Health & Rural Communities
While there is no single definition of rural and key federal agencies apply different standards for policymaking and administrative purposes, the term generally describes areas with low and/or geographically dispersed populations. An estimate from one such agency, the Office of Management and Budget, suggests that as much as 20% of the U.S. population lives in rural communities.
What is clear is that residents and health care providers in rural areas like ours face unique challenges due to social, cultural, geographic, and economic circumstances. A framework for understanding these conditions, known as the social determinants of health, has emerged in recent decades. Race/ethnicity, income, education, employment, housing, access to food and many other factors are now understood as factors that shape the health and well-being of individuals and groups.
As we will briefly describe below, health outcomes are worse and access lower for rural residents, but promising solutions – including some underway right now in our region – can help turn the tide.
Why it Matters
In general, rural Americans tend to be older and sicker than their urban counterparts, and more likely to die of some of the leading causes of death in the U.S., including heart disease, cancer, unintentional injury, and stroke.
These disparities can be significant, such as the estimated 50% higher risk of death from unintentional injury attributable to motor vehicle accidents, falls and drug overdoses for rural Americans. They also impact children in rural areas, whose rate of risk of death from unintentional injury is also double that of their urban peers. Additionally, children with mental, behavioral, and developmental disorders confront more family and community challenges than their urban peers.
On other key measures, health inequities persist across the lifespan. Rural residents experience higher infant mortality rates, and higher rates of mental, behavioral, and developmental disorders in children and suicide among youth. Preventable cancers, such as those due to tobacco use or lack of colorectal or cervical screenings, are more common, and overall mortality rates—which had decreased nationally until the pandemic—have been slower to come down in rural counties.
Health outcomes also differ by race and ethnicity. For instance, rural counties that are majority non-Hispanic Black have been found to have the highest rates of premature death, and the higher infant mortality rates that all rural residents face are even worse for rural people of color and Indigenous people.
Health Systems & Care Delivery
Although as many as 20 percent of Americans live in rural areas, only 11 percent of physicians practice in them. Lower salaries, fewer amenities and geographic isolation from peer networks contribute to ongoing recruitment and retention problems.
As a result, more than 20 million Americans live in areas where population-to-provider ratios are well under the federal recommendation of 2,000:1, and thus designated as health professional shortage areas. Even more severe is the lack of mental health professionals. Three-quarters of all counties qualifying as shortage areas are rural.
FCH serves towns in three counties – Litchfield in Connecticut, and Dutchess and Columbia in New York – where population-to-provider ratios significantly exceed those of the state overall. Only Columbia County exceeds the federal recommendation. For mental health providers, Dutchess County’s ratio is roughly on par with the state, while Litchfield and Columbia counties have notably higher shortages. While other comparative measures such as mammography screening rates match state percentages, others such as rates of preventable hospital stays vary, with Litchfield’s rate lower and Dutchess and Columbia’s slightly higher than state rates.
As with health outcomes, examining health access by race and ethnicity reveals inequities. Rural adults of color are less likely to have a personal doctor than non-Hispanic white adults, and more likely to forgo care due to cost.
Public and private investment can strengthen rural health access and improve health outcomes. Here’s a look at four strategies at work in our region:
Federally Qualified Health Centers
These community-based centers are safety-net providers serving patients with limited or restricted access to health care. Typically offering primary care, dental care and mental health services along with supportive case management, they receive government funding that requires a sliding scale payment system and a governing board that includes patients. In the summer of 2019, FCH awarded a $1.3M grant to Community Health & Wellness Center of Greater Torrington, an award-winning Federally Qualified Health Center, to establish a 7,300-square-foot health center. It will expand access to primary care, behavioral health care, and walk-in non-emergency services in northwest Connecticut. In 2022, Connecticut’s State Bonding Commission approved $3 Million towards the health center’s construction.
School-Based Health Centers
Around the country, students and their families get health care services at or near their school campuses through an estimated 2,000 school-based health centers. By providing a range of primary care, mental health care and even dental services right in schools, these centers advance health equity, address the frequent fragmentation of services for youth and help boost student achievement.
In 2020, FCH partnered with the Webutuck Central School District, supporting their efforts to establish a school-based health center in partnership with Open Door (a Federally Qualified Health Center). Webutuck’s school-based health center will provide comprehensive care to the nearly 700 students in the district. Webutuck’s school-based health center opened in May 2022. Listen to Webutuck’s school nurse Charlie Davis speak about the center’s opening here.
By providing services in the confines of a school, school-based health centers effectively remove cultural, financial, privacy and transportation related barriers that are typically experienced at a separate center site. Students who use school-based health centers have better grade point averages and attendance compared to students who do not use such centers. School-based health centers are also linked to a myriad of health-related outcomes, such as increased use of vaccinations and prevention services, reduced asthma morbidity, fewer emergency department visits and hospital admissions, lower illegal substance use and alcohol consumption and reduced violence. Simply put, school-based health centers provide culturally competent, developmentally appropriate, easily accessible, high quality services to students.