Rural Public Health Agencies
Rural public health agencies work to protect and improve the health of rural populations by:
- Preventing injuries and the spread of disease
- Protecting rural population against environmental hazards
- Promoting and encouraging health behaviors
- Responding to disasters
- Assuring the quality and accessibility of services
Rural public health agencies encounter many challenges while trying to meet the unique and diverse needs of rural Americans, including:
- Workforce recruitment and retention
- Workforce education and training
- Information technology
Public health agencies work to address chronic disease and health disparities within the populations they serve. To learn more about the differences in health status for rural residents, see RHIhub's Rural Health Disparities topic guide. RHIhub's Chronic Disease in Rural America topic guide details how specific health conditions affect rural populations and provides additional resources and funding opportunities to improve chronic disease conditions in rural populations.
Frequently Asked Questions
- What federal agencies focus on public health in rural areas?
- Is there any funding for public health programs in rural communities?
- What infrastructure and governance exists in rural areas for public health agencies?
- What public health services are provided in rural areas?
- How can I locate my local governmental public health agency?
- What education and training opportunities are available related to rural public health?
- What challenges and opportunities do rural public health departments face?
- To what extent do rural public health agencies struggle to maintain an adequate workforce?
- Where can I find public health datasets or information particular to my region or state?
- How can my public health department become accredited and what is the process?
- How can I connect to peers interested in rural public health issues?
- How can rural healthcare providers and public health departments work together to improve population health in their communities?
What federal agencies focus on public health in rural areas?
The Federal Office of Rural Health Policy (FORHP), located within the Health Resources and Services Administration (HRSA), is the federal office charged with promoting health and access to quality healthcare for rural residents. FORHP directs activities, policy work, and funding to rural healthcare issues. FORHP works to increase access to care and improve the delivery of healthcare services through multiple programs.
The Centers for Disease Control and Prevention (CDC) does not have a centralized rural office; however, the Office of the Associate Director for Policy coordinates policy and programmatic efforts across the agency. CDC has recently increased its focus on rural public health, with a series of articles published in the Morbidity and Mortality Weekly Report (MMWR) and several rural-focused program activities. The Center for Surveillance, Epidemiology, and Laboratory Service (CSELS) is responsible for communications related to rural health.
Partners in Information Access for the Public Health Workforce (PHPartners) is a collaboration between U.S. government agencies, public health organizations, and health sciences libraries assisting the nation's public health workforce with resources to improve and protect the nation's health.
Other federal agencies also have programs that support public health in rural areas. The U.S. Department of Agriculture (USDA) provides financial resources and support for rural communities, residents, and businesses through their Rural Development mission area. Rural Development funds water and waste disposal programs; community facilities, such as health care facilities, public safety services, and local food systems; and other programs that build infrastructure and address social determinants of health.
The U.S. Environmental Protection Agency (EPA) works to protect human health and the environment; programs include ensuring clean air, land, and water in rural and urban areas.
Is there any funding for public health programs in rural communities?
RHIhub maintains a list of federal, state, and foundation funding opportunities for public health. You can contact us at 800.270.1898 or firstname.lastname@example.org to request a list of funding opportunities specific to your project and location.
What infrastructure and governance exists in rural areas for public health agencies?
CDC defines the public health system as:
all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.
Delivering essential public health services in rural areas requires a coordinated, collaborative effort from multiple stakeholders involved in the public health system.
Rural public health infrastructure varies from community to community. The National Association of County and City Health Officials (NACCHO) report, 2016 National Profile of Local Health Departments, describes local health department governance, infrastructure, funding, leadership, workforce, programs, practice, and more. The report analyzes survey data from 2,533 LHDs from every state except Hawaii and Rhode Island, which do not have a sub-state level public health unit. Areas without LHDs are not represented in the NACCHO national profile report. The report reveals the following about small and rural LHD infrastructure:
- 83% of small LHDs, which serve a population under 50,000, have a local board of health, compared to 52% of LHDs serving a population of 500,000 or more
- 39% of top executives at rural LHDs have graduate degrees, compared to 75% of top executives at urban LHDs
- 52% of top executives at rural LHDs have degrees in nursing, compared to 16% of top executives at urban LHDs. Urban top executives are more likely to have degrees in public health and medicine.
