“the conditions in the environments where people are born, live, learn, work, play, worship, and age that
affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Income-level, educational attainment, race/ethnicity, and health literacy all impact the ability of people to
access health services and to meet their basic needs, such as clean water and safe housing, which are essential
to staying healthy. Rural residents are more likely to experience some of the contributing social factors that
impact health, such as poverty. The impact of these challenges can be compounded by the barriers already present
in rural areas, such as limited public transportation options and fewer choices to acquire healthy food.
This guide focuses on the barriers and challenges that rural residents experience, discussing the impact of
and documenting rural differences related to:
Income, employment, and poverty
Educational attainment and literacy
Sexual orientation/gender identity
Adequate community infrastructure, which can ensure public safety, allow access to media, and promote
Environmental health, including water quality, air quality, and pollution
Access to safe and healthy homes, including issues related to energy costs and weatherization needs,
lead-based paint, and other safety issues
Access to safe and affordable transportation, which can impact both job access and healthcare access. Unsafe
transportation, such as vehicles in poor condition, may increase risk of injury.
How does Rural America differ from the nation as a whole, regarding the social determinants of health?
Rural America experiences many inequities compared to the nation as a whole. Often rural residents have fewer
individual resources and, on average, are poorer and less educated. This Economic Research Service chart shows
the ongoing gap between metropolitan and non-metro poverty rates:
Additionally, many rural residents face barriers related to access to housing, transportation, food, and water
that are safe, healthy, and affordable. These barriers can impact all residents, though they are particularly
problematic for those already struggling financially.
Rural communities also face many environmental challenges. Hazardous materials often end up in remote areas
where the land is cheap and fewer people overall are put at risk. Rural industries like mining and farming bring
with them their own dangers and environmental impacts.
The Geography of Need:
Identifying Human Service Needs in Rural America, a 2011 publication from the Rural Policy Research
Institute (RUPRI), identified 8 demographic and 4 economic characteristics that are indicators that a community
has high human service needs. Demographic indicators included minority population, population 65 and older,
veterans, adults without a high school diploma, and other factors. Economic indicators included poverty,
households without vehicles, households receiving SNAP (food stamps) benefits, and income received from
government transfer programs. Based on this set of 12 indicators, only 9% of metropolitan counties had three or
more risk factors, while among non-metropolitan counties, 17.3% of micropolitan (large rural) and 31.2% of
non-core (small rural) counties had three or more risk factors.
A 2014 article in the Annals of Internal Medicine, Neighborhood Socioeconomic Disadvantage and
30-Day Rehospitalization, examined rehospitalizations based on patients' place of residence. The study
used the Area Deprivation Index (ADI – data available via the
Neighborhood Atlas), a set of measures
of socioeconomic deprivation such as poverty level, educational attainment, and household information, to
compare neighborhoods. Patients in the study who lived in the most disadvantaged neighborhoods were at higher
risk for rehospitalization, and nearly one-third of rural patients lived in such locations. One contributing
factor related to rural readmissions that was not covered in this study is the lack of home health and other
supportive services for discharged patients.
A variety of well-being indexes and tools share data and rankings based on factors that include social
determinants of health. Some examples include:
What is being done to address the social determinants of health for rural residents?
An ever-increasing number of federal agencies, foundations, and health-related organizations are taking an
interest in the social determinants of health in general, and many are looking specifically at rural areas.
Just a few of these undertakings include:
2015 and 2016 meetings of the National Advisory Committee on Rural Health and Human
Services in Kentucky,
Mexico looked at rural poverty and the social determinants of health. The December 2015 NACRHHS
policy brief, Child
Poverty in Rural America, summarizes their findings from the Minnesota meeting. A January 2017
policy brief, Social
Determinants of Health, summarizes their findings from the New Mexico meeting and offers policy
recommendations for addressing the social determinants of health in rural communities.
The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and
Evaluation issued December
2020 reports to Congress on Medicare's value-based purchasing programs that looked at a variety of
social factors that impact health, including rurality.
