Rural-urban disparities in chronic conditions such as diabetes and obesity remain even after adjusting for individual-level behaviors, suggesting that rural environments may play an important role in explaining the health gap. The “Close the Health Gap” Grand Challenge emphasizes place-based initiatives that aim to improve the daily life conditions, also known as social determinants of health, and reduce health inequities. The aim of this research project was to understand rural residents’ perspectives about the community conditions impacting their health in order to propose place-based interventions that integrate these insights with best available evidence. Ecosocial theory--which systematically links social and biological processes with political economy, inequality, lifecourse, and historical context--guided our inquiry.
We partnered with a county public health department to conduct an ethnographically-informed health needs assessment in two unincorporated low income rural Texas communities. We held eight focus groups: five with community residents and leaders in English and Spanish, one with school nurses, and two with middle and high school youth. Additionally, we collected observation data during site visits. We analyzed data using Guest and colleagues’ (2012) applied thematic analysis for focus groups.
While community leaders primarily focused on intrapersonal factors (e.g., choosing not to exercise), residents primarily focused on community-based barriers to health. Residents identified the following challenges associated with social determinants of health: 1) limited economic opportunities, 2) limited access to resources, including healthcare, 3) limited social capital, 4) limited access to trustworthy information and communication (e.g., limited WiFi access), and 5) limited community competence (e.g., collective ability to solve problems). They also identified: 1) road safety (e.g., lack of sidewalks), 2) community aesthetics, and 3) absence of public spaces/recreational facilities (e.g., YMCA) as barriers to active living. Local schools emerged as healthcare and active living community hubs. Despite their limited scope of practice, school nurses delivered healthcare to students and adults. Furthermore, residents regularly utilized the elementary school’s new running track and saw school sport leagues as important opportunities for active living. Finally, youth congregated around schools after regular school hours to access the WiFi network.
Given the limited resources typically available in rural areas, making use of existing resources to improve educational and health outcomes is critical. Full‐service community schools seek to remove barriers to students’ learning and address educational inequities by strategically partnering with individuals, families, and community organizations to optimize and strengthen resources associated with academic success. Our findings suggest that full-service community schools may also play an important role in closing the rural-urban health gap. School nurses already play a crucial role in delivering community healthcare. Thus, collocating healthcare services within schools provides an avenue for increasing access to healthcare for youth and adults. Residents’ usage of the school track and emphasis on the importance of sports leagues suggest that community school model may also inform active living opportunities expansion. Schools could also increase residents’ access to information through public WiFi access. Finally, schools can strengthen social networks and expand community competency through trainings such as community organizing.