An analysis completed by NORC Walsh Center for Rural Health Analysis and the East Tennessee State University College of Public Health determined that both large rural LHDs and small rural LHDs relied more heavily on state and federal funding sources compared to urban LHDs. While urban LHDs had a higher proportion of revenue from non-clinical fees and fines, large rural and small rural LHDs had more funds from clinical funding sources, for example Medicare/Medicaid, private insurance, and personal patient fees.
NACCHO's 2016 National Profile of Local Health Departments classifies LHD governance into four categories:
- Local or decentralized – all LHDs in a state are units of local government
- State or centralized – LHDs in a state are units of state government
- Shared – all LHDs in a state are governed by both state and local authorities
- Mixed – LHDs in a state have more than one governance type
A November 2017 report, ASTHO Profile of State and Territorial Public Health, Volume 4, illustrates the number of LHDs and identifies if there is a regional health department in each state (Figure 1.2). The report also includes a flow chart describing state and local health department governance classification (Figure 1.3).
A 2015 report, State
and Local Public Health: An Overview of Regulatory Authority, from the Public Health Law Center
discusses how local boards of health, whose members are appointed or elected, serve as the administrative body
for LHDs. The Public Health Law Center report details how
the role, legal authority, and regulatory powers of local boards of health vary by jurisdiction. In 2012,
National Association of Local Boards of Health (NALBOH) identified six
key governance functions of local boards of health:
- Policy development
- Resource stewardship
- Legal authority
- Partner engagement
- Continuous improvement
What public health services are provided in rural areas?
LHDs provide a variety of programs and services. Each locality is different. Clinical programs and services may include:
- Screening for diseases/conditions
- Treatment for communicable diseases
- Maternal and child health services
- Other clinical services, such as school-based clinics, oral health services, home health care, and correctional health services
Population-based programs and services may include:
- Epidemiology and surveillance
- Population-based primary prevention
- Regulation, inspection, and/or licensing
- Environmental health services
- Other population-based services, such as vital records, outreach and enrollment for medical insurance, and collection of used pharmaceuticals
NACCHO's 2016 National Profile of Local Health Departments report identified programs and services that were more likely to be provided at rural LHDs:
- Child immunizations
- Maternal and child health surveillance
- Women, Infant, and Children (WIC)
- Blood lead screening
- Body Mass Index (BMI) screening
- Maternal and child health home visits
- High blood pressure screening
- Family planning
- School-based clinics
- School health
- Early and periodic screening, diagnosis, and treatment
- Home healthcare
An analysis completed by NORC Walsh Center for Rural Health Analysis and the East Tennessee State University College of Public Health found rural LHDs are more likely to provide specific clinical services and remain part of the healthcare delivery safety net, while urban LHDs are more likely to provide specific population-based services. Rural communities without LHDs are more likely to have fewer public health services available. State public health agencies, rural hospitals, rural clinics, private practice physicians, and community groups may provide some public health services to communities without LHDs. To learn more about access to healthcare in rural areas, see RHIhub's Healthcare Access in Rural Communities topic guide.
Some services may be provided on a regional basis either by state health departments, multiple local governments, or independent LHDs sharing staff and resources between jurisdictions. A November 2017 Center for State and Local Government Excellence report, Staff Sharing Arrangements for Local Public Health, describes how sharing public health staff between jurisdictions can fill gaps, provide public health services that otherwise might not be economical, and allow rural public health departments to qualify for grant funding.
Cross-jurisdictional sharing can also provide cross-training for employees and allow for multiple service locations. To review a model of a public health staff sharing agreement, see RHIhub's Model & Innovations, Genesee and Orleans County Cross Jurisdictional Sharing Project (GO Health).
The National Indian Health Board provides information on tribal public health.
How can I locate my local governmental public health agency?
Look in your local phonebook, contact your town or city government offices, or consult the NACCHO Directory of Local Health Departments for your local governmental public health agency. The agency may serve the city and/or the county and can be referred to as a health department, board of health, health district, or public health agency.
If your community does not have a local governmental public health agency, contact your state or territorial health department to find an agency or organization that may be providing public health services in your community.
What education and training opportunities are available related to rural public health?
If you are looking for a degree program with a specific emphasis or focus area you can search by degree programs from Council on Education for Public Health (CEPH) accredited institutions. CEPH is the accrediting body for schools and programs of public health. CEPH maintains a list of accredited public health schools and programs.
