Chronic disease is a concern to rural healthcare systems and rural residents due to its impact on
quality of life, mortality, and healthcare costs. The Centers for Disease Control and Prevention's
(CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) About Chronic Diseases webpage provides an
chronic disease in the U.S., detailing health and economic costs; prevention strategies; surveillance systems;
Rural communities have fewer resources to prevent and treat chronic diseases and conditions than urban
communities, while facing higher rates of multiple chronic conditions, which are difficult and expensive to
This guide will discuss the impact of chronic disease on rural America, how providers and communities
can help patients with chronic diseases, and where to look for funding and opportunities to establish programs
address chronic conditions. Specific chronic diseases highlighted on this guide include:
What contributes to higher rates of chronic diseases and conditions in rural areas?
Some contributing factors to the rural disparity in chronic disease include:
An Aging Population
As individuals age, their risk of having multiple chronic conditions increases and rural areas tend to have
older adults as a larger percentage of the population. Table
from the 2017-2021 American Community Survey 5-Year Estimates shows 20.8% of the noncore (small rural) area
and 18.5% of the micropolitan (large rural) area population is 65 years of age or older, compared to 16.0% of
the nation’s population as a whole.
Health-Related Behaviors Related to Chronic Disease
A 2017 MMWR article, Health-Related
Behaviors by Urban-Rural County
Classification — United States, 2013, discusses how rural residents have a lower prevalence of several
positive health-related behaviors that can contribute to chronic disease. Rural residents were less likely to be
nonsmokers, maintain a normal body weight, and meet physical activity recommendations. The rates of these
health-related behaviors decreased as rurality increased.
Prevalence of Health-Related Behaviors in Rural Counties, 2013
How can wellness and self-management programs help to prevent and address chronic
Wellness programs promote healthy habits through lifestyle changes, such as healthy eating and increased
physical activity, and disease management practices. Schools, workplaces, healthcare facilities, and other
community organizations can offer wellness programs.
Wellness programs may target a particular age group, population, or chronic disease. For example,
Fit & Strong!® focuses on osteoarthritis in older adults. The StrongPeople™ Program serves older adults through community-based healthy
living classes, including strength training, aerobic exercise, dietary education, and more.
Some wellness programs not only focus on the physical aspect of managing disease, but also the mental
Hospital Twin City's Fit for Life program educates to counter obesity and diabetes through the body,
mind, and soul. The curriculum was developed and is taught by one of hospital's family practice physicians,
which lends more credibility to the program and interest from the community.
Self-management programs can help patients manage different aspects related to their chronic
diseases. A 2012 Journal of Nursing Scholarship article, Processes
of Self-Management in Chronic
Illness, identifies the following self-management processes for patients with a chronic illness:
Learning about their condition and related health needs
Taking ownership of their needs by monitoring and managing symptoms, taking medications, keeping
appointments, and other health-related activities
Engaging in activities promoting health and minimizing the impact of the condition, such as eating
healthy and being physically active
Activating healthcare, psychological, spiritual, social, and community resources
Adjusting to living with their illness
Disease Self-Management Program (CDSMP), originally developed at Stanford University, is a widely used
evidence-based approach that can be used by patients in rural and urban areas. The model consists of online and
in-person workshops led by individuals who have at least one chronic disease. CDSMP includes action planning,
problem-solving, decision making, interactive learning, behavioral modeling, and social support strategies with
the training and materials geared toward specific chronic diseases.
A 2014 Rural and Remote Health article, Qualitative
Exploration of Rural Focus Group Members' Participation in the Chronic Disease Self-Management Program,
USA, examined the experiences of rural participants in a CDSMP. Participants in the program reported
prioritizing health behavior changes as a result of the program. Examples include increasing their physical
activity and improving their eating habits. Participants found their CDSMP group to be a supportive environment
for discussing their condition, an important factor in rural communities where those with a chronic condition
may feel socially isolated. Peer Support for People with
Chronic Conditions in Rural Areas: A Scoping Review, a 2016 Rural and Remote Health article,
provides an overview of rural peer support programs that offer support to those with chronic conditions provided
by someone with the same condition or otherwise in similar circumstances. These types of programs offer social
support and skill development to participants, helping educate patients and increasing their chronic disease
self-management abilities. The article offers recommendations for rural communities interested in developing a
peer support program.
What are strategies to ensure access to necessary care for rural residents with chronic
disease? How can rural providers work with other healthcare facilities and healthcare professionals
to address chronic diseases?