How do poverty and unemployment impact health in rural communities?
Poverty is an ongoing problem for many rural areas. The 2014 RUPRI publication Persistent Poverty Dynamics:
Understanding Poverty Trends Over 50 Years reports on counties with poverty rates above 20% over the
past 50 years. Sixty-four percent of non-core (small rural) counties are persistent poverty counties, compared
to 22% of micropolitan (large rural) and 14% of metropolitan counties.
Rural areas have higher poverty rates, particularly among children and the elderly:
Average income is lower in rural areas. The nonmetro median household income in 2021 was $53,750, compared to
$70,784 for the nation as a whole, as reported in the U.S. Census Bureau's Income in the
United States: 2021.
A May 2016 report from the USDA Economic Research Service, Understanding the Rise in Rural Child
Poverty, 2003-14, identifies factors related to the ongoing crisis of rising child poverty, including
the impact of income inequality. Growing
Up Rural in America, a 2018 Save the Children report, describes the impact of poverty on rural children
and provides state-by-state rural child poverty data. It also addresses a number of other social determinants
impacting rural children, including malnutrition, teen births, and high school drop outs.
Among the impacts of poverty on health is the barrier it creates in paying for healthcare services and meeting
basic living needs, such as food and shelter, that are necessary to be healthy. Poverty also exerts an influence
over health in the stress it causes. A 2012 Psychological Science article, Poverty and Health: The Mediating Role of Perceived
Discrimination, reports on a longitudinal study of rural adolescents. The study looked at a range of
health measures that can have long-term health consequences, such as blood pressure, cortisol levels, and body
mass index. For study participants, poverty was associated with greater perceived discrimination, which in turn
was associated with worse health measures.
The availability of good jobs — jobs that pay a living wage, offer adequate hours, and include benefits
health insurance coverage and paid sick leave — can also impact rural residents' ability to stay healthy.
The 2013 Carsey Institute report Middle-Skill Jobs
Remain More Common Among Rural Workers describes the continued rural reliance on mid-level jobs that
require on-the-job training or apprenticeship. Urban areas tend to have a similar percentage of low-skill jobs
as rural areas, fewer mid-skill jobs, and more high-skill jobs that come with bigger paychecks and benefits. In
addition, workers with a college degree may find they earn less than their counterparts who work in urban
areas, though those with less education may fare better in rural areas:
Annual Median Earnings, Age 25 and Older, by Education Level
Nation as a Whole
All education levels
Less than high school graduate
High school graduate
Some college or associate's degree
Graduate or professional degree
Source: Table B20004,
2017-2021 American Community Survey 5-Year Estimates
A 2011 brief, also from the Carsey Institute, Rural Workers Have Less
Access to Paid Sick Days, reports that 44% of rural workers lack access to paid sick leave, compared to
34% for suburban workers, and 38% for central city workers. Rural workers also fare worse in terms of paid
leave to care for sick children.
How does early childhood development act as a social determinant? What resources are available to address this?
Early childhood development programs have the potential to impact health at a young age and set children on a
path to growing up to be healthy adults, whatever background and resources their families have. According to Healthy
“Early childhood development and education are key determinants of future health and well–being.
disparities in access to early childhood development and education opportunities can greatly bolster young
children's future health outcomes.”
Responsive caregiving from parents and other direct caregivers
Early learning opportunities
Optimal nutrition for infants and young children
Maternal mental health
How do rural areas fare on key factors impacting early childhood development?
Disparities in Rural Women, from the American College of Obstetrics and Gynecologists Committee on
Health Care for Underserved Women, reports on decreasing access to obstetric services in
rural areas. More than half of rural women live more than 30 minutes from a hospital offering delivery and
nursery services. Rural women also tend to begin prenatal care later than suburban women. A
2020 infographic from the University of Minnesota Rural Health Research Center, Loss
of Hospital-based Obstetric Services in Rural Counties in the United States, 2004-2018, demonstrates
that the percentage of rural counties with hospital-obstetric services decreased from 82 to 77% in
micropolitan counties, and 40 to 27% in noncore counties.