You can also search the Association of Schools & Programs of Public Health (ASPPH) member institutions for degree programs by area of study. ASPPH is a national organization representing schools and programs of public health that are accredited by CEPH.
Training and Continuing Education
The Public Health Foundation (PHF) coordinates the TRAIN Learning
Network, comprising state and federal affiliates providing education, training, and resources to professionals
at little or no cost. You can narrow your search of available
rural, course format, date, selected public health competencies and capabilities, and
The American Public Health Association (APHA) offers continuing education programs for public health professionals online and in-person at their annual meeting. APHA is a national, professional organization for public health professionals and works to promote and improve the health of all communities. APHA-affiliated state and regional public health associations may provide education, training, and resources within your state.
NACCHO University has online trainings and educational webinars and offers continuing education programs at NACCHO's three conferences:
NACCHO also offers training, workforce development, and performance improvement opportunities including:
- Workforce Resource Center
- Roadmap to Ready: A Training and Mentoring Program for New Preparedness Coordinators
- Adaptive Leadership and Change Management
CDC offers multiple resources for education and training, including:
- CDC Learning Connection
- Public Health Associate Program
- Public Health Informatics Fellowship Program
- E-learning Institute Fellowship
The Bureau of Health Workforce (BHW), within HRSA, funds the Regional Public Health Training Centers (Regional PHTC) program to improve the public health system by strengthening the technical scientific, managerial, and leadership competencies of the public health workforce through education, training, and consultation services. There are ten Regional PHTCs throughout the U.S. Each PHTC focuses on a specific topic, including:
- Public health preparedness
- Health disparities, health equity, and social determinants of health
- Health informatics and health information technology
- Infectious disease
- Environmental public health
- Behavioral health
- Nutrition, physical activity, and obesity
- Violence and injury prevention
What challenges and opportunities do rural public health agencies face?
CDC's Morbidity and Mortality Weekly Report (MMWR)
Rural Health Series discusses the health of rural Americans, specifically how chronic diseases and
injuries affect rural populations compared to urban populations. According to a
CDC press release,
residents tend to be older and sicker than their urban counterparts, which increases the burden on rural
health agencies and rural healthcare systems. At the same time,
household income is lower in rural areas and poverty is more persistent, particularly in the
southern U.S., which impacts the available resources for public health programs and healthcare services.
A 2012 NORC Walsh Center for Rural Health Analysis report, Establishing and Maintaining Public Health Infrastructure in Rural Communities, describes funding, public health jurisdictional issues, and the lack of support from community members and elected officials as common barriers rural public health agencies encounter when establishing or expanding public health infrastructure and services.
Rural public health agencies encounter many challenges related to workforce and infrastructure as well. A 2015 AcademyHealth report, Rural Public Health Systems: Challenges and Opportunities for Improving Population Health, describes rural public health departments as less capable of performing core public health functions and providing essential public health services. The report highlights the need for a tribal and rural public health research agenda:
While the body of research specific to local public health systems is growing, a very small proportion of the evidence focuses on rural health departments—which comprise approximately 60 percent of all LHDs. Noticeably absent are studies specific to Tribal public health; the Tribal population accounts for a major segment of rural communities.
Despite the many challenges faced by rural public health agencies, the AcademyHealth report identified accreditation, evidence-based policies and practices informing continuous quality improvement processes, and multijurisdictional partnerships as opportunities that exist for LHDs to improve healthcare services and delivery.
A single rural healthcare provider or public health department cannot address all aspects of a patient's health. A 2014 Commonwealth Center for Governance Studies, Inc. report, Improving Community Health through Hospital – Public Health Collaboration, examined twelve partnerships between hospitals, public health departments, and community organizations working to improve the health of their communities. The study identified successful examples of organizational models, partnership management, and sources and levels of financial support. Through collaborative efforts and community health partnerships, rural healthcare providers and public health departments can work together to address the clinical, social, economic, and environmental factors that influence patient health.
The Center for Sharing Public Health Services serves as the national resource on cross-jurisdictional sharing. The center maintains a cross-jurisdictional sharing resource library with a section specifically for rural and small jurisdictions.
To what extent do rural public health agencies struggle to maintain an adequate workforce?
