Health Equity in the Healing Communities Study: Comparing Evidence-Based Practice Implementation in Rural and Urban Ohio Counties

Background and Purpose: Research consistently demonstrates that rural communities face significant disadvantages in addressing opioid use disorder (OUD) and overdose prevention, resulting in disproportionately higher rates of overdose deaths compared to urban areas. These disparities are rooted in limited access to treatment and prevention services, an overreliance on criminal legal system responses, and broader structural and cultural barriers. Rural areas also contend with declining economic conditions, deindustrialization, underdeveloped infrastructure, geographic isolation, limited recreational opportunities, and reduced anonymity in seeking care. These challenges are further exacerbated by heightened stigma and restrictive policies that limit access to harm reduction services. Advancing health equity in rural communities requires culturally responsive, context-specific strategies. These include expanding access to medications for opioid use disorder (MOUD), increasing overdose education and naloxone distribution (OEND), particularly in homes where overdoses most often occur and offering tailored training and interventions for high-risk and underserved populations.

Methods: The HEALing Communities Study (HCS) was a four-year, parallel-group, cluster randomized controlled trial conducted in 18 communities across Ohio. HCS aimed to reduce opioid overdose deaths through the implementation of the Communities That HEAL (CTH) model, which employed a community-engaged, data-driven approach to promote the adoption of evidence-based practices (EBPs), supported by targeted communication campaigns to reduce stigma and increase EBP uptake. This analysis examined differences in the implementation of two key EBP strategies, OEND and MOUD, between urban and rural communities in both Wave 1 and Wave 2 cohorts. Rural–urban classifications were based on the National Center for Health Statistics (NCHS) definition, which does not fully align with Ohio’s state-specific classification. To assess disparities in implementation, two-sample t-tests were used to compare rural and urban outcomes using both the HCS and state-level definitions.

Results: Rural communities reported a higher mean number of fully implemented MOUD and OEND strategies using both Ohio and HCS definitions. However, there were no statistically significant differences between urban and rural communities in the full implementation of either strategy. These findings contrast with prevailing literature and the initial hypothesis that rural communities would implement fewer strategies than their urban counterparts.

Conclusions: These preliminary findings suggest that, despite resource limitations and infrastructure challenges, rural communities are capable of successfully implementing EBPs when supported through community-driven, contextually relevant approaches. The CTH model emphasized leveraging local assets to select strategies that were both feasible within the project timeline and supported through funding that facilitated infrastructure development and sustainability planning. This suggests that rural communities can meaningfully engage in addressing complex public health challenge, particularly when implementation strategies align with their cultural and structural contexts, as demonstrated in HCS. Although the sample size is limited, these results underscore the importance of further exploring similar models to address opioid-related disparities and other challenges related to health equity in underserved communities.