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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 populations who 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 Community Survey (ACS) 5-year estimates for 2014-2018, nearly 32.7% of rural immigrants had less than a high school diploma or equivalent, compared to approximately 12.1% 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 live in poverty, with 14.0% of rural non-citizen immigrants living in poverty, compared to 11.5% 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

Approximately 15.1% 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 (12.6%). 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. The Access to Care for Rural People with Disabilities Toolkit describes additional considerations for rural residents with disabilities.

Children

Approximately one-fourth of children in rural areas lived in poverty according to the 2014-2018 American Community Survey estimates, compared to approximately one-fifth 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 adverse 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.

Older Adults

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 2014-2018 American Community Survey reveals that in rural non-core regions, close to 20% of adults are 65 and older, compared to nearly 15% 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 Toolkit describes additional information about older adults in rural communities.

Veterans

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 rural veterans.

Lesbian, Gay, Bisexual, or Transgender (LGBT) Populations

Recent estimates suggest that between 2.9 and 3.8 million people who identify as LGBT live in rural communities across the nation. Some aspects of rural life can pose challenges to the health and well-being of LGBT populations. For example, due to general healthcare shortages in rural areas, an LGBT 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 LGBT populations may experience difficulties in building community with other LGBT people and accessing support structures, such as LGBT community-based centers and organizations.

Healthy People 2020 describes oppression and discrimination as key SDOH that affect health outcomes for LGBT 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 LGBT populations also intersect with age and race. LGBT youth are two to three times more likely to attempt suicide than non-LGBT youth, and older adults who are LGBT face difficulties accessing healthcare due to social isolation and lack of culturally competent care. In addition, youth who are black and LGBT are four times more likely to experience homelessness than youth who are white and non-LGBT.

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

Equity at the Intersection of Poverty, Migration and Health
Video/Multimedia
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
Date: 09/2016

In Focus: Reducing Racial Disparities in Health Care by Confronting Racism
Document
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
Date: 09/2018

Rural Data Explorer
Map/Mapping System
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