A 2016 National Rural Health Association policy brief, Rural Public Health, describes some of the challenges rural public health agencies face, including workforce retention, recruitment, education, and training.
NACCHO's 2016 National Profile of Local Health Departments reports:
- A 23% decrease in the number of LHD employees from 2008-2016
- LHDs serving a population of fewer than 10,000 people employ an average of eight employees or six full-time equivalents (FTEs)
- Only 5% of LHD FTEs serve rural populations
NACCHO's 2017 Forces of Change survey reports small LHDs, serving fewer than 50,000 individuals, were least likely to experience difficulty hiring staff for clinical positions. Rural LHDs reported a slightly higher level of difficulty (64%) hiring core public health positions than urban LHDs (54%) but reported almost twice the level of difficulty hiring for administrative positions (45%) compared to urban LHDs (27%). The report goes on to identify the most common barriers to hiring staff reported by LHDs:
- Uncompetitive pay
- Candidate has insufficient work related experience
- Geographic area of position is not desirable
Healthy People 2020 identifies multiple objectives to increase the public health workforce through training and education by increasing the number of two- and four-year degree programs. Workforce objectives aim to integrate use of Core Competencies for Public Health Professionals into multiple aspects of state, local, and tribal public health agencies' human resources, continuing education, and business practices, for example, job descriptions and performance evaluations.
Where can I find public health datasets or information particular to my region or state?
Numerous public health datasets are available, but accessing local data for rural communities can be a challenge due to small numbers and insufficient sampling. RHIhub's Finding Statistics and Data Related to Rural Health topic guide discusses challenges and limitations of various data sources related to rural areas.
These CDC tools and databases are particularly useful to rural public health:
- Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey that collects data on health-related risk behaviors, chronic health conditions, and the use of preventive services.
- National Center for Health Statistics (NCHS) provides statistical information about the health of U.S. residents. Data is collected from birth and death records, medical records, interview surveys, and through direct physical exams and laboratory tests.
- Web-based Injury Statistics Query and Reporting System (WISQARS) is a database housing fatal and nonfatal injury, violent death, and cost of injury data.
- Wide-ranging Online Data for Epidemiologic Research (WONDER) manages multiple sets of public-use data for U.S. births, deaths, cancer diagnoses, Tuberculosis cases, vaccinations, environmental exposures, population estimates, and other topics. Tables, maps, charts, and summary statistics are just a few features available to analyze the data.
Many state health departments offer health data resources or access to datasets and information. Contact your state or territorial health department to learn more.
RHIhub's State Guides, U.S. Territories and Commonwealths, and State-by-State Resources for Rural Health are starting points for reports, data, and resources on a wide range of topics for public health professionals. Additional county-level and rural-specific data on public health topics are included in Finding Statistics and Data Related to Rural Health and Data Sources and Tools Relevant to Rural Health.
Additional information may be available from these state-level organizations:
- State and Regional Public Health Associations
- State Offices of Rural Health and State Rural Health Associations
The National Health Security Preparedness Index and Trust for America's Health Ready or Not? 2017 Report include state-by-state assessments of readiness for public health threats including natural disasters, infectious diseases, and man-made threats.
How can my public health department become accredited and what is the process?
The Public Health Accreditation Board (PHAB) evaluates the performance of
a public health department against a set of nationally recognized practice and evidence-based standards. PHAB
accreditation is a voluntary program
to improve and protect the health of the public by increasing the
quality and performance of tribal, state, local, and territorial public health governmental entities.
Currently, about 12% of LHDs serving populations of 50,000 or fewer are engaged in PHAB accreditation. If you
are interested in becoming an accredited public health department, first you need to
determine your eligibility. PHAB
governmental entities with a primary statutory or legal responsibility for public health at a
tribal, state, local, or territorial level.
Public health department accreditation is a seven step process:
- Document Selection and Submission
- Site Visit
- Accreditation Decision
PHAB accreditation has a five tier graduated fee schedule based on the size of the population the public health department serves. Public health departments serving populations of 100,000 persons or fewer are classified as Category 1. As the population served by the public health department increases so does the fee schedule. For a Category 1 public health department, the initial accreditation review fee is $14,000 and the annual accreditation services fee is $5,600. The cost of accreditation can be prohibitive or raise questions for rural public health departments. PHAB can work with your public health department to create an individualized payment plan.