There are many ways rural communities and healthcare facilities can support the health of individuals
with chronic conditions:
Integrating behavioral health services with primary care can be an effective strategy to ensure rural residents
with chronic depression or other chronic behavioral health conditions have better access to care. For example,
Cross-Walk is a program in rural Michigan that provides access to counseling
and treatment to address depression and substance abuse issues in a primary care setting. Our Rural Services Integration Toolkit provides information and
resources to help rural communities and healthcare organizations integrate health and human services.
Rural healthcare providers and communities can provide transportation to help patients with chronic conditions
get to healthcare appointments and supportive services, such as wellness programs. Transportation options such
as mobility vans, van pools, and local public transit can help patients access care within their rural community
or reach specialty and subspecialty care available elsewhere. For more information on rural transportation and
grant opportunities, see our Transportation to Support Rural
Healthcare topic guide. For examples of transportation programs or guidance on program development and
sustainability, see our Rural Transportation Toolkit.
Programs that bring specialists and subspecialists to rural healthcare facilities can help patients with chronic
conditions receive the care they require without leaving their community. A 2016 Journal of
American Heart Association article, Providing
Cardiology Care in Rural Areas Through Visiting Consultant Clinics, highlights a program that increased
access to cardiologists in rural Iowa through the use of a cardiology outreach program.
Telehealth can expand access to specialty and subspecialty care, as well as training for rural providers related
to patients with chronic conditions. Project ECHO® — Extension for
Community Healthcare Outcomes is a widely known and evidence-based program that connects primary care
providers and academic specialists in a team to discuss care management and treatment for patients with chronic
and complex conditions. Our Telehealth Use in Rural Healthcare topic guide
has many resources on how telehealth can improve access to care in rural communities. For examples of telehealth
programs or resources to help in developing a telehealth program, see our Rural
Networking with Larger Systems
Rural facilities and providers may seek out relationships with larger healthcare systems or networks as a
strategy to help their patients access needed care. This type of relationship, whether formal or informal, may
facilitate and support access to traveling specialists, telehealth, and many of the other approaches listed
above. Affiliation with larger hospital systems or networks is explained further in our Healthcare Access
in Rural Communities topic guide question What are some
strategies to improve access to care in rural communities?
How can rural communities and healthcare facilities work together to prevent chronic diseases?
Rural communities and healthcare facilities can work together to address common risk factors for many chronic
conditions. Below are some approaches to help rural communities and healthcare organizations create an
environment that supports healthy behaviors:
Support for Physical Activity
Walking trails, sidewalks, and parks are all aspects of the built environment that can encourage residents
to be active. Rural communities can also develop programs to get residents moving such as the Albert Lea Blue Zones Project that created walking
initiatives in rural areas of Minnesota, or The Walking Classroom that
incorporates walking with educational lessons multiple times throughout the week.
Access to Healthy Foods
Community gardens, healthy cooking and nutrition classes, and exposure to healthy foods are all ways to
support healthy eating practices among rural residents at risk for chronic disease.
Another aspect of prevention is early detection and treatment through health screenings. Early warning
signs, such as high blood pressure or cholesterol, can help identify rural residents who would benefit from
wellness programs or other interventions to prevent or control a chronic condition(s):
Communities and local healthcare providers can sponsor screening fairs to bring rural residents together for
a common purpose of health and the prevention of chronic disease. Incorporating screening fairs into
existing community events can be an effective way to reach rural residents who might otherwise not be
How can community health workers, home health providers, and school nurses help a patient
manage chronic diseases?
Community Health Workers
Chronic diseases require follow-up care, accountability, education, and preventive measures to better manage
symptoms and disease. Community Health Workers (CHWs) fill gaps in the healthcare workforce to help provide
healthcare services in rural areas. CHWs can play many roles in helping chronic disease patients in rural
communities, such as:
Providing wellness programming and education on chronic conditions and guidance on diet, physical activity,
and smoking behaviors.
Serving as patient navigators to help patients access their healthcare facility's services and to ensure the
most appropriate care is provided.
Offering counsel, support, and advocacy to patients and their families.
Providing screenings and other basic services to patients.
Our Community Health Workers Toolkit offers step-by-step
guidance for rural communities interested in using CHWs to improve health in their community and includes
information on model programs, training, sustainability planning, measuring CHW program impacts, and more.
Additional information and resources on CHWs are available on our Community Health Workers in Rural Settings topic guide.
