While primarily focused on education, rural schools also play an important role in the health of students and
the community. Working on health-related initiatives makes sense for rural schools as physical and mental health
status, physical activity, and good nutrition all impact how students learn. Schools serve as an important
community resource and can engage in health-related activities such as:
Teaching children about health and wellness topics
Providing nutritious meals and snacks
Providing opportunities for and education related to physical activity
Discouraging and preventing bullying
Serving as a location where healthcare is provided
Serving as an advocate for children with special health needs
Providing counseling and resources related to mental health and emotional well-being
School-based health centers can provide access to healthcare for students who may not otherwise
Rural students may face barriers to accessing healthcare services, including long distances to providers, lack
reliable transportation, work demands of students' parents, poverty, lack of health insurance, and the
cost of healthcare. School-based health centers often operate as a partnership between the school and a
community health center, hospital, or local health department to improve the health of students, as well as the
community as a whole.
Frequently Asked Questions
What role can rural schools play in improving the health of their students?
Schools play a significant role in promoting the health and safety of students. Ideally, rural schools will
strive to provide a healthy physical environment for students to learn, provide nutritious meals, and encourage
One strategy some rural schools have implemented is the creation of a School
Health Advisory Council or a School Wellness Committee, which works to promote a healthy and safe school
environment for students and staff. This council often has input from students, parents, teachers, and school
administrators to identify barriers and solutions to improving the health and well-being of students.
The Centers for Disease Control and Prevention (CDC) promotes a coordinated school health approach that
integrates health-promoting initiatives in schools and in policies that support students’ well-being and health.
CDC has expanded this methodology to the Whole
School, Whole Community, Whole Child (WSCC) collaborative
model, engaging leaders from the health, public health, education, and school health sectors to unify and
strengthen their approach to improve students' learning and health, and also engages students as active
participants. The WSCC model highlights ten
elements supporting a whole child approach to education:
Social and emotional school climate
Physical education and physical activity
Nutrition environment and services
Counseling, psychological, and social services
The CDC and
Association for Supervision and
Curriculum Development (ASCD) provide more information about the Whole School, Whole Community, Whole
Child model. For other examples of evidence-based programs schools can
implement, see How
Can Rural Schools Address Obesity? in RHIhub's Rural Obesity Prevention Toolkit.
Schools can serve as a location for providing students with counseling and behavioral health
to a CDC report, the percentage of children
with diagnosed mental, behavioral, and developmental disorder (MBDD) is consistently higher in rural areas. For
illustration, 18.6% of children 2-8 living in small rural areas in 2011-2012 had a reported MBDD diagnosis
compared to 15.2%
of children of same age group in urban areas. Schools are the most common
location for children to receive mental health services. Providing Access to Mental Health
Services for Children in Rural Areas identifies ways in which school-based health centers can provide
these services. RHIhub's Mental Health topic guide has resources on how schools can take action to
Oral health is another area where schools can play a role in improving children's health and
develop healthy habits. School-based dental programs can provide dental screenings, fluoride varnishes, dental
sealants, and a variety of oral health education to students without them having to leave the school. For
examples of what some rural schools have implemented, see the School-based
Model section of RHIhub's Rural Oral Health Toolkit.
In addition to school health promotion initiatives and policies, some rural schools are able to employ a school
nurse or house a school-based health center, both of which work to directly address the health needs of
students. These programs are described in the following question.
How can healthcare services be provided in rural schools?
School nurses provide health services in some rural schools. They work with parents, teachers, and other health
professionals to provide a plan for the health needs of the school. School nurses provide services for students
with special health needs, such as prescription medications, asthma inhalers, and catheters so that those
students can attend school. They also provide health promotion activities and education including:
Fitness and nutrition education
Tobacco use prevention
Sexually transmitted disease prevention
Teen pregnancy prevention
Hearing and vision screenings
In rural schools, nurses often fill multiple roles including clinician, administrator, record keeper, and grant
The 2015 NASN School Nurse Survey
reports on a survey of school nurses in all 50 states. The majority of school nurses who responded to the survey
were employed by a public school district and their position were funded by the regular education budget. Just
of survey respondents worked in at least one school in a rural area.
