strong sense of place and independence. Longtime rural residents may feel bonded and closely connected to others in their community. Compared with larger cities, rural government and agency leaders often play multiple roles in their communities and have fewer constraints to getting things done quickly. The following examples help illustrate how organizers and leaders in rural communities are succeeding by building on the strengths and longstanding networks to advance social connectedness, physical activity, and food and nutrition security.

  • Youth 360: Building Social Connections among Young Alaskans

Schools and public spaces in Alaska’s Mat-Su Valley region have become places for young people to connect through an approach adapted from an Icelandic Prevention Model: “Activity Participation as Primary Prevention.” School facilities are natural gathering places, and school personnel help connect Youth 360 organizers to isolated families. In addition, young people in Wasilla, Alaska, contribute their ideas for programs and other community approaches to bring youth together. In collaboration with the community, Youth 360 has decreased social isolation among youth and increased partners’ local capacity to address it. Read more about social isolation and recommendations for communities to increase social connectedness here.

  • Auburn University: Supporting Safe and Active Travel in Rural Alabama

As a recipient of CDC’s HOP (High Obesity Program) grant, Alabama Extension at Auburn University’s ALProHealth team assists rural Alabama communities in collaborating to implement active transportation plans, policies, and projects. Like so many rural communities, Linden, Alabama, lacks many basic infrastructure features more common in urban and suburban areas, such as sidewalks, marked pedestrian crossings, lighting, and bike lanes. A coalition of committed contributors to community initiatives came together to address safety and physical activity access. The group included Cooperative Extension specialists, retired teachers, a nursing home director, and others who were new to transportation planning. Partners created a vision for transforming a local street into a safe and active corridor connecting neighborhoods, schools, and other important destinations. A striped “road diet” (narrowing the vehicle travel lanes), new lighting, and crossings were added. The city now plans to create a nearby pocket park where an abandoned building once stood. For more ideas, tips, and guidance for creating healthy environments in rural settings, check out the ALProHEALTH Guide.

  • South Carolina Department of Health and Environmental Control: Adopting FoodShare as a Hub for Nutrition Security in South Carolina’s Pee Dee Region

Despite the higher burden from chronic disease, community members have longstanding social relationships, family bonds, and a strong desire and curiosity for helping families and neighbors thrive. In the Pee Dee region of South Carolina, the South Carolina Department of Health and Environmental Control works with the SC Office of Rural Health to implement the FoodShareSC model in Marlboro, Dillon, Lee, and Williamsburg counties. Based in Columbia, South Carolina, FoodShareSC serves as a hub for food producers and communities that need fresh food. In addition, FoodShareSC brings capacity and support to local groups and food advocates to create their own fresh food distribution hubs capable of processing SNAP food benefits. Mt. Calvary Missionary Baptist Church in Lee County and CMD’s Pantry in Williamsburg County are now member hubs expanding food access in rural communities where the need is highest. The Northeastern Rural Health Network is also working to establish a hub and distribution efforts in Marlboro and Dillon Counties.

Organizers in rural communities are making steady progress bridging gaps in health disparities due to geographic isolation, limited resources, and inequities in social and physical infrastructure. Even during lean times, community leaders, local organizations, and residents leverage assets that are common to rural places. They utilize well-established social relationships, gatekeepers who wear multiple hats, and the belief in their own resilience.

More to Come: Unpacking Equity in Rural Communities

The issues, obstacles, and solutions presented here represent differences and disparities between rural and non-rural areas. Stay tuned for a future article on our blog specifically exploring how rurality intersects with and compounds systemic inequities facing rural residents due to race, ethnicity, LGBTQ+ status, language, and disability.



1 Webinar recording, for CDC-funded BRIC (Building Resilient and Inclusive Communities) grant recipients:; Passcode: 0EC%E3G4
Speakers: Diane M. Hall (Senior Scientist for Policy and Strategy, Centers for Disease Control and Prevention, Atlanta, GA); Tyler Healy (Director, Youth 360, Wasilla, AK); Ruth Brock (Extension Specialist and Program Manager, Auburn University, Alabama Extension, Auburn, AL); Lori Phillips (Director, Division of Nutrition, Physical Activity and Obesity, South Carolina Department of Health and Environmental Control, Columbia, SC)

2 See MMWRs: and

Phil Bors

Senior Project Director

Community collaborator, enthusiastic brainstormer, and devotee of down time