Rural Schools and Health
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 receive care. Rural students may face barriers to accessing healthcare services, including long distances to providers, lack of 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?
- How can healthcare services be provided in rural schools?
- What programs are available to provide children with healthy and affordable meals?
- What are strategies that rural schools can use to increase the nutritional value of foods served to their students?
- What are strategies that rural schools can use to increase the amount of physical activity their students get during the school day?
- What health education and prevention programs can be implemented in a rural school to improve students' knowledge of how to maintain their own health?
- How can schools promote population health within their communities?
- How are schools addressing the shortage of health professionals and getting students interested in health careers?
- What funding programs are available to support school-based health services?
- How can rural schools work to address and prevent Adverse Childhood Experiences (ACEs)?
- What role can schools play in providing human services to address social determinants of health?
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 physical activity.
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:
- Health education
- Social and emotional school climate
- Physical education and physical activity
- Health services
- Nutrition environment and services
- Counseling, psychological, and social services
- Employee wellness
- Family engagement
- Community involvement
- Physical environment
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 services. According 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 prevent suicides.
Oral health is another area where schools can play a role in improving children's health and helping them 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 writer.
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 over 30% of survey respondents worked in at least one school in a rural area.
The 2016 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 summer too…”
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:
School Breakfast Program
Assistance to states to operate breakfast programs in schools and residential childcare programs.
National School Lunch Program
Nutritious low-cost or free lunches to children in schools and residential childcare programs.
Special Milk Program
Reimburses schools for milk they serve to children who do not participate in other federal meal service programs.
Child and Adult Care Food Program: Afterschool
Nutritious meals and snacks for afterschool programs served in a group setting to children and teenagers.
Summer Food Service Program
Provides funding to local sponsors who want to combine a meal program with a summer activity program for children 18 years old and younger.
What are strategies that rural schools can use to increase the nutritional value of foods served to their students?
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. For example, Focus on Agriculture in Rural Maine Schools (FARMS) is a farm-to-school program developed in 2008-2009 that connects children, cafeterias, local farms, and communities to promote healthy meals for more than 1,500 children. FARMS started in one school, and is now in five elementary schools and one private secondary school. This program worked with superintendents, principals, and school board members, and included school food service in the discussions to grow the program.
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 members.
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 of 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 activity.
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 careers?
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 Program, HRSA's 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 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 Services 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; and
- 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 guide.
Last Reviewed: 3/16/2021