School Nurse Workforce Study reports 25% of America's schools do not employ a school nurse, with only
39% having a school nurse available at all times during the school week. A Robert
Wood Johnson article warning of the consequences of a school nurse shortage states:
“Many rural counties lack even a single physician or nurse practitioner, so the school nurse—if
there is one—becomes the ‘frontline expert’ during the school year and sometimes during the
School-Based Health Centers
A school-based health center (SBHC) provides a variety of services to improve the overall health of students and
their family members, including primary care, immunizations, health screenings, and health education. Some SBHCs
provide additional services such as mental health services, vision and hearing examinations, dental services,
substance abuse services, and reproductive health services.
According to The
Complementary Roles of the School Nurse
and School Based Health Centers from the National Association of School Nurses, having a school-based
health center improves students' access to healthcare services, but the center does not necessarily take the
place of a school nurse. School nurses are employed by the school district and serve all students. School-based
health centers, on the other hand, are usually run by a community health center and students must enroll in the
clinic to receive services. Collaboration between school nurses and health professionals at the
SBHC is important for improving the well-being and education of rural students.
For information on how to start a school-based health center, HRSA's
School-Based Health Center Capital Program Technical Assistance website has information regarding how to
apply. The School-Based Health Alliance offers Sustainability
Tools to help SBHCs build a stable foundation to ensure long-term viability.
What programs are available to provide children with healthy and affordable meals?
There are several programs available through USDA's Food and Nutrition Service which provide nutritious
meals and snacks to students including:
What are strategies that rural schools can use to increase the nutritional value of foods served to their
USDA's Tools for Schools provides subject-specific
resource materials to help schools meet federal nutrition and compliance standards, such as nutrition education
curricula and literature as well as food buying guides. Tools for Schools also offers information on obtaining
local foods, enhancing school lunches, school wellness policy, and regulatory requirements.
The National Farm to School Network is a movement to bring more
local food into schools and to teach children about where their food comes from. The network encourages schools
to purchase, prepare, and serve locally-grown items. The program also supports bringing students to local farms
to teach children about the importance of nutritious food and local farming.
If school land is available, planting school gardens provides an opportunity for students to be involved in
growing different types of fruit and vegetables as well as learning where their food comes from. School gardens
are an excellent source of nutritious items for food service staff to prepare for students and school staff
For examples of strategies that rural schools can use to improve healthy
food choices, RHIhub compiles rural
models and innovations regarding food and hunger. Additionally, Farm to School Models are
discussed in RHIhub’s Rural Food Access Toolkit with resources and program examples.
What are strategies that rural schools can use to increase the amount of physical activity their students get
during the school day?
Children need quality physical activity throughout their day to lead healthy lives, to learn, and to prevent
obesity. A 2015 literature review of childhood and
adolescent obesity indicates children aged 2-19 living in rural areas have a higher rate of obesity, and a 26%
greater chance of becoming obese when compared to urban children. Increasing physical activity is a key obesity-prevention strategy.
Rural schools can serve as the ideal location to promote and foster physical activities, and serve as a
community resource to support afterschool physical activities.
There are several model programs that address physical activity and healthy eating in rural schools. According
to an April 2016
Rural Monitor article, Meeting
the Needs of the Whole Child through CATCH, the Coordinated Approach To
Child Health (CATCH) program is very adaptable to a rural setting and can be modified to support the
needs of both the school and the local population. This program focuses on creating healthy behaviors in
children by enabling them to identify nutritious foods and to increase their time spent engaging in physical
activity. This program has been successfully established in several rural settings. For example, the CATCH
Early Childhood Pre-K program in Illinois, which is featured in the Rural Monitor article, provides a
curriculum that includes stories, games, puzzles, and equipment to encourage healthy food choices and
physical activity in preschool children. The Coast
to Cascades C.H.E.F.
(Culinary Health Education and Fitness) program is a rural program that engages many community
partners, including school districts, healthcare organizations, and public health departments. This program
addresses childhood obesity by establishing a fun curriculum of encouraging healthy eating practices, increased
physical activity, and culinary education for early childhood education and afterschool education sites.
