April 6-12 is National Public Health Week. In light of Tuesday's theme of "Starting from Zip," focusing on geographical disparities in health, and the week's overall theme of Healthiest Nation 2030, we present this article, adapted from Chapter 1 of the award-winning Rural Public Health, edited by Jacob Warren, Ph.D. and K. Bryant Smalley, Ph.D., Psy.D.

The idea of protecting the health of rural populations, or rural public health if you will, is not new. But in reality, however, most public health principles and practices are developed, applied, and evaluated in urban settings. It is easy to see how this “urban-centric” approach to public health would have developed: Given that most of public health has its foundation in infectious disease epidemiology and control, it is not surprising that urban models were at the forefront of development. After all, urban areas are the places where risk of contagion is the highest.

As the field of public health grew beyond infectious disease concerns to encompass areas such as maternal and child health, chronic diseases, and mental health, the shift from an urban focus to a more inclusive view of all geographic diversities did not follow, however. Despite its influence in all of our lives from the food we eat to our frequent source of recreational activities, rural areas are remarkably understudied—particularly given the fact that approximately one in five Americans lives in a rural area and 75% of the nation’s counties are rural. Although surprisingly limited, the literature does agree, however, that rural areas have unique health considerations that ultimately result in persistent health disparities in outcomes ranging from diabetes to suicide.

Two of the most pressing challenges faced by rural residents are poverty and access to basic health services. Rural residents are more likely to live below the federal poverty line, with minority rural residents particularly impacted (African Americans, for instance, have poverty rates that are more than double that seen in nonminority rural residents). Rural residents also go longer periods of time without health insurance and are much more likely to live in a health professional shortage area; in fact, 63% of all Health Resources and Services Administration (HRSA)-designated primary care health professional shortage areas are in rural/frontier areas, and it would take more than 4,000 new rural-practicing primary care providers to address this need.

Unfortunately, despite the recognition of the breadth of challenges faced in rural public health, there has been remarkably little progress in eliminating rural health disparities. Much research and action make the assumption that theories, practices, and programs developed in urban settings will be, for the most part, translatable into rural settings. But this simply is not the case, although this notion has largely stifled rural-focused research for the better part of at least 50 years.

But how to define rurality? Unfortunately, there is no one definition, though rural areas are largely accepted to be those in which population density is lower than a “typical” setting and one in which access to basic services (including health care) is often impeded by sometimes great distances. However, they are also marked by cultural differences from more densely populated areas, including but not limited to:

  • Remoteness and isolation from support systems and other people in general, which encourage a culture of self-reliance that can discourage seeking medical treatment;
  • High rates of poverty, further limiting access to care;
  • Religion, which many rural residents see as an alternative to mental health care, but whose places of worship can also serve a positive role as partners in providing public health services;
  • Behavioral norms which may encourage risky behaviors such as drug use, smoking, and a sedentary lifestyle;
  • Stigma frequently associated with mental health services, as well as those for certain physical conditions such as HIV/AIDS (already stigmatized around the country, but heightened even further in rural areas..

Only recognizing the importance of rural life - whether in in resources, norms, personal decision making, worldview, or interaction patterns with other people - can the helping professions begin to culturally tailor their messages, approaches, and interventions in a way that will provide maximum impact for rural populations.

For more information on geographic disparities in public health, read:


Rural Public Health cover