Home health providers offer a wide range of services for chronic disease patients in the comfort of their own
homes. Many home health programs utilize remote patient monitoring (RPM) to manage patients with chronic
diseases, many of whom might otherwise require a hospital stay. Home health services can also serve as an extra
support to patients between clinic visits. RHIhub’s Rural Home Health Services
topic guide provides an overview of home health services in rural communities and discusses the availability of
services and challenges they face providing home health care in rural areas.
School nurses help students with their overall health needs, including managing chronic conditions while in
school. Nurses serve as a liaison between students, their parents, and healthcare providers. Since schools are a
significant institution in the lives of children, partnerships between schools and local healthcare facilities
provide an avenue to help children with chronic diseases manage their conditions on a regular basis. School
nurses can also educate youth on healthy nutrition and physical activity habits, and chronic disease prevention.
information on rural school nurses and student health
education and prevention programs, see our Rural Schools and Health topic
How can policymakers support rural communities' efforts in fighting chronic diseases?
For an overview of policymaking to support rural health, see our Rural
Health Policy topic guide.
How prevalent are specific chronic diseases in rural America and what is being done to treat and prevent them?
Heart Disease and Stroke
Heart disease and stroke are historically more prevalent in rural areas, and rural residents have higher death
rates from these diseases.
Age-adjusted death rates per 100,000 population, 2019
Source: Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019. Data table for Figure 3.
Age-adjusted death rates for the 10 leading causes of death, by urban-rural classification: United
In 2017-2018, the prevalence of stroke in rural areas was reported as .1% lower than in urban areas for the
first time, according to Table 13 of the
National Center for Health Statistics report Health, United States, 2019.
Rural community health programs focusing on nutrition, weight control, tobacco cessation, physical activity, and
limiting alcohol use can help prevent heart
disease and prevent stroke. Implementing
strategies to target high blood pressure and high cholesterol, focusing on screening and intervention to help
prevent or control heart disease.
Diabetes Statistics Report, 2020, from the CDC’s National Center for Chronic Disease Prevention and
Health Promotion, Division of Diabetes Translation, identifies American Indian and Alaska Native (AI/AN) people
having the highest rates of diagnosed diabetes in the U.S. This chronic disease is also more common among
non-Hispanic African American and Hispanic populations than White and Asian populations.
Prevention and Treatment in Rural Areas
Rural programs supporting access to healthy foods and opportunities for physical activity aid in diabetes
prevention efforts. Programs focusing on weight control and healthy living may also reduce obesity, a risk
factor for diabetes.
Screening programs can help rural residents find out if they are at risk for diabetes, which can allow them to
make lifestyle changes, increase their knowledge of diabetes, and receive medical care to help prevent the
disease from developing. Screening programs can also help in targeting diabetes self-management education and
support (DSMES) programs for rural residents with diabetes or at risk of developing the chronic disease. A 2017
MMWR Surveillance Summary, Diabetes
Self-Management Education Programs in
Nonmetropolitan Counties — United States, 2016, provides an overview of diabetes self-management
education (DSME) programs in rural areas. The article reports, in 2016, 62% of nonmetro counties did not have a
DSME program and the counties lacking a DSME program tended to be poorer, with larger percentages of racial and
ethnic minority populations, as well as higher rates of diabetes.
Chronic respiratory diseases, such as asthma and Chronic Obstructive Pulmonary Disease (COPD), make it difficult
to breathe due to problems with the airways and other lung structures. Death rates for chronic lower respiratory
disease are higher in rural areas, driven by a higher prevalence of COPD in rural areas. Despite having higher
rates of COPD, rural communities are
less likely to have pulmonary rehabilitation
facilities. Similarly, rural communities also lack
pulmonologists, who could provide guidance in the management of COPD, asthma, and other conditions.
Age-Adjusted Estimates of Selected COPD Measures, by Urban-Rural Status, 2015
Avoiding lung irritants, such as dusts, chemical fumes, pollution, and secondhand smoke
Health-Related Behaviors by Urban-Rural
County Classification — United States, 2013, a 2017 MMWR article, found that smoking increases
of rurality. The report analysis found that only 74.9% of the noncore or small rural and 76.5% of micropolitan
or large rural residents are nonsmokers, compared to 81% of the nation as a whole. Rural programs targeting
tobacco use prevention and cessation are useful in addressing both direct exposure through smoking and exposure
to tobacco smoke.