Brain breaks or
brain energizers are short activities in the classroom, and they are a great way for schools to add
small amounts of physical activity to the school day without losing valuable educational time with students.
What health education and prevention programs can be implemented in a rural school to improve students'
knowledge of how to maintain their own health?
There are many health education programs that rural schools can implement to improve students' knowledge
how to maintain their own health. For example, in South Dakota, the Harvest of the Month Program encourages schoolchildren to make
healthy eating choices by tasting different fruits and vegetables. Students in the program can
sample new foods and are encouraged to make healthy food choices at school and at home. Exposing young children
to a variety of nutritious foods in a positive setting will help them improve life-long healthy food behaviors.
This Harvest of the Month program is based on a model from Network for a Healthy California and has
been implemented in other states as well.
CATCH is a popular health education program
that introduces healthy eating and physical activity options during the school day as well as encourages
positive behaviors outside of school.
It is important for rural schools, teachers, and coaches to take an active role in preventing
injuries, particularly brain injuries, during gym classes, school practices, and during school
sporting events. Teachers and coaches can educate student athletes and parents about the dangers of head
injuries and can teach and promote safe playing techniques. More information is available from the Centers for
Disease Control and Prevention regarding brain injury safety while playing
sports and monitoring the health of student athletes who have symptoms of a concussion.
Schools can also be involved in helping students navigate brain injury recovery. An April 2020 Rural
Monitor article, Concussion
in Rural America: Experts Detail Injury and Recovery of Traumatic Brain Injury, describes Remove/Reduce, Educate, Adjust/Accommodate, Pace (REAP), a
community-based model developed to help with concussion management. REAP was originally created to be used by
communities with scarce resources, including those in rural settings. Although the tool was first established in
Colorado, according to the Rural Monitor article, it can and has been modified for use by schools and
other organizations in various states.
Several examples of wellness programs for children can be found in RHIhub’s Models and Innovations under the
topic of Wellness,
health promotion, and disease prevention and narrowing by topic to Children and youth.
How can schools promote population health within their communities?
Population health is defined as the health outcomes of a group of individuals, such as the residents of a
specific rural community. Schools can promote population health by providing health promotion and disease
prevention education to their students, staff, parents and other family members. The prevention of obesity and
diabetes can have an impact on the whole community's health and vitality.
Schools can also partner with health departments, businesses, and community groups to support physical activity
programs by allowing community members to use school gymnasiums and playgrounds when school is
not in session.
In small rural communities where funding for gymnasiums, exercise equipment, and playground equipment is
limited, it is important for community organizations to work together to provide opportunities for physical
Rural schools can motivate staff, students and community members to increase physical activity by
creating walking clubs, running clubs, or other opportunities for group exercise.
Rural schools could also provide health fairs and wellness days for staff and students to gain
awareness of health issues and inspire individuals to take an active role in their healthcare.
How are schools addressing the shortage of health professionals and getting students interested in health
In looking at the health of the community long-term, many rural schools realize the need to expose students to
healthcare careers, in hopes of “growing their own” healthcare providers that can care for the
community's citizens down the road. To do this, many schools partner with Area Health Education Centers (AHECs),
which provide health career education programs for students.
AHEC initiatives address healthcare workforce issues by exposing students to career opportunities. AHECs also
help host career fairs for schools to showcase the variety of careers within the healthcare industry. For
example, the West Virginia AHEC is involved in health workforce pipeline programs including:
High school health career clubs that meet monthly
Shadowing opportunities for high school students at Federally Qualified Health Centers and their affiliated
school-based health centers
- Health career fairs that target middle and high schools
Opportunities for students to learn about medical procedures using robotic simulators
Assistance to students preparing for college admission tests
The National AHEC Organization provides a directory of
contact information for AHECs by state.
What funding programs are available to support school-based health services?
The Federal Office of Rural Health Policy offers the Rural
Health Care Services Outreach grant program. This program supports collaborative projects that
demonstrate effective models of outreach and service delivery in rural communities. Funding can be used to
address school-based health services including health promotion and disease prevention activities.
