Rural counties are less healthy than their urban counterparts, a disparity driven partly by unequal access to civic infrastructure, according to a Daily Yonder analysis of data gathered by County Health Rankings & Roadmaps (CHR&R), a public health research initiative based out of the University of Wisconsin Population Health Institute.
Nonmetropolitan, or rural, counties make up 17 of the top 20 most unhealthy counties in the health outcome index, a CHR&R tool that measures the length and quality of life in a county. In all but two states—Nebraska and Maryland—health outcomes are worse in rural areas compared to urban areas.
But health outcomes also vary by region. Both rural and metro counties in the South are the least healthy compared to other regions, while some of the healthiest counties are in New England.
The 2024 CHR&R National Findings Report, Creating Thriving Communities Through Civic Participation, highlighted the significance of civic participation and civic infrastructure—how often we participate in our community activities and the resources that make that participation possible—as two key factors contributing to geographic health disparities.
Rural counties are more likely to be in the bottom 25% of all counties with the worst health outcomes.
For ease of analysis, I divided every county for which there is data into quartiles, or four groups, ranked from best to worst. Counties in the first quartile are in the top quarter of the nation’s healthiest counties, scoring the best scores in the health outcome index, while counties in the fourth quartile are the least healthy.
Only 20% of nonmetropolitan counties are in the first quartile, the healthiest group, even though they make up 62% of all counties in the dataset. While 32% of metropolitan counties occupy the healthiest quartile, even though they represent only 38% of all U.S. counties.
A smaller share of metropolitan counties occupy the three worst quartiles, however. Only 15% of metro counties occupy the worst quartile, a disproportionately small share, compared to 31% of nonmetropolitan counties.
A perfectly equal index would exhibit a quarter of every county type in each quartile. But that’s not what we see. Instead, we see fewer than a quarter of rural counties in the best quartile and more than a quarter of rural counties in the worst.
Another way to look at this data is to generate the average rural index and compare that to the average metropolitan index. At the county level, index values range from 2.98 to -1.76; lower values are healthier than higher index values, while a value of zero is the national average.
The average health outcomes index in nonmetropolitan counties is 0.13, compared to -0.23 in metro counties. In other words, a greater share of metropolitan counties see longer lifespans and greater quality of life compared to rural counties.
The rural South exhibits the worst index scores compared to all other regions in both nonmetropolitan and metropolitan areas.
About 62% of rural counties and 30% of metropolitan counties in the South are in the worst health outcome quartile. Less than 2% of counties in the rural South occupy the best quartile, meanwhile.
Rural counties in South Carolina score the worst on the health outcome index, with an average value of 1.31. With an average value of 1.23, Mississippi is a close second.
The states with the worst inequalities between rural and urban counties are Alaska and Hawaii. All of the metropolitan counties in these states occupy the top two quartiles in the health outcomes index.
None of the metropolitan counties in Alaska and Hawaii are in the bottom quartile, but 30% of the rural counties are.
But not all rural places are the same. Nonmetropolitan counties in New England exhibit the best health outcomes compared to all other regions. Half of all rural New England counties occupy the best quartile, while none occupies the worst quartile.
With an average score of -1.2, nonmetropolitan counties in Massachusetts score the best on the health outcome index, with other New England states like Vermont and New Hampshire following close behind with average values of -0.72 and -0.79, respectively.
Life expectancy and quality of life tend to suffer in areas where it’s hard to access civic infrastructure, resources that include things like public libraries, high speed internet, and local news, among other things.
People who live in rural areas are more likely to experience unequal access to civic infrastructure, according to the 2024 CHR&R report. Rural communities are more likely to lack access to broadband internet and to pay more for a subscription when they do have it, for example.
The report also emphasizes that low-income and marginalized urban neighborhoods suffer from the same civic infrastructure issues that plague many rural communities.
The CHR&R researchers found that areas with more civic infrastructure contribute to civic participation, which includes activities like voting, joining neighborhood groups, or volunteering. Both civic participation and civic infrastructure “are tied to how well and how long we live,” according to the report.
The health of a community tends to be better in counties where more people vote and participate in local politics because it “builds power to break down structural barriers” that have historically made it hard for everyone to have a seat at the table, the report says.
Sarah Melotte of Bakersville, N.C., is data correspondent for Daily Yonder. This story was originally published in the Daily Yonder. See the original story, with links. For more rural reporting and small-town stories visit dailyyonder.com.
From The Progressive Populist, January 1-15, 2025
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