Infant mortality is higher in nonmetropolitan counties, with a 2019 rate of 6.4 per 1,000
in nonmetro counties compared to 5.4 in metro counties:
A 2018 Center for American Progress report, America's Child Care
Deserts in 2018, found that 59% of rural communities in the United States are classified as child
care deserts, or areas lacking in adequate child care center spaces for children under age five. According
to a Bipartisan
Policy Center (BPC) survey conducted in 2019 by Morning Consult, nearly 62% of families living in
rural areas said they had difficulty finding quality child care to fit their budget; however, less than
half of families living in urban areas said the same.
Rural Head Start programs also have difficulty maintaining an adequately trained workforce of early
childhood educators, according to a 2012 National Advisory Committee on Rural Health and Human
Services policy brief, Challenges
to Head Start and Early Childhood Development Programs in Rural Communities. They also face
challenges providing the transportation necessary to get rural children to both the
preschool and healthcare services required for Head Start. Some Head Start programs are home-based, and use
a home visiting model to
bring services directly to families, which can be an effective delivery method in rural areas.
Programs that support full-day, full-year quality childcare, with healthy food, physical
activity, appropriate learning opportunities, and role models for healthy emotional and social well-being.
For example, Healthy Kids, Healthy Future provides tools
for childcare and early education providers to help children develop healthy habits.
Early childhood education programs like Head Start
and Early Head Start, which help low-income families and children get ready for school through
preschool education, health, and social services.
What are the roles of literacy, health literacy, and educational attainment in the health of rural residents?
One of the most obvious impacts of educational attainment is that lower education levels impact earnings. This
chart from the USDA Economic Research Service shows the relationship of education levels and median earnings
for rural adults:
However, income levels are not the only impact that education has on well-being.
Less likelihood of having health screenings and prevention services
Higher risk of hospitalization
Poorer health status
Health literacy is the degree to which patients understand basic health information such as following
instructions from a healthcare provider, managing a chronic illness, or taking medication properly. Rural
residents are at risk for low health literacy because they have lower educational levels as
compared to residents of metropolitan areas. Low health literacy is a particular problem for people in poverty
and people with limited education or English proficiency. According to the book, Health Literacy Interventions and Outcomes, limited
health literacy is associated with a lower likelihood of using preventive health services, a greater likelihood
of taking medicines incorrectly, and poor health status.
Learn more about how rural providers can help address health literacy in these Rural Monitor articles,
which highlight health literacy tools and resources:
Many studies have shown that educational attainment, beyond basic literacy, also impacts
health. A 2006 report for the OECD's Centre for Educational Research and Innovation, Measuring the Effects
of Education on Health and Civic Engagement: Proceedings of the Copenhagen Symposium, includes the
chapter What Are the Effects
of Education on Health? This document reviews the evidence that more years of education result in:
Better health outcomes, including birth outcomes
Higher use of preventive healthcare
Increased life expectancy
A 2011 Population and Development Review article, The Education Effect on Population Health: A
Reassessment, points out that many assume education is merely a stand-in for better socioeconomic
status. The authors examined a wide range of studies that looked at education and health, and found that when
socioeconomic status was controlled for, the positive impact of education persisted. A 2014 Center on Society
and Health issue brief, Health
Care: Necessary But Not Sufficient, reports that, for a group of patients with the same access to
healthcare via coverage by the same healthcare plan and providers, those with less education had poorer health.
The role of education, literacy, and health literacy on health is critical for rural communities, where
educational attainment lags behind the nation as a whole.
Rural programs to help students complete high school could have a long-term impact on the health of the rural
population. Programs to help adults with low literacy improve their reading skills likewise could have health
benefits for participants.
What types of environmental hazards do rural communities face that endanger the health of their residents?
