The chart shows the percentage of counties in each geographic category that rank in the top and bottom quartiles. For example, for the first category, 40% of large central metro counties are in the top quartile and 18% are in the bottom quartile. The percent of counties in the top quartile peaks in the suburbs of major metropolitan areas. From there, as the counties become more rural, the percentage of counties in the bottom quartile climbs. (Daily Yonder using 2018 County Health Rankings)

When it comes to your health, place matters. If you live in a rural county, the bottom-line truth is that you’re less apt to be healthy than if you lived in a more urban one. A couple of recent reports shed some light on both the issues and potential solutions. 

According to the 2018 County Health Rankings, published by the Robert Wood Johnson Foundation in partnership with the University of Wisconsin Population Health Institute, rural counties continue to lag behind more urbanized ones in factors that play a critical role in a community’s overall health. These include child poverty, low-birthweight babies and teen birth rate. 

But rural communities have within their DNA the resources to rise to these challenges.  

In another report, titled “Exploring Strategies to Improve Health and Equity in Rural Communities,” researchers at the University of Chicago’s NORC Walsh Center write that while much of the research exploring rural health issues in the U.S. focuses on disparities – increased health risks “related to geographic, socioeconomic, environmental and other factors” – seldom is attention paid to the strengths and assets within these communities that can be, and often are, deployed to improve health.  

These communities’ greatest assets, the researchers assert, are their people: “Commonly reported individual assets include civic and community engagement in the form of volunteerism, strong entrepreneurship, and the resilience and adaptive capacities of rural residents.” 

The County Health Rankings report is a call to action. It petitions community “changemakers” to explore the data to better understand the nature of the challenges, and to then more fully leverage assets within the community to address them, implementing strategies that will allow every community member to lead the healthiest life possible. 

To advance this initiative, the County Health Rankings & Roadmaps program sends coaches out to assist individual communities.  

“We’ve been partnering with the National Association of Counties for the past two years on the Rural Impact County Challenge, working with counties who bring teams together to think about opportunities to take action addressing children in poverty,” says Aliana Havrilla, one of those coaches. “But in my experience, it’s become a much broader conversation about opportunities and assets that exist at the local level.” 

Slow Recovery 

The County Health Rankings underscore the primary role poverty plays in health outcomes and indicate that while child-poverty rates are declining, they remain at levels higher than before the recession. 

“In the wake of the Great Recession, rates of children in poverty stayed high through 2012 and, despite declines in recent years, remain higher than the pre-recession era,” says Anne Roubal, a population health analyst for the Rankings & Roadmaps program.  

Rates of recovery, she stresses, vary by place and race. “In general, child-poverty rates have not bounced back in many rural counties or those with a greater share of people of color.” 

Rural counties continue to have the highest child poverty rates (23.2%), followed by large urban metro (21.2%), smaller metro (20.5%) and suburban counties (14.5%). 

The County Health Rankings authors write that poverty limits opportunities and increases the likelihood of poor health. Children living in poverty are less likely to have access to quality schools and have fewer chances to prepare for living-wage jobs leading to upward economic mobility and good health.  

“Children in poverty is an upstream measure that assesses both current and future health risk,” they write. “Recent data on poverty show that rates among children and youth are at least 1.5 times higher than rates among adults aged 18 and older.” 

Disparity among Neighbors 

Health outcomes in the County Health Rankings are measured by how long people live and how healthy they feel. Length of life is measured by premature death – deaths that occur before individuals reach their statistical life expectancy. Quality of life is measured by the percentage of days people report poor or fair health, the percentage who report physically and mentally unhealthy days within the past 30 days and the percentage of low-birth-weight babies. 

The disparity between rural and urban counties in these measures and others is often stark. 

Take, for example, the North Carolina counties of Wake and Robeson. Wake County, where Raleigh, the state capital, is located, is part of a thriving metropolitan area with more than 2 million residents. It ranks first in the state in the report’s health outcomes. 

Robeson County, an hour-and-a-half drive to the southeast, is largely rural. The largest city, Lumberton, has a population of about 21,000. It’s ethnically diverse, roughly 40 percent Native American, 30 percent white and 25 percent black. Robeson ranks last, 100th, in health outcomes in the state. 

County Health Rankings data indicate that Robeson County residents reported more than twice as many days being in poor or fair health than Wake County residents (29% vs. 13%). Nearly twice as many Robeson County residents reported physically unhealthy days within the past 30 days (5.4% vs. 2.9%) and more reported mentally unhealthy days (5.4% vs. 3.6%). A Robeson County adult is also much more likely to be obese (39% vs. 23%). 

The data further indicate that there are more than two and a half times as many premature deaths each year in Robeson County than in Wake County.  

According to a report published by the child advocacy group NC Child, life expectancy in Wake County in 2014 was 81.4 years; in Robeson, it was 74.2 years. 

Now consider poverty. Its correlation with poor health outcomes is underscored in the contrast between these two counties. 

Robeson County has the highest rate of poverty in the state, among the highest in the country. Nearly a third of all residents live below the federal poverty level (in 2017, $24,600 for a family of four); nearly half of all children live in poverty. Almost twice as many Robeson residents as Wake residents are unemployed (7.9% vs. 4.2%) and twice as many are uninsured (20% vs. 10%). 

Lumberton, the county seat of Robeson County, is 100 miles and a world of difference from Raleigh. 

Local Connections 

“Things are improving,” Anne Roubal says of the national outlook – slowly. “Starting in 2008, we saw a jump in poverty pretty much everywhere and that trend continued for three years.” Things then began to improve, but not as quickly as they’d gone into decline. “We’re still not back to where we were in 2006 and 2007.” 

The resources needed to recover and to build healthier communities are found in rural America. Health care institutions in many rural regions are taking innovative approaches to meeting their communities’ needs. In Robeson County, the local hospital, Southeastern Health, is tackling its community’s health care issues by remaining independent and offering a broad range of care under one roof. 

But it’s often individuals who step forward. According to the NORC Walsh Center report, “participation in community life in rural areas often stems from strong individual relationships and connections that people form with one another.” Such connections “lead people to participate in volunteering, community organizing and coalition building.” 

The report cites, for example, an initiative to combat diabetes in Appalachia. 

“One thing I really appreciate about rural communities is that they have a culture of such strong collaboration,” Aliana Havrilla says. “Sometimes, it’s everybody knows everybody because many people wear many hats. There’s also often just that tight-knit community feel … a strong asset-based collaborative approach that they’re bringing to this work addressing complex issues.”  


Recommendations from the 2018 County Health Rankings report for addressing child poverty: 

  • Invest in education from early childhood through adulthood to boost employment and career prospects. 
  • Increase or supplement income and support asset development in low-income households. 
  • Ensure that everyone has adequate, affordable health care coverage and receives culturally competent services and care. 
  • Foster social connections within communities and cultivate empowered and civically engaged youth. 

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