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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?

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

Other resources providing more information about the Whole School, Whole Community, Whole Child model are available from the CDC and Association for Supervision and Curriculum Development (ASCD). For an example of this collaborative model, there is a work group in Kentucky that has developed health initiatives for the rural Appalachian region.

SPARK is a research-based K-12 school health organization that provides programs to teachers and recreation leaders on physical activity and health promotion programs to counter childhood obesity and support lifelong wellness. 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 have a reported MBDD diagnosis compared to 15.2% of children with a reported MBDD diagnosis of same age group in urban areas. Schools are the most common location for children to receive mental health services. 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.

What types of healthcare services can be provided in rural schools?

School Nurses

School nurses provide health services in the rural school setting. They work with parents, teachers, and other health professionals to provide a plan for the health needs of the school. School nurses also provide services for students with special health needs such as prescription medications, asthma inhalers, and catheters so that those students can attend school. Nurses in schools 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 was 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 or hospital, 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 about 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 students?

USDA's Tools for Schools provides subject-specific resource materials to help schools meet federal nutrition and compliance standards. Information offered includes nutrition education curricula and literature, food buying guides, 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 5 elementary schools and 1 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.

In rural Southeast Alaska, the Hoonah Fun and Fit Partnership was developed to address the high rates of obesity in rural Alaska by encouraging good nutrition, increasing access to physical activities, and by raising awareness of diabetes. This partnership of school district representatives, local healthcare staff, and the Hoonah Indian Association worked together to promote nutrition by adding locally caught fish to school lunch menus, planting vegetable gardens, and by evaluating school menus regarding calories, fruit and vegetable servings, and sodium content.

The Coordinated Approach to Child Health in the Upper Peninsula (CATCH-UP) located in rural Western Michigan's Upper Peninsula was developed to reduce the incidence of obesity and the risk of chronic disease for children aged 5-12 by increasing physical activity and healthy eating. Teachers and afterschool workers received training by health educators on the Coordinated Approach to Child Health (CATCH) model they could use in the classroom and in school health committees. CATCH-UP served more than 3,500 children in 12 independent school districts by teaching health and nutrition through the use of games, increasing exercise through equipment packs with balls, hoops, and flags, and by developing safe routes to school for walking and biking.

For more examples of CATCH implementations and other strategies that rural schools can use to improve healthy food choices, RHIhub compiles rural models and innovations regarding food and hunger.

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 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 Cascade Coordinated Approach to Child Health (CATCH) Program is a rural program that engaged 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 and increased physical activity for preschoolers to 5th graders.

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 and SPARK are two popular health education programs that teach health promotion activities during the school day as well as encourage positive behaviors outside of school.

It is important for rural schools, teachers, and coaches to take an active role in preventing 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.

According to the article, Rural Schools, Medical Facilities Partner for Athletic Training Services, some rural schools in Montana and Ohio are receiving free athletic training services from hospital staff. In exchange, the hospital receives exclusive marketing and sponsorship rights to the school's sporting events. Since many rural schools do not have an athletic trainer, this is an opportunity for injured student athletes to be examined and given instructions on exercises for rehabilitation.

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 display 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 or Health Occupations Students of America (HOSA) clubs
  • Opportunities for students to learn about medical procedures using robotic simulators
  • Assistance to students preparing for college admission tests, including the Medical College Admission Test (MCAT)

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 2013-2014 School-Based Health Alliance report, more than half of SBHCs in the US 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. The National Survey of Children's Health 2011-2012 found that rural children were more likely than their urban peers to have experienced ACEs such as divorce, a family member who has mental illness or a substance abuse problem, witnessing domestic violence, or had an incarcerated parent. ACEs can cause mental, emotional, and physical health issues for impacted children, and are likely to impact their health as adults.

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 define trauma informed care as:

“A program, organization, or system that is trauma-informed:

  1. Realizes the widespread impact of trauma and understands potential paths for recovery;
  2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
  3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
  4. 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 that involved 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.

Last Reviewed: 1/4/2018