Many rural areas face water quality, air quality, and other environmental challenges. Some of these problems are
due to limited infrastructure to support public health, while others relate primarily to the impact of
agriculture, logging, mining, and other industries on the environment.
In addition to the infrastructure challenges, rural water quality may also be impacted by industrial pollution.
The Environmental Protection Agency, in a 2015 publication Ground Water Contamination
– Getting Up to Speed, identifies the following sources of contamination, all of which may impact
Waste from active and abandoned mines
Agricultural sources such as pesticides and manure
Improperly constructed or abandoned wells
Underground and aboveground storage tanks
Oil and natural gas production, including hydraulic
fracturing (fracking), also can negatively impact rural surface-water and groundwater quality.
Outdoor air quality is critical to everyone's health, and is particularly a concern for children, the
elderly, people who have underlying health concerns, and those who are frequently outdoors, with health-related impacts of air pollution that include:
Asthma and other breathing problems
Pneumonia and bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
Heart disease and stroke
Rural areas face a range of air pollutants caused by:
The West Virginia Rural Health Research Center, which was funded by the Federal Office of Rural Health Policy
from 2008-2013, undertook a number of projects related to environmental health. While the center is no longer
in existence, an archive of its environmental health
projects and publications is available.
How does the quality of housing available in rural areas impact people's health?
While the quality of rural housing has improved in recent decades, there are still pockets of rural America
where the housing available doesn't meet the basic health needs of the population. Taking Stock: Rural People,
Poverty, and Housing in the 21st Century, a 2012 report from the Housing Assistance Council (HAC),
identifies several rural high poverty populations that face particular housing challenges, including
farmworkers and people living in Appalachia, the Mississippi Delta, on Native American lands, and in the
U.S.-Mexico border region.
Some of the key housing concerns that impact health include:
Plumbing and wastewater systems (or lack thereof), which can impact water quality and contribute to
Heating and cooling methods, which impact indoor air quality and safety, for example through the use of
Lack of smoke alarms, carbon dioxide, and carbon monoxide detectors
Weatherization needs and energy costs, which impact whether a house can be maintained at a temperature
healthy to its inhabitants
Safety concerns such as lead-based paint, mold, and pests
Overcrowding, which can spread communicable disease and also negatively influences issues such as substance
abuse and domestic violence
HAC's Taking Stock report
identifies a number of concerns related to rural housing quality:
30% of the nation's housing without piped hot and cold water are in rural areas.
Some rural residents lack even basic plumbing, with this burden falling disproportionately
on those living in colonias on the U.S.-Mexico border, on Native American lands, in Central Appalachia, and
Overcrowding is a problem among some rural populations, particularly Hispanic residents and
Rural minority populations are twice as likely as non-Hispanic White populations to live in substandard
Rural renters are more likely to live in substandard housing and to experience multiple housing problems
related to affordability, quality deficiencies, and crowding, compared to rural homeowners.
Drinking water from sources not covered by the Safe Water Drinking Act
Reliance on septic tank systems to treat wastewater, which can result in contamination of the water supply
Use of fuel-fired heat sources, such as coal, fireplaces, and wood stoves, which put rural residents at risk
for fires. These types of heat sources, if not properly vented, may result in poor indoor air quality.
For additional information on living conditions along the U.S.-Mexico border, see RHIhub's Rural Border Health topic guide.
How does rural homelessness impact health?
Rural homeless families and individuals face a variety of challenges accessing healthcare. The lack of a stable
address can make it difficult to enroll in programs they are eligible for, such as Medicaid. Even when coverage
is obtained, rural people who are experiencing homelessness may face challenges finding a healthcare provider.