A 2018 article published in the Journal of Public Health Management and Practice, Public Health Agency Accreditation Among Rural Local Health Departments: Influencers and Barriers, found that significantly fewer LHDs located in rural (4.1%) or micropolitan (8.9%) areas were seeking accreditation compared to LHDs in urban areas (87.0%). The top three barriers rural LHDs reported to pursuing PHAB accreditation are:
- Time and effort required for accreditation application exceeds the benefits (88.0%)
- Fees for accreditation are too high (83.2%)
- Accreditation standards exceed the capacity of my LHD (50.5%)
NACCHO's Accreditation Support Initiatives (ASIs) provide funding and technical assistance to LHDs preparing for accreditation through PHAB. NACCHO's Project Public Health Ready (PPHR) program is a criteria-based training and recognition program that assesses the capacity and capability of LHDs to plan for, respond to, and recover from public health emergencies. PPHR can help LHDs prepare for PHAB accreditation.
ASTHO maintains an Accreditation and Performance Resources and Tools section on their website. It includes toolkits, guides, trainings, webinars, case studies, and more. ASTHO's Accreditation Library provides examples of documentation from states and territories, which could be useful for local, county, or rural public health agencies seeking PHAB accreditation.
How can I connect to peers interested in rural public health issues?
There are several ways to connect with peers interested in rural public health issues. One option would be to: join the National Rural Health Association (NRHA) Public Health Constituency Group. The Public Health Constituency Group represents members interested in community-level policy development and advocacy to promote and improve access to healthcare services and a community's overall health status. Membership in NRHA is required to become a member of the interest group. If you are interested in joining the interest group, contact Alana Knudson, Co-Director, NORC Walsh Center for Rural Health Analysis, at email@example.com.
You can also explore the Rural Health Section at NACCHO. The Rural Health Section is comprised of NACCHO members and partners working together across programmatic areas to develop a high level strategy for advocacy, goal attainment, structural system requirements, resources and approaches to improve rural health. NACCHO also has a Rural Public Health Preparedness Collaborative to connect with peers and share resources for public health and emergency preparedness, response, and recovery in rural communities.
Another way to connect with like-minded peers is through the APHA Rural and Frontier Health Committee. If you are interested in reaching out to this group, contact the co-chair Cody Mullen at firstname.lastname@example.org.
How can rural healthcare providers and public health departments work together to improve population health in their communities?
Long lasting improvements in population health will require the coordinated efforts of rural healthcare providers and public health departments. The Institute of Medicine (IOM) Committee on the Integration of Primary Care and Public Health 2012 report, Primary Care and Public Health: Exploring Integration to Improve Population Health, identified five principles that are essential for integration of primary care and public health:
- A shared goal of population health improvement
- Community engagement
- Aligned leadership
- Sharing and collaborative use of data and analysis
The IOM committee identified three examples of successful primary care and public health integration efforts:
- Working together on specific health issues identified as an area of concern by the community
- Working with multiple groups and organizations to provide community health services
- Sharing and using data
In 2016, the National Quality Network developed a step-by-step community action guide, Improving Population Health by Working with Communities: Action Guide 3.0, that describes how to bring multiple community groups together, including rural healthcare providers and public health departments. The community action guide presents ten key elements communities, healthcare providers, and public health departments can use to identify and design initiatives to improve population health.
Rural healthcare providers and public health departments can also work together to perform a community needs assessment to understand the needs and resources in their community. For additional information on conducting community needs assessments, types of assessments, or Community Health Needs Assessments (CHNAs) requirements, see RHIhub's Conducting Rural Health Research, Assessments and Evaluation topic guide.
Partnerships among public health, healthcare, and other community partners are essential for leveraging scarce resources to address community health challenges. NACCHO supports Mobilizing for Action through Planning and Partnerships (MAPP). MAPP is a planning process to assist communities in identifying, addressing, and improving health concerns. MAPP works to address community health concerns through the application of strategic thinking that allows communities to prioritize public health issues and identify resources to address them. MAPP integrates data collected through community health assessments (CHAs) and Community Health Improvement Plans (CHIPs) to prioritize issues and develop community-wide action plans.
NACCHO's Toolbox is a collection of free tools and
resources for public health. Planning guidance, tools, and templates specific to rural public health and their
partners can be found by searching
rural in the toolbox.
Last Reviewed: 3/6/2018