Members of Arizona's Sonoita-Elgin Fire Department participate in a training exercise in the desert. Photo via the University of Arizona Center for Rural Health

Rural communities face a double whammy when it comes to improving public health, says a community-health “coach” who works in both rural and urban areas.

Rural areas tend to start with poorer health conditions than their suburban counterparts. And they frequently have a tougher time working to improve public health indicators because of a lack of civic and physical infrastructure.

But those deficits may disguise a hidden advantage some small communities have when it comes to working on civic issues like public health.

This article is published in anticipation of National Rural Health Day, designated each year as the third Thursday in November by the National Organization of State Offices of Rural Health. #PowerofRural

The 2017 County Health Rankings shows that rural counties are, once again, far less likely to receive high marks for health. Adding to the disadvantage, rural counties are also less likely to have organizations, people, and infrastructure in place that can work together to improve community health, according to Jerry Spegman a community coach with County Health Rankings & Roadmaps. But rural areas’ characteristics also may give them advantage: layers of strong, personal connections that can help communities respond to opportunity.

Urban community-health advocates tend to work through organizational relationships, Spegman said. When they are trying to expand their impact, they are more likely to ask whose organization has a relationship with another organization, he said.

“In the rural communities, it’s much more likely, ‘Who used to babysit for so-and-so’s kid?’ or ‘Who goes to church with so-and-so?’” Spegman said. “There are some advantages in a more rural area that perhaps we take for granted.”

The chart shows the percentage of counties that scored in the top (blue) and bottom (red) health-ranking “quartiles,” sorted by urban and rural geographies. In general , the more rural a county, the more likely it is to be ranked near the bottom (red bars) in its state. Metropolitan counties are more likely to be ranked near the top (blue bars), with the exception that the fringe areas (or suburbs) tended to have higher rankings than the core counties of major metropolitan areas. (Daily Yonder graphic based on County Health Rankings and Roadmaps)

Spegman is one of 10 coaches working in 55 to 60 communities nationwide as part of County Health Rankings & Roadmaps to help local leaders make “sustainable community change” in healthcare policy and programs. Spegman serves the Eastern U.S. and is part of rural projects in the Northeast.

“Because things are smaller and people just know each other more … [rural leaders] are having a little bit more success reaching out to local business leaders and the faith-community folks, and trying to get some of the school people and the healthcare folks to work together.” Spegman said.

“It almost feels easier in a way. Everybody’s connected to somebody. Everybody goes to church with somebody or knows somebody.”

But there’s no denying that rural counties have a long way to go to improve community health. The County Health Rankings scores counties relative to other counties in their state, so there’s no way to compare counties head to head nationally. But the data does show that rural counties are more likely to fall in the bottom fourth (or quartile) of their state rankings, a Daily Yonder analysis shows.

The chart tells the story. The blue columns show the percent of counties that ranked in the top quartile (or the top one-fourth) of counties. These are the counties that are doing the best, and there’s a greater percentage of them clustered toward the left, which is the more urban side of the chart. (This story uses the National Center for Health Statistics rural classification system.) The red columns show the percentage of counties that ranked in the bottom quartile (or the bottom fourth). These are the counties that are doing the worst, and they tend to cluster toward the right side of the chart, which is the more rural side.

Rural counties tended to do worst, while the suburbs of major metropolitan areas tended to do best. Only 14% of rural counties were ranked in the top quartile of their state. By comparison, more than half of all the counties in the suburbs of major metropolitan areas were ranked in the top quartile of their state.

The findings are similar to an analysis that County Health Rankings prepared for the Daily Yonder in 2014.

On the other end of the spectrum, more than a third of rural counties ranked in the bottom quartile of their state, while only 8% of suburbs of major metropolitan areas did.

The rankings are based on the health of residents (measured in things such as longevity and chronic disease), behavioral activities (such as exercise and diet), and environmental factors (measured by access to healthcare or exercise facilities and other community conditions).

Spegman said that a big challenge in working with rural communities is what he called “infrastructure” issues.

“If you live in a metropolitan area and you’re pushing … some kind of policy change, you have not only a multitude of nonprofit organizations to join in and help the cause, but you have multiple media outlets that you can utilize and leverage and amplify your message,” he said. Smaller and more remote communities tend to lack those resources.

“The [rural] coalitions we’re working with have as much smarts and as much passion as any coalition in the city, but they don’t necessarily have the advantages those coalitions in the cities have,” Spegman said.

“We’re working on the same issues as we are in metro areas, but we’re working with coalitions that oftentimes are just playing shorthanded. That, I think, slows down the progress to some extent.”

That doesn’t mean rural communities can’t improve. But progress might manifest in different ways than it does in urban areas.

“It’s an incremental victory and we may be two or three years further down the pike from actually achieving a policy outcome, but we’re not dissuaded from hanging in there because we realize in some of these communities, there’s a lot of groundwork that needs to be laid before you can move forward on policy change.”

Spegman said health policy change may not be as formal in rural areas. “I’m working with a group in West Virginia where a primary focus is just to get the local employers to pay more attention to employee wellness and to promote better food in the cafeteria at the work site or to allow for exercise time or whatever.” That’s a different type of goal than changing state or federal health programs.

Improving community health doesn’t necessarily mean improving the healthcare system, Spegman said.

“The healthcare system, after all is there to treat sick people. What we’re trying to do is get ahead of the sickness.”

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