Many need help with mental health and substance abuse problems, and the availability of these services is often
limited in rural areas.
in Rural America, a 2014 policy brief from the National Advisory Committee on Rural Health and Human
Services (NACRHHS), offers an overview of how homelessness impacts rural people. Families with children are a
bigger proportion of the homeless population in rural areas, compared to urban areas. A 2019 report from the
Institute for Children, Poverty & Homeless, Student Homelessness in
Rural America, reports that homelessness among rural public school children is growing at four times the
national rate, with an increase of 11% from the 2013-2014 school year to the 2016-2017 school year. The children
in families experiencing homelessness are at risk for a range of health-related consequences. According to a
2012 Child Trends publication, When
the Bough Breaks: The Effects of Homelessness on Young Children, children who have unstable housing are
more likely to experience:
Emotional and behavioral problems
Negative impacts on their physical, emotional and cognitive development
Missed educational opportunities and poorer academic performance
Acute and chronic health problems
Exposure to violence
The NACRHHS brief describes the nature of rural homelessness and the barriers faced by the homeless in rural
areas. Rural homeless people are more likely to live in substandard housing, in vehicles, or doubled up with
family or friends, rather than on the street. The barriers to addressing rural homelessness include:
Difficulty finding transportation to reach services
A sense of isolation
Lack of homeless-specific services in their community
Funding programs that lack the flexibility to meet the particular needs of rural areas
Lack of employment opportunities to help people become self-sustaining
Difficulty applying for services, either due to lack of a permanent address or lack of Internet access
Shortages of affordable housing
Since 2010 Pathways Vermont has addressed the homelessness challenge by using an evidence-based, cost-effective
housing model, the rural-focused Housing First program, that offers a rapid re-housing program and support
services to individuals with mental health and substance use conditions. Pathways also partners with state and
community organizations to expand their reach to other populations including families at-risk, veterans, and
incarcerated individuals transitioning into society to offset the negative effect of prolonged exposure to
homelessness. The Rural Monitor article, Looking at the Rural Homelessness Experience: Definitions, Data, and
reports on how this approach is helping the state's rural homeless population. The Rural Monitor also
features other programs aimed at addressing rural
How can a lack of transportation options impact low-income, frail elderly, and disabled rural residents?
People living in rural areas tend to be dependent on cars for transportation. These regions often lack the types
of public transportation available in more populous areas. Even if there is some form of bus service, it is less
likely to run at convenient times for getting to a job, taking children to daycare, or accessing needed
healthcare. Of workers 16 and over who live in rural areas, only 0.4% traveled to work by public (non-taxi)
transportation, compared to 4.15% for the U.S. as a whole, based on 2017-2021 American Community Survey data (Table
Low-income rural residents who are fortunate enough to own a vehicle may find the costs of gas and maintenance
make it difficult to maintain reliable transportation. Poor rural residents' vehicles are often older and
unreliable, and rural drivers are likely to be driving longer
distances on secondary roads. Depending on the region, weather and industry may also impact road safety.
These factors contribute to the higher risk of traffic injury and death for rural residents.
For those who are not able to drive due to physical limitations, lack of transportation options in rural areas
can make it difficult to get to the grocery store and pharmacy, take advantage of social interactions that
support good mental health, and access healthcare services.
How do rural residents experience food insecurity?
Many rural residents have fewer choices to buy fresh and affordable food, making it difficult for them to
purchase the nutritious food needed to stay healthy. For those on limited incomes and with limited
transportation options, it is even more difficult to meet nutritional needs. According to the USDA Economic
Research Service report, Household
Food Security in the United States in 2021, 10.8% of rural households are food insecure
— lacking access to sufficient food — compared to 10.2% for the nation as a whole. Households with
children are impacted even more, with 13.7% of rural households with children being food insecure, compared to
What additional challenges do rural racial and ethnic minority populations face related to staying healthy?
This 2019 series of policy briefs from the Rural & Minority Health Research Center looks at social
of health for specific rural racial and ethnic minority populations. Each brief provides socioeconomic data,
information on types of rural communities where these populations are concentrated, access to healthcare
services, risk factors, and more:
Many rural minorities face discrimination and racism that can result in stress, negatively impacting their
health. Unfair treatment may impact rural minorities' ability to fully access services to support health,
including healthcare services.
