Americans living in rural communities have traditionally fared worse than those living in cities and suburban areas, as educational achievement and income levels historically have measured higher in urban centers. Geographic isolation in rural areas can hinder access to a variety of resources that play a role in health and well-being, including access to quality healthcare, food and job opportunities.
In 2019, Sharecare’s Community Well-Being Index (CWBI) demonstrated how the COVID-19 pandemic is underscoring this growing geographical divide.
The CWBI shows American’s living in rural parts of the country are experiencing lower levels of well-being and social determinants of health—factors comprising the environments in which they live, work, learn and play that affect their health and overall quality of life. Rural Americans are more likely to die from heart disease, cancer, chronic lower respiratory disease, and stroke than people living in urban areas, according to the U.S. Centers for Disease Control and Prevention (CDC). Rates of fatal accidents are also about 50% higher in rural communities, where residents also tend to be older and in worse health than city dwellers, the CDC reports.
These longstanding health and social disparities may put the 46 million people living in rural America at higher risk for severe COVID-19 infection, the CDC points out. 
“Inequities in health in Rural America have been well established, including everything from lower levels of education to higher rates of obesity and diabetes,” says Dr. David Hess, dean of the Medical College of Georgia. “To make matters worse, and in places like Georgia, these individuals also struggle to receive access to care, which is impacted by seven rural hospital closures since 2010, 41% of counties having no pediatricians, and almost half of counties in Georgia having no OGBYNs.”
Lower Resilience in Rural Areas Pre-Pandemic
Even before the pandemic began, rural counties generally exhibited lower levels of well-being and social determinants of health, according to the 2019 CWBI in collaboration with Boston University’s School of Public Health (BUSPH) and Biostatistics and Epidemiology Data Analytics Center (BEDAC).
The CWBI defines well-being across five domains:
- Purpose: liking what you do each day and being motivated to achieve your goals
- Social: having supportive relationships and love in your life
- Financial: managing your economic life to reduce stress and increase security
- Community: liking where you live, feeling safe and having pride in your community
- Physical: having good health and enough energy to get things done daily
Sharecare and BEDAC found that individuals in counties classified as urban achieved well-being scores more than 1 point higher than their rural counterparts.
As it relates to social determinants of health—access to quality healthcare and education, safe and affordable housing, transportation, food security, and financial stability—counties considered urban achieved scores more than 6 points higher than their rural counterparts. These findings underscore a stark geographic divide among factors that contribute to individuals’ ability to achieve good health and optimal levels of well-being.
States with Greater Well-Being in Rural Areas
While urban areas in the United States are generally associated with greater well-being and social determinants of health, the CWBI reveals notable exceptions, including 7 of 47 states with both rural and urban counties seeing higher levels of well-being in rural counties:
- Alaska (+0.49)
- Arizona (+0.41)
- Delaware (+3.2)
- Montana (+0.6)
- Nevada (+1.07)
- North Dakota (+0.64)
- Wyoming (+2.29)
While almost 15% of states saw improved well-being scores in rural counties compared to urban counterparts, Wyoming was the only state with both rural and urban counties that saw higher social determinants of health scores in rural counties.
So why do some rural areas fare better than expected? While rural communities do experience health challenges related to factors such as geographic isolation, many also exhibit health-protective traits.
Economic prosperity, for instance, is a known protective factor at both a societal and individual level, and many rural counties do attract financial investment. In Wyoming, residents have invested heavily in the economic well-being of National Park-adjacent rural areas, leading to economic Social Determinants of Health index (SDoHi) scores that are comparable in both urban and rural designated counties.
Social support is also known to correlate positively with health outcomes, even among rural elderly populations. Wyoming, for example, has statistically comparable and, in fact, slightly higher WBI scores for ‘social’ and ‘purpose’ among rural-designated counties.
“Put simply, while rural communities on the whole face challenges nationwide, many rural ares exhibit health-protective factors such as fiscal investment or strong social support, which can turn the tide in favor of the community,” says Dr. Nina Cesare, post doctoral researcher and SDOH content expert at BEDAC.
America’s large and more densely populated cities and suburbs have already faced spikes in COVID infection rates and deaths, but confirmed cases are reportedly set to rise in rural America, where there is reduced access to healthcare, and medical resources are already stretched thin.
Since 2005, 170 rural U.S. hospitals have closed, the CDC reports. Fewer people seeking inpatient care and Medicare payment reductions have led to unsustainable financial strain on these medical facilities, according to the U.S. Government Accountability Office (GAO). Now, amid the pandemic, some 700 more rural hospitals in the U.S. are reportedly on the verge of financial collapse, the CDC adds.
Complicating matters, some experts believe that people living in rural America, as well as political leaders in states that have recently experienced a rise in confirmed infections, haven’t taken the threat of COVID-19 seriously enough. Ultimately, this could increase the risk of poor health outcomes among this more vulnerable population, which also faces more financial insecurity.
The result is a perfect storm for rural America: a dwindling number of hospitals that are working with fewer resources, but treating more patients who are at higher risk for severe cases of COVID-19.
Identifying Solutions to Close the Gap
“The CWBI can help identify areas that might be at risk given what we know about COVID-19 and vulnerability in rural America,” according to Dr. Cesare. “By identifying the obstacles to health and well-being among rural communities, solutions may be developed to mitigate these disparities and close the geographical divide in America.”
Several solutions surfaced include leveraging telemedicine in areas where healthcare access is limited, as well as public health campaigns to educate and support rural communities in better adhering to COVID-19 CDC guidelines and policies. Business leaders in Effingham County, Georgia, for example, are discussing a campaign to augment the number of individuals wearing masks, keeping their distance from others, and avoiding crowds, especially events, the Wall Street Journal reports.
“Because Rural America already exhibited vulnerability pre-COVID-19, and because many of these populations have not experienced the worst of COVID-19 yet, it is critical we address risk from multiple standpoints, including education, infrastructure support, and innovative approaches to healthcare access,” Dr. Hess says. “For rural Georgia, we have already seen what COVID-19 can do to places like Albany that at least have some infrastructure in place. We do not want to see what happens when areas with even lower levels of well-being and social determinants are hit next.”