Many schools rely on a mix of public, private, and nonprofit funding to support a school-based health center
(SBHC). According to the 2016-17
School-Based Health Alliance report, more than half of SBHCs in the U.S. receive funding from the
federal government. Top sources
include HRSA's SBHC Capital
Service Area Competition Funding, and Title X Family Planning funding.
Private foundations contributed financial support to 40% of SBHCs. Also, the majority of SBHCs receive state
dollars for operation. States can direct funds to SBHCs from various sources including the general fund, taxes,
and the federal Maternal and Child Health Block Grant.
Other funding programs for school-based health may be found on RHIhub's list of funding opportunities related to
schools, which includes federal, state, and private foundation funding opportunities. Information
regarding the sustainability of grant-funded school programs can be found in the Planning for Funding and Sustainability module of the Rural Community Health Toolkit and the Sustainability Planning Tools page.
How can rural schools work to address and prevent Adverse Childhood Experiences (ACEs)?
Adverse childhood experiences can have great impacts on children's growth and development. A National Survey of
Children's Health (NSCH) data brief, Rural/Urban
Differences in Children's Health, states that, compared to children from urban areas, children from
large and small rural areas were more likely to experience the following ACEs in 2017-2018: parental divorce,
living with someone who engaged in alcohol or other substance misuse, having an incarcerated parent or guardian,
living with someone who had a mental illness, or witnessing parental violence. ACEs can cause mental, emotional,
and physical health issues for impacted children and are likely to impact their health as adults. According to
the data brief, depression, behavior problems, and anxiety were all more prevalent in children aged 3-17 who
were from large and small rural areas than those from urban locations.
Schools can take a trauma-informed approach to helping children who may have been impacted by ACEs. The Substance Abuse and Mental Health
Administration defines trauma-informed care as:
“A program, organization, or system that is trauma-informed:
- Realizes the widespread impact of trauma and understands potential paths for recovery;
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved
with the system;
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices;
- Seeks to actively resist re-traumatization.”
The Rural Monitor article, Confronting Adverse
Childhood Experiences to Improve Rural Kids' Lifelong Health, discusses the Compassionate Schools
initiative that was implemented in Buncombe County, North Carolina. The program works to recognize signs of
trauma in children and respond to their needs. In addition, the program teaches students skills such as
resiliency and self-regulation. The article also details the Fostering Futures program of Menominee Nation in
Wisconsin, a collaborative effort involving numerous agencies, including the local school district, to
address and prevent ACEs. The program has increased behavioral health visits, decreased school suspensions, and
increased graduation rates. For additional information about the program, see Fostering Futures in
Menominee Nation in RHIhub's Models and Innovations section.
For additional information and resources, see a summary of the December 2017 Rural Health Chat, Adverse
Childhood Experiences in Rural Areas.
What role can schools play in providing human services to address social determinants of health?
Social determinants of health (SDOH) can negatively impact academic participation and success, which may in turn
lead to poorer health outcomes. Education
and Health: Long-Term Trends by Race, Ethnicity, and Geography, 1997–2017, a publication from the Robert
Wood Johnson Foundation and Urban Institute, states that less education is associated with lower life
expectancy, greater risk for chronic conditions, and poorer self-reported health. These health disparities are
exacerbated in rural communities, with more reports of fair or poor health in 2017 among rural adults with some
(9.5%) or no college (18.7%) than among urban adults with some (6.3%) or no college (14.5%). To help address
SDOH and enable students to pursue postsecondary education, schools can provide human services or refer students
to outside agencies for needed assistance. According to an issue brief from the U.S.
Department of Education, common social services provided by schools include:
- Mental health services
- Health services
- Assistance to address transportation, shelter, clothing, and other material needs
- Parent/family engagement
- Parent/family support to increase awareness of child's progress in school
- Child care for teenage parents
- Immigrant/new arrivals services
- Other services
Unfortunately, schools in rural settings are less likely to offer social services compared to their nonrural
counterparts. The issue brief states that 97% of suburban schools and 98% of city schools provided one or more
social services, while only 93% of rural schools offered these services in 2014-2015.
For information about how educational attainment affects rural residents' health, see the Social Determinants of Health topic