The health of rural communities has been declining for decades. From 1999-2019 age-adjusted death rates for 10 leading causes of death were higher in rural areas, including heart disease, cancer, unintentional injuries, stroke, diabetes, kidney disease, Alzheimer disease, respiratory illness (influenza, pneumonia, etc.) and suicide. Rural communities are often blamed for their poor health – blamed for having inadequate health care resources, blamed for unhealthy behaviors, and blamed for poor health outcomes – without regard to social factors that influence health in many ways.
But social determinants such as economic conditions, employment opportunities, housing, and access to educational institutions, transportation, and internet connectivity play a role in community health. Social determinants are powerfully influenced by law and policy at local, state, and federal levels. The complexity of law, policy, and regulations, and an apparent need to have an attorney by your side, may keep rural communities from discussing many social determinants of health. Fortunately, a useful set of tools – aiming to improve deliberations about social determinants and rural communities’ health – was recently made available, free of charge, online.
ChangeLab Solutions– a nonpartisan, nonprofit organization — has published a portfolio of tools that inform and support local and state decision makers’ uses of policy to improve rural communities’ health. Changelab’s Toward Racial Equity & Rural Prosperity, Legal & policy resources for rural communities provides brief guides on a number of social determinants of rural health such as the following:
- Rural Policymaking, a collection of strategy briefs and case studies, on Advancing Racial Equity in Rural Communities and Advancing Rural Prosperity.
- Water Access in Rural Communities.
- Improving Housing Quality in Rural Places.
- Broadband Connection in Rural Communities.
- Identifying Equitable Policies for Rural Places.
- Equitable Policymaking in Rural Communities, an archived recording of a panel discussion.
- Promoting Health Equity in Rural Communities.
While this is by no means a complete list of social determinants, it is an excellent start.
Changelab historically began with law and policy around tobacco control programs and now focuses on “fundamental drivers of health inequity,” including racism, poverty, disparities in political power, and barriers to public engagement and participation in policy. Changelab’s aim is to demystify law and policy, for anyone, especially for local jurisdictions without access to legal and policy experts.
Here are some highlights from Changelab’s portfolio:
Several of the guides in the portfolio deal with practical social determinants: water access, housing quality, and broadband connection. Safe and healthy housing is a critical social determinant of health. Many rural communities have active chapters of Habitat for Humanity or other groups that expand housing supply. Changelab’s guide Improving Housing Quality in Rural Places focuses on preserving and improving quality of housing. Their discussion of housing quality intersect with discussion in other practical tools about Water Access and Broadband Connection.
“Quality housing is a foundational element in retaining residents in rural communities as well as attracting new residents … Quality housing can also help attract and retain new workforce talent, including remote workers, to rural communities … funding for quality housing can catalyze investment that supports more jobs, positive health outcomes, and the revival of rural communities.”
Changelab links other tools – for example, their Healthy Comprehensive Plan Assessment Tool [ l ] – that may be more frequently used in metropolitan areas but may be helpfully adapted for rural areas.
Changelab also uses links to sustain interest and to get you to what may be most useful. For example, the guides link to groups like the Center for Rural Innovation, which has resources for rural communities to improve capacity to attract and build “tech economy ecosystems,” and the Community Strategies Group (CSG) of the Aspen Institute, which offers the Thrive Rural Framework. The Community Strategies Group also has resources for supporting “thinking and acting that are powerful enough to move communities to action, build shared purpose across regions, and change the status quo … to achieve equitable rural prosperity that is both sustainable and durable.”
One of the most impressive tools in Changelab’s portfolio is Policy Table: State & Local Policies with Potential to Advance Racial Equity & Rural Prosperity [PDF]. The document categorizes, lists, and describes 50 or more policy examples. The resource was adapted from CSG/Aspen’s Thrive Rural Framework.
An area for future development in Changelab’s tool kit might be looking at the impact of age and disability, or different abilities, in rural health. Changelab’s focus on racial equity misses critical intersections with other social circumstances requiring attention to equity. That is problematic for rural communities where aging and disability ought to be prominent concerns for policy. Rural residents are dramatically more likely to experience disability. Resources exist that could help address this need, for example the Rural Institute for Inclusive Communities, housed at the University of Montana:
Changelab has provided an excellent portfolio of tools for rural communities to use and adapt in ways that best suit local needs, values and priorities. As communities use these tools and provide feedback – including their own stories of success — the toolkit will only get stronger.
Edward Strickler Jr., MPH, is a member of the Ethics Section of the American Public Health Association and a retired programs coordinator for the Institute of Law, Psychiatry and Public Policy at the University of Virginia School of Medicine. He lives in rural Virginia.