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Rural Health Pathway

This pathway complements NNLM’s resources on rural health by exploring evaluation considerations for programs that seek to improve health outcomes for individuals in rural communities.

Rural settings can be defined in many ways, but perhaps most simply by stating that it is any population, housing, or territory not located in urban areas. In 2010, the US Census found that 19% of the population, or almost 60 million people, live in rural areas.

Working on a project with a small award (less than $10,000)? Use the Small Awards Evaluation Toolkit and Evaluation Worksheets to assist you in determining key components for your evaluation!


When developing an evaluation, consider the context of your program. The context can change how your evaluation is designed and implemented since different settings and populations have different needs and abilities to participate in evaluations.

Access to Health Care

  • Evaluate what level of access participants have to health services and health information. The low-density populations of rural areas, combined with long distances to reach health services and providers, mean that residents in rural areas are more predisposed to issues with access compared to their urban counterparts.
  • Review multiple dimensions of access. Access includes not only whether the service or information is available or not, but also the ability to utilize the service. Finances and health insurance status, as well as transportation, broadband and internet access, and language barriers can all play a part in access.
  • When developing a sampling strategy, remember that issues with access may result in sampling some participant groups more than others. If you are seeking information that could be applied to the community as a whole, remember that you will have to sample the entire community, and not just those who have access to the program.
Barriers to Access
Barrier Definition & Examples
Structural The number, type, concentration, location, and organizational configuration of providers (often predicated by the health care financing system)
  • Health care plan or provider refuses care
  • Inadequate supply of providers
  • Prolonged waiting times
Financial The cost of care to individuals and families, including the presence and type of health insurance coverage (includes consideration of those who are underinsured)
  • High costs of healthcare are unaffordable for uninsured
  • Co-pay, deductible, and medication costs are not always covered by insurance
  • Absent coverage for certain conditions
Personal & Cultural A set of either explicit or implicit rules that determine the behavior of social subjects in relation to their health
  • Long distances or limited transportation to care
  • Ineffective communication by healthcare providers
  • Lack of transportation services for individuals who do not speak English
  • Disrespectful provider behavior

Social Determinants of Health & Health Disparities

Link to Rural Social Determinants of Health PDF
  • Gather information on social determinants of health. The National Advisory Committee on Rural Health and Human Services advises that in order to improve health and quality of life in rural areas, policy makers should consider the social determinants of health of geography; wealth, income and poverty; education and labor markets; and transportation.
  • Consider how health disparities change who and how participants engage in the program. Health disparities are evident in rural populations, because of the complex systemic issues related to the social determinants of health. For example, from 1999-2014, the rates of death of all five leading causes of death in the United States were higher in rural areas than in urban areas.
  • Analyze data on health disparities and social determinants of health separately for each geographic location. When evaluating across multiple geographic areas, remember that social determinants of health and health disparities may be different for each area. Some areas, such as Appalachia, the US-Mexico Border, and American Indian and Alaska Native communities, have larger health disparities than other rural areas.
  • Present health disparities from an equity lens. Health disparities are the result of complex systemic and structural inequities, rather than qualities inherent to a group of individuals. When examining and communicating health disparities through a lens of equity, one should recognize the issues leading to the disparities, including the social determinants of health.

Health Literacy

  • Consider how health literacy levels change your program. A higher proportion of residents of rural areas have lower health literacy than urban areas, which can be explained by differences in age, gender, race, ethnicity, education and income between rural and urban populations.
  • Measure health literacy at the start of the program. Health literacy has been shown to change the success of programs and should be measured at the start of the program to see if it could affect program outcomes.