Rural patients with a chronic respiratory condition may find it more difficult to access the treatment,
specialty, and subspecialty care needed to manage their condition. As with other chronic conditions, telehealth
may help by providing access to subspecialists, and increasing rural providers’ knowledge and education
regarding chronic diseases. Learn more about COPD in rural areas:
“HIV is of particular concern to rural America because lack of
resources can lead to gaps
in detection of the infection and in treatment maintenance.”
A 2019 CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) slide set, HIV
Urban and Nonurban Areas through 2018, provides detailed statistics on HIV and AIDS in rural areas. In
general, the rate of HIV infection is lower in nonmetropolitan areas than metropolitan areas across all racial
and ethnic groups. In 2017, African Americans had the highest rate of adults and adolescents diagnosed with HIV
infection in nonmetro areas at 715.6 per 100,000 population. The other racial
and/or ethnic groups most affected in rural areas were individuals of multiple races and Hispanic/Latino
and 239.8 respectively. Regionally, the South is most
impacted by diagnosed HIV infections for rural areas, followed by the Northeast.
HIV in the Southern United
States, a 2019 NCHHSTP issue brief, points out that while the HIV epidemic in the South is primarily
urban, 24% of new HIV diagnoses are in rural or suburban areas, which is a higher proportion than in other
regions of the U.S. The brief also includes information and considerations on addressing HIV in rural
Rate of Diagnosed HIV for Adults and Adolescents per 100,000 Population, 2017
Metropolitan Statistical Area (MSA), population over 500,000
For additional county-level data on HIV and AIDS, as well as location information for testing and
treatment centers, see AIDSVu.
Prevention and Treatment in Rural Areas
Just as in urban areas, rural HIV diagnoses are connected to sexual contact and injection
drug use. Programs to prevent HIV
infection may focus on abstinence, the use of condoms, safe sex, and syringe exchanges to prevent the
sharing of needles, which can spread infections. Offering pre-exposure prophylaxis (PrEP) and post-exposure
prophylaxis (PEP) medications can help prevent the spread of HIV. Those with an HIV infection can take
antiretroviral therapy to help prevent passing the infection on to others. The AIDS Education and Training
Center Program (AETC) National Coordinating Resource Center offers a Non-Occupational Post-Exposure Prophylaxis (nPEP)
Toolkit with information on nPEP in rural America and perspectives from rural providers.
Screening for HIV infections is an important step in both prevention and treatment. Stigma and privacy are concerns are problematic in rural areas where
there is less anonymity. Programs offering screening and treatment in a setting where other healthcare services
are also provided can help patients more readily access treatment.
Rural patients diagnosed with an HIV infection may face challenges accessing specialty and subspecialty care.
The use of telehealth is one promising method for both providing access to AIDS specialists and helping rural
providers gain greater expertise related to HIV/AIDS. The National HIV
Curriculum is a free educational resource for healthcare providers to help them learn more about HIV
prevention, screening, diagnosis, and ongoing treatment. HIV Nexus is a one-stop location for information
HIV, including up-to-date tools and guidelines for providers, and educational materials for patients.
In recent years, clusters/outbreaks of HIV related to injection drug use have occurred in all regions of the U.S.
in jurisdictions of varying urbanicity. Injection drug users are at a greater risk for infectious disease
related to unsterile injections, including HIV, viral hepatitis, and endocarditis, an infection of the lining of
the heart. Some communities choose to implement preventive syringe
services programs (SSPs) that offer a variety of services, including:
Providing access to sterile syringe and injection equipment
Sterile syringe and injection equipment exchange and disposal
Infectious disease testing
Referrals to infectious disease and substance use treatment and services
“new users of SSPs are five times more likely to enter drug treatment and about
three times more likely to stop using drugs than those who don't use the programs.”
Adolescence is a critical period of time for the prevention of substance use that can progress into addiction.
Adolescents with substance use disorders (SUDs) have increased rates of physical and mental illnesses, and
poorer health and well-being overall. Teens can be at increased risk for HIV, sexually transmitted diseases
(STDs), and teen pregnancy based on their experiences connected to four risk behaviors: sexual behavior,
high-risk substance use, violence victimization, and mental health.
Ending the HIV Epidemic: A Plan for America provides an
overview of the ten-year initiative starting in fiscal year 2020 to end the HIV epidemic in the U.S. and links
to related federal resources. In addition, the HIV.gov resource What Is 'Ending the HIV
Epidemic: A Plan for America'?, includes background information, goals, and discussion of the three
different phases of the plan, with phase one focusing on 57 jurisdictions that include seven states with a
substantial number of HIV diagnoses in rural areas.