A 2020 Health Affairs article, Discrimination: A Social
Determinant of Health Inequities discusses discrimination as a social determinant of health and
its contribution to health inequities in people and communities of color. Research noted that discrimination
impacts health in 3 major ways: psychosocial stress, access to health and social services, and violence and
bodily harm, which may interact with one another. Discrimination can result in:
Cultural beliefs can also act as a social determinant. A belief might undermine health. For example, not
expecting a long lifespan may result in life choices that don't support health. Cultural beliefs may also serve
as barriers to connecting with healthcare providers.
Culture as a Social Determinant of Health, a 2012
paper commissioned by the Institute of Medicine's Roundtable on the Promotion of Health Equity and the
Elimination of Health Disparities, discusses how a healthcare system that doesn't respect the beliefs and
culture of Native American patients may result in patient experiences that include:
Patients not following healthcare providers' advice and instructions
Reluctance to use the healthcare system
An experience of alienation, fear, and disrespect
Healthcare providers, in turn, may misunderstand their patients, assuming they are not interested in their own
health or not able to follow instructions. The development of cultural competence is a key method for healthcare
providers to help better address the needs of minority populations.
Examples of rural communities working to address these challenges include:
Good Health and Wellness in Indian Country, a CDC
initiative supporting tribes and tribal organizations implementing culturally adapted, community-selected
strategies to address health literacy, nutrition, physical activity, and more.
How do sexual orientation and gender identity impact health for rural residents?
Rural lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ+) residents face a range of challenges
to staying healthy related to their sexual orientation and gender identity. A May 2016 Rural Monitor
article, LGBTQ Healthcare: Building
Inclusive Rural Practices, describes some of the barriers to healthcare that rural LGBTQ+ people face,
Not accessing healthcare due to anticipated, internalized, and enacted stigma
Privacy and confidentiality concerns
Patients not disclosing sexual orientation or gender identity to a provider, which could impact provision of
needed urgent and preventive care
Limited training of healthcare providers related to LGBTQ+ health-related issues
Provider bias or discrimination, which can be more problematic in a rural area with fewer providers to
The NACRHHS policy brief, The
Intersection of Rural Poverty and Federal Human Services Programs, features case studies of two
communities using strategies to integrate services to make it easier for people experiencing poverty to access
the range of services they need. RHIhub's Rural Services Integration
Toolkit is a guide to developing programs that integrate rural health and human services to better meet
rural residents' needs. The toolkit identifies 9
programs in a variety of settings and regions that are taking different approaches to services
State human service agencies provide varying degrees of access to services and to assistance programs via online
portals. When available, together with adequate broadband service and other necessary infrastructure, access to
human services is faster and easier. Some agencies also offer mobile van services to rural residents, although
these tend to be confined to specific populations such as migrant workers.
What can healthcare providers do to help address the social determinants of health for their patients?
The American Hospital Association (AHA), in an invited commentary in the September 2018 issue of Academic
Medicine — Ensuring Access to Quality
Care in Vulnerable Communities — identifies “addressing social determinants of health”
as an important
strategy for hospitals. Providers can screen for health-related social needs, help patients access community
services, and align local services with patient needs. AHA offers a collection of guides to help hospitals
address food, housing, and other social determinants of health in their communities:
How can rural medical-legal partnerships help address health-harming legal needs?
An April 2022 study from the Legal Services Corporation, The Justice Gap: The Unmet Civil Legal Needs of Low-income Americans,
reports on legal needs related to healthcare access, the impact of COVID-19 on American families, and other
issues that influence health, such as housing and poverty. It includes an infographic highlighting the
prevalence of civil legal problems and the need for legal help for people in rural areas.
Medical-legal partnerships help healthcare providers and lawyers work together in addressing patients'
health-harming legal needs. The National Center for Medical-Legal Partnership's How Legal Services Help Health Care
Address Social Needs, identifies the following issues where legal aid interventions can help:
Appealing denial of benefits, such as health insurance, disability benefits, and food stamps
Addressing housing quality, housing subsidies, and access to utilities
Protecting workers from discrimination
Helping veterans with discharge status
Managing family law concerns related to domestic violence, custody, and other issues
How do telephone services and broadband access impact health?
