Population Considerations for Addressing the Social Determinants of Health
Rural communities may need to tailor programs that address social determinants of health (SDOH) to acknowledge
populations with unique health and social needs. Rural community members may belong to several population
groups. Intersecting challenges related to race, disability status, socioeconomic status, language abilities,
age, and other factors can have complex implications for health and well-being.
American Indian/Alaska Native Tribal Populations
The American Indian/Alaska Native (AI/AN) population experiences lower life expectancy and higher
disease burden compared to the rest of the nation. This is a result of many social and environmental
factors including poverty, lower educational attainment, and discrimination. AI/ANs have a life expectancy that
is 5.5 years less than the U.S. average and experience higher rates of chronic liver disease, diabetes,
unintentional injuries, suicide, chronic respiratory disease, and assault/homicide.
According to First
Nations Development Institute, 54% of the AI/AN population lives in rural areas and 68% live on or near
tribal homelands. These communities may therefore face additional barriers associated with rurality, such as
food insecurity or lack of access to public transportation. A lack of infrastructure on tribal lands also
contributes to AI/AN health disparities. For example, more
than 65% of the 104,000 miles of public roads owned by the Bureau of Indian Affairs, Indian tribes,
states and counties are unpaved. This may be one factor in the 52.5% increase in fatal motor vehicle crashes on
reservations over the past 25 years. Successful models for addressing SDOH in AI/AN communities should take into
account the culture and context of tribal populations. Programs that target improving health disparities in
tribal populations should also consider how AI/AN communities access healthcare services. Due to a combination
of treaties, legislation, court decisions, and executive orders, the federal government has a unique obligation to provide healthcare to American Indians and
Alaska Natives (AI/ANs).
The Rural Tribal Health topic guide includes information on best
practices and model programs to address AI/AN health disparities.
Racial and Ethnic Minority Populations
SDOH, including individual
and structural discrimination, can have major consequences on the health of racial and ethnic
minorities, also referred to as people of color. Individual discrimination can include negative interactions
between healthcare professionals and patients based on the race of the patient. One 2017
study found that 32% of Black/African American respondents reported racial discrimination during a
medical visit. In addition, 22% of Black/African American and 20% of Hispanic/Latino respondents reported
avoiding medical care because of concerns about discrimination. Personal experiences with discrimination and
knowledge of historic unethical medical treatment, such as the Tuskegee syphilis study, contribute to distrust in the healthcare system and can
limit research participation among racial
and ethnic minorities, in particular Black/African Americans.
Structural discrimination, also called structural
racism, refers to macro-level systems and policies that reinforce inequities among racial and ethnic
groups and limit opportunities for people of color to lead healthy lives. For example, residential segregation is
a root cause of health inequity that affects various SDOH. Black/African American and Hispanic/Latino
live in highly segregated communities experience more poverty, less job and educational opportunities,
and substandard housing.
Concentrated poverty among people of color is particularly evident in rural areas, where racial and ethnic
minorities experience some of the highest poverty rates in the United States. In 2017, 33%
of Black/African Americans and 28% of Latino/Hispanics in the rural South were living in poverty. In addition,
31% of Black/African Americans in the rural Northeast and 32% of American Indian/Alaska Natives in the rural
West were living in poverty. Rural racial and ethnic minorities are
more likely to
live in substandard or cost-burdened housing.
Cost-burdened families are those who spend more than 30% of their household income on housing and, in turn, face
difficulties in paying for items that address social determinants of health such as food and transportation.
Immigrant and Migrant Populations
Rural immigrant populations face unique SDOH that may make them vulnerable
to health challenges, including lower levels of educational attainment. For example, according to the American
Survey (ACS) 5-year estimates for 2016-2020, just over 29% of rural immigrants had less than a high
school diploma or equivalent, compared to approximately 10.1% of native-born rural residents. Lower educational
attainment is linked to worse health outcomes and higher rates of poverty. Rural immigrants are more likely to
in poverty, with 18.0% of rural non-citizen immigrants living in poverty, compared to 11.9% of American
citizens. Migratory and seasonal agricultural workers (MSAWs) may face additional barriers to living healthy
lives, including limited access to safe housing, clean water, adequate transportation, healthcare access, and
health insurance. The majority of MSAWs do not have citizenship in the United States, and immigration
status can be a substantial barrier to accessing affordable healthcare services.
Populations with Limited English Proficiency
Populations with limited English proficiency can experience challenges with accessing health and social
services. Communication between a patient and provider is important for managing health, especially for patients
with chronic conditions. The use of medical interpreters can improve communication in care settings, but in many
rural areas professionally-trained
interpreters are not readily available. According
to the U.S. Census Bureau, at least 350
languages are spoken in U.S. homes, with approximately 60.4
million Americans (20.7% of the population) speaking a language other than English. Of those who speak a
language other than English at home, only 58.3% reported speaking English “very well.” This figure
suggests that roughly four out of 10 Americans may require additional language or communication support when
accessing health and social services.
