Document Type

State of the Science Report


University of Montana Rural Institute

Publication Date



Ultimately, the challenge of health care reform is the challenge of building community (Shortell et al., 1996). It makes little sense to discuss health without also discussing environment. Environments may be toxic physical environments due to pollution, noise and crime, or toxic social environments that promote health risk behavior like smoking and sedentary living. Alternatively, environments may be constructed to promote health behavior (e.g., physical activity) or reduce health risks (e.g., indoor smoking policy). In either case, the population’s health status is shaped by their environment. Rural people are less healthy than urban people (Institute of Medicine, 2005). Rural environments have fewer healthcare resources to address health problems and to promote health of rural populations. However, the cause of this disparity goes well beyond access to healthcare, the focus of most rural health researchers and advocates (Bailey, 2010). The World Health Organization (WHO) defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948). Further, WHO defined and operationalized health promotion during the Ottawa Convention in 1986. From those proceedings: Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being (World Health Organization, 1986). These documents indicate the global community has understood the far reaching inputs and impacts of health status for the world’s population for well over 25 if not over 60 years. Further, the role of social and physical environments that promote good health status have been described in detail suggesting the current trend in the US toward community-based interventions is woefully behind other countries with regard to population health. For example, the US ranks 28th in life expectancy despite spending more money per capita on healthcare than any other nation (National Research Council, 2011). Given these figures it is no surprise that very little of the $2.6 trillion annually allocated to healthcare is spent on health promotion (Centers for Medicare & Medicaid Services, 2012). It is true that medical researchers have made tremendous contributions in treating diseases. Yet, as better treatments emerge, they present us with the ethical question of how to make such treatments available to meet the standards of a just society. That challenge is particularly pronounced for those populations with economic challenges and those populations living in sparsely populated, remote rural areas. Still, even when medical service providers patch together a system to deliver medical care, we are no closer to achieving better population health. Instead, we need policies that improve “the [rural healthcare] system as it affects rural interests” (Mueller, 2010). While improving access to and the delivery of medical services is a worthy goal, finding ways to promote and maintain health remains a challenge. In this case, focusing on health encompasses medicine but expands our view to include more than delivering treatment, which increases our options for action. Further, focusing on health has particular advantages for addressing rural issues which are brought together through an ecological model of health. Using such a model shines a light on the numerous pathways to promoting and maintaining the health of entire populations. The purpose of this paper is to examine rural health and disability looking through the ecological lens to examine the relationship between rural environments and the health of rural people with disabilities. This paper encompasses 1) rural health ecology; 2) a multi-level ecological model for addressing the health needs of rural people with disabilities; 3) rural health and disability topics, working from the rural health ecological model; 4) two case examples: a program that demonstrated community level interventions for rural populations, and a program that adapted and implemented a health promotion program for rural people with disabilities; and 5) recommendations to improve the health of rural people with disabilities.


© 2011 RTC:Rural.

Granting Agency

National Institute on Disability and Rehabilitation Research


Our research is supported by grant #H133B080023 from the National Institute on Disability and Rehabilitation Research, U.S. Dept. of Education.

Project Number