Access to basic telephone service and smartphone technology helps ensure that rural residents can:
Make appointments with healthcare providers and other service providers
Contact emergency medical services
Receive health coaching and other disease management services available by phone
Stay in touch with family and friends, which may allow rural older adults to stay independent longer
Connectivity now plays a much greater role in healthcare, with broadband access offering the potential for
rural residents to:
Learn about health topics online
Access their electronic health records
Participate in home monitoring and other telehealth services
Have face-to-face connections to distant family and friends
Learn about and access government programs
Despite the promise of this technology, not all families are in a position to take advantage of these
opportunities. According to the Pew Research Center's August 2021 article, Digital
Gap Between Rural and Nonrural America Persists, only 72% of rural households have home broadband
access, compared to 77% of urban and 79% of suburban households. Mapping
Broadband Health in America, a visualization tool from the Federal Communications Commission (FCC),
shows broadband access as it relates to health factors and demographics and includes rural data.
In many rural communities, the local library provides access to public computers and the internet, as well as
training on how to search for health and other information. Rural
Libraries in the United States: Recent Strides, Future, Possibilities, and Meeting Community Needs, a
2017 report from the American Library Association, documents the availability of different services, finding
that rural libraries typically offer slower broadband than their urban counterparts but are just as likely as
urban libraries to provide public Wi-Fi.
The Federal Communications Commission's Lifeline Program
can help make telephone service more affordable for low-income people. To better meet the expanding need for
connectivity, in March 2016 the program was expanded to also support discounted broadband for those who qualify.
The FCC's Connect America Fund (CAF) aims to
accelerate infrastructure development by subsidizing telephone companies to add broadband service where it is
not yet available, including rural areas. Connecting
Americans to Health Care is an FCC initiative supporting telehealth focused on the potential of remote
patient monitoring and mobile health applications to help rural patients.
How do the social determinants impact healthcare access for rural residents and how does healthcare access
itself act as a social determinant of health for rural people?
Social determinants that impact access to healthcare include:
Poverty, income, and employment status, all of which contribute to whether an individual has:
Health insurance coverage, whether through an employer, a public program, or their own purchase
The ability to pay out-of-pocket costs such as co-pays and prescription drug costs
Access to dental care, either through dental insurance or the ability to pay for treatment
Time off work to go to an appointment
A means of transportation to visit a healthcare provider
Resources to afford retirement and pay for healthcare and health-related expenses in retirement,
including costs related to aging in place
The health literacy skills to effectively communicate with healthcare providers and self-manage their
Healthcare access can itself act as a social determinant for rural residents. Living in a rural
community that has limited health services available is an added barrier to achieving good health. The burden
may be a lack of a specific kind of service, such as dental or behavioral health services, or may be related to
the hours that a service is available, for example weekends and evenings. A June 2016 issue brief, Impacts
Affordable Care Act's Medicaid Expansion on Insurance Coverage and Access to Care, found that increased
healthcare access through Medicaid expansion improved individuals' financial well-being.
Certain public health services, which support population health, may also be less available in rural
For example, rural residents have less access to fluoridated water. While this is partly because they are more
likely to be on well water, rural water systems are also less likely to be fluoridated. For more information on
fluoridation, see Where can I find information about fluoridation in
rural community water supplies? on RHIhub's Oral Health in Rural Communities topic guide. For additional
information on rural public health services, see RHIhub's Rural Public Health
Agencies topic guide.
A lack of healthcare and public health access may also deter businesses from locating in or expanding in a rural
community, meaning fewer jobs that could lift rural residents up and make it easier for them to achieve good
health. A 2006 Health Services Research article, The Effect of Rural Hospital Closures on
Community Economic Health, reports that communities where the sole hospital closed saw both a reduction
in per capita income and an increase in unemployment.