Rural Program Examples
Teens Linked to
Care (TLC) began as a three-year pilot project in Indiana, Kentucky, and Ohio that sought to
determine how prevention strategies and activities can be implemented to address substance use, HIV, and
sexual risk behavior prevention among high-risk rural youth. The initial project was a collaboration between
CDC's Division of Adolescent
and School Health (DASH), the CDC Foundation, the Conrad N. Hilton Foundation, and three grantees. The
second phase of the project started in the summer of 2019 with two grantees and will focus on behavior-based
outcome evaluation and preventive health screenings.
Sisters HIV/AIDS Ministry is a faith-based program that increased HIV testing rates in rural Ohio.
The program also works with clients to help them with suppressing their viral load and thereby staying
healthier. Learn more in this brief video:
TelePrEP provides preventive care and PrEP medication through
telehealth visits and prescription delivery services to prevent HIV infections in rural Iowa.
The groups most affected by arthritis in rural areas are the same as those most affected nationwide:
older adults, women, people who smoke, people who are overweight, those who are physically inactive,
and those with less education.
The same study reports that rural adults with arthritis reported higher rates of arthritis-attributable
activity limitation, and this is true across different demographic and health behavior groups.
Prevention and Treatment in Rural Areas
The CDC identifies many risk
factors for arthritis, including some that cannot be prevented or controlled, such as aging, gender, and
genetics. Arthritis risk factors that can be controlled include overweight and obesity, infections, joint
injuries, occupations with repetitive motions, and smoking. Given that obesity rates tend to be higher in rural
areas, programs to help rural residents achieve and maintain a healthy weight are well-suited for preventing
arthritis. Physical exercise is also helpful in addressing arthritis, though it can be more difficult in rural
areas to find areas to walk or engage in a formal exercise program. The 2017 MMWR article mentioned
above noted that self-management programs that are generally helpful for controlling symptoms, are less
available in rural areas. However, self-directed versions of evidence-based interventions are available, and
could be recommended by rural practitioners and supported by community service organizations. The same article
discusses how rural communities and organizations can deliver effective self-management programs and support
physical activity to help residents better manage arthritis.
Rural Program Examples
Strong!® is an 8-week series of community-based physical activity and education classes to help
promote and support patients with the self-management of arthritis symptoms.
Self-Management Program is a well-established program implemented in rural areas to address many
conditions, including arthritis. The 6-week workshop provides skill learning and strategies for patients to
better manage their chronic disease.
Are particular parts of the country more prone to certain chronic diseases?
Due to the diverse landscape and demographics throughout the U.S., certain chronic diseases are more common
in particular regions of the country. Health disparities are differences in health status compared to the
population as a whole and rural risk factors for health disparities can include socioeconomic status,
race/ethnicity, education level, and access to healthcare facilities. The following largely rural regions have
well-documented health disparities for a range of chronic conditions.
Appalachia is the area following the Appalachian Mountains, stretching from Mississippi to New York. A 2017
Appalachian Regional Commission report, Health
Disparities in Appalachia, examines mortality disparities related to chronic disease and risk factors
contributing to chronic disease in the region. Mortality is higher in Appalachia for all chronic conditions
included in the report and mortality rates in rural Appalachian counties are even higher:
Appalachia Mortality Rates per 100,000 population (2008-2014)
In terms of risk factors, rural Appalachian counties fare worse in terms of physical activity and
smoking. Rural counties in the region also face more challenges for a range of social determinants of
health, including poverty and education levels.
The Delta Region
The Delta Region includes 252 counties and parishes across
eight states from Illinois to Louisiana. A 2015 Rural Health Reform Policy Research Center report,
Exploring Rural and Urban Mortality Differences in the Delta Region, examines the leading causes of
death for the region. The rural areas of the Delta Region fare worse for all the chronic conditions included in
the report, compared to rural areas nationwide:
Mortality Rates per 100,000 population (2011-2013)
Delta Region Map Tool from the North Carolina Rural Health Research Program provides metro, nonmetro,
and state-level data on obesity and diabetes prevalence, cardiovascular disease hospitalization, stroke
hospitalization, and cancer incidence for the Delta region. To address the various social determinants of health
(SDOH) that contribute to chronic disease in economically distressed counties of the Delta region,
Delta Regional Authority works to improve quality of life through
transportation infrastructure, basic public infrastructure, workforce training, and business development.