Populations with Disabilities
of people who live in rural areas have
a disability, which is higher than the national average of people in the U.S. with a disability (12.7%). Adults with
disabilities are more likely to be obese and significantly more likely to smoke than adults without
disabilities. Women with disabilities are less likely to receive preventive healthcare services than women
without disabilities. Factors such as limited access to
specialized healthcare, accessible housing, transportation, and employment opportunities impact persons
with disabilities living in rural areas.
Approximately 21.2% of children living in micropolitan areas and 22.3% of those not in a metro or
micropolitan area lived
in poverty according to the 2016-2020 American Community Survey estimates, compared to 17.5% of children
nationwide. Family income plays a large role
in determining economic mobility, or the ability to move out of
poverty during one's lifetime. Poverty can have lasting impacts on children as they transition to adulthood, particularly in
rural areas. Children living in rural communities are also more likely than non-rural children to experience
health effects associated with their physical environment, socioeconomic status, access to healthcare,
and their family's health behaviors. For example, in 2014 one-third of children in rural areas lived with
someone who smokes, compared to less than one-fifth of urban children.
In addition, households with children are
more likely to report being food insecure than households without children. Although the average median income
is slightly higher in households with children, they may experience greater financial limitations resulting from
larger household sizes and the expense of childcare. The USDA found that in 2019 16% of rural nonmetro households with
children were food insecure.
The population of Americans age 65 and older will double during the next
25 years. Rural populations have a higher
percentage of older adults than other
regions. Data from the 2016-2020 American Community Survey reveals that in rural non-core regions, 20.9%
of adults are 65 and older, compared to nearly 16.0% nationwide. Rural older adults face a number of
challenges due to limited access to healthcare services in rural areas. Compared to urban older adults, rural
older adults more frequently face social
isolation — a predictor of mortality. The Rural Aging in Place
describes additional information about older adults in rural communities.
According to the U.S. Department of Veteran's Affairs Office of Rural
Health, 5.2 million veterans live in rural
communities. Veterans are more likely to live in rural areas than civilians, with 23% of veterans living
in rural regions compared to 19.3% of the general population. Veterans living in rural areas may face
difficulties accessing healthcare due to lack of specialized care in rural areas, transportation, poverty,
homelessness, or substance misuse. The Rural Veterans and
Access to Healthcare Topic Guide includes additional information about population considerations for
Lesbian, Gay, Bisexual, Transgender, and Questioning/Queer (LGBTQ+) Populations
Recent estimates suggest that
between 2.9 and 3.8 million people who identify as LGBTQ+ live in rural communities across the nation. Some
aspects of rural life can pose challenges to the health and well-being of LGBTQ+ populations. For example, due to
general healthcare shortages in rural areas, an LGBTQ+
individual may have few or no alternatives if they experience discrimination, lack of knowledge, or
affirmation from a healthcare or social service provider. In addition, due to the geographic isolation and low
population density of many rural communities, rural LGBTQ+ populations may experience difficulties in building
community with other LGBTQ+ people and accessing support structures, such as LGBTQ+ community-based centers and
People 2020 describes oppression and discrimination as key SDOH that affect health outcomes for LGBTQ+
populations. These SDOH contribute to persistent
health disparities, and in particular, disparities related to mental and behavioral health. Challenges
to health and well-being among LGBTQ+ populations also intersect with age and race. LGBTQ+ youth are two to three
times more likely to attempt suicide than non-LGBTQ+ youth, and older adults who are LGBTQ+ face difficulties
accessing healthcare due to social isolation and lack of culturally competent care. In addition, youth who are
black and LGBTQ+ are four times more
to experience homelessness than youth who are white and non-LGBTQ+.
People Experiencing Homelessness
Homeless populations are heavily
affected by SDOH and are likely to experience negative health outcomes related to lack of housing
stability, exposure to unsafe environmental conditions, interactions with the criminal justice system, lack of
accessible healthcare options, and social isolation, among other challenges. Rural homeless populations may
face additional difficulties with leading healthy lives. For example, low population density in rural areas may
decrease the visibility of homelessness and the ability of health and human service providers to track and reach
out to homeless individuals. Rural communities may also lack infrastructure to meet the needs of homeless
individuals, including accessible transportation or affordable housing.
Resources to Learn More
at the Intersection of Poverty, Migration and Health
Video and podcast recordings of a presentation by Deliana Garcia of the Migrant
Clinicians Network focused on equity, poverty, migration and health challenges encountered by migrant
workers and the relation of these challenges to health equity.
Organization(s): The Colorado Trust
Focus: Reducing Racial Disparities in Health Care by Confronting Racism
Describes racial and ethnic disparities in healthcare, includes examples of ways healthcare professionals are
combatting disparities by acknowledging race and racism.
Organization(s): The Commonwealth Fund
Rural Data Explorer
An interactive map providing county level data on health disparities, health workforce, demographics, and more.
Compares data from metropolitan and nonmetro counties across the U.S. and by state.
Organization(s): Rural Health Information Hub