Rural Health Research in the 21st Century: One Health Considerations

I read with interest the commentary on rural health research in the 21st century by Moloney and associates in the December 16, 2024 issue of Journal of Rural Health.¹ In the commentary, the authors begin with the premise that “rural health research…has faced significant challenges in defining rural area, methodological constraints in studying dispersed populations, and complex social and cultural factors.” The authors present reasonable 21st-century digital and technologic solutions for these challenges.

The purpose of the present commentary is to offer additional considerations on rural health research in the 21st century, especially addressing the “complexity of rural socio-cultural dynamics.”¹ The present commentary draws from my experience in the Commonwealth of Pennsylvania, where I currently conduct rural health research and, along with my wife, manage a small farm that has been in her family for over 50 years.

I agree that there is definitional inconsistency for “rural.”¹ While use of a quantified definition (e.g., based upon the US Census) of a geopolitical area offers objectivity, socioeconomic and cultural components are also important to a rural definition. First, areas not designated by the US Census or another organization as “rural” may have a “rural” economic base, such as agriculture. For example, greenhouse, nursery, and agritourism are often agriculture enterprises in non-rural areas. Second, classification of a geopolitical area may change even though the people who reside there may not. Six of the 67 counties in Pennsylvania classified by the 2013 Rural-Urban Continuum Codes (RUCC) classification as nonmetropolitan (RUCC designation of 4+) or metropolitan changed with the 2023 RUCC classification: one nonmetropolitan county changed to metropolitan status while five metropolitan counties changed to nonmetropolitan status.² Finally, rural identity may be associated with a sense of place, culture and longevity among the residents.³ While it is necessary to quantify characteristics (e.g., population density, health care facilities) of geopolitical areas, the socioeconomic and cultural characteristics of the people who reside there may be not be consistent with the area's designation and introduce misclassification bias.

Recently, the Federal Reserve Bank of Philadelphia created the Reliance Index to quantify the importance that hospitals and higher education institutions play in regional economies.⁴ While most of their 524 US regions are metropolitan, the initiative identifies nonmetropolitan regions, including the northern, southern, and western nonmetropolitan regions in Pennsylvania. The average Reliance Index for these three nonmetropolitan regions was 0.59, substantially lower than the 1.0 for the United States. These data quantify the lack of a traditional anchor institution in these nonmetropolitan regions. Indeed, closure of a rural hospitals has substantial impact upon the economic base in a rural community, as well as residents’ access to health care.⁵

Instead, the economic base, such as that from agriculture, in rural communities is often housed in small businesses, rather than anchor institutions. For example, Pennsylvania has a strong agricultural economy that is a primary economic driver in rural communities. Approximately 600,000 persons in Pennsylvania are employed in agriculture; 1 in every 10 jobs.⁶ However, farms tend to be small, with the average farm size being 144 acres, compared to the average of 423 acres for US farms. Within agriculture, there is substantial diversity; dairy, poultry, and crop farming constituted 28%, 27%, and 19% of total agricultural sales in Pennsylvania in 2022, respectively.

As Moloney et al state, “rural health researchers must first understand the complexity of rural socio-cultural dynamics…”.¹ In particular, rural health research in the 21st century should recognize the characteristics of people and culture, as well as the interconnectedness and diversity in rural communities. The One Health approach to rural health research meets this expectation. One Health is an approach that recognizes that the health of people is interconnected with the health of animals, plants and their shared environment.⁷ One Health is not new, but has become important recently, especially in rural communities that also have a strong agricultural industry. One Health research is often focused upon zoonotic diseases because of the close association of people and animals in agricultural communities. A current zoonotic example of a One Health approach is highly pathogenic avian influenza, which has caused infected poultry flocks in Pennsylvania to be depopulated⁸ resulting in economic challenges to farmers, their families, and related industries. In other states, contaminated dairy products have been destroyed and farm workers infected.⁹

One Health is gaining recognition in Pennsylvania. First, in 2024, a consortium of individuals from universities, state and federal agencies, and museums, as well as private citizens, established the Pennsylvania One Health Consortium. While still in its early stages, the Consortium promotes and conducts research, education, and engagement to further a One Health approach throughout Pennsylvania. Importantly, Consortium members have backgrounds in public health, agriculture, human and veterinary medicine, and environmental health. Second, in January 2025, the Board of Directors of the Pennsylvania Farm Bureau (PFB), the largest farm organization in Pennsylvania, approved the recommendation that the “PFB support and promote One Health efforts to protect the health and productivity of the agricultural workforce.” Of note, this recommendation links together “health and productivity” within agriculture, demonstrating that human health and economic viability of the agricultural workforce are interconnected. Finally, One Health was recognized within public health preparedness during a virtual mini-symposium, entitled Preparedness in Rural Communities: National and State/Local Perspectives and Plans on January 30 and 31, 2025. A primary intent of the mini-symposium was to develop recommendations and strategies to enhance preparedness in rural Pennsylvania communities, particularly incorporating public health and agricultural considerations because these are intertwined in rural Pennsylvania. The mini-symposium developed One Health recommendations such as to “Support the research on and development of a One Health approach, especially developing One Health strategies, programs and policies that provide incentives for farmers, rural communities, and providers to adopt One Health practices” and “Encourage data scientists to integrate human, animal and environmental data for rural Pennsylvania communities in One Health surveillance systems.”

Rural health research in the 21st century could extend One Health to explicitly include social determinants of health.¹⁰ While One Health does not exclude social determinants of health, its emphasis to date has largely been on zoonotic diseases, animal production, antimicrobial resistance, and the natural environment. Explicit inclusion of social determinants of health, such as socioeconomic and cultural factors, would extend One Health research to be more holistic. This holistic approach could be entitled “One Rural Health,” which can be characterized as “an integrated approach to human health that recognizes that the health of people is interconnected with the health of animals, plants and their shared environment, including social determinants of health.” One Rural Health would include factors such as economic viability and productivity of farmers and farming.

Thus, the population for rural health research in 21st century would include those who live, work, learn, or worship in designated geopolitical areas and could be extended to those who have socioeconomic and cultural characteristics consistent with rural identity. For example, research may study those who are engaged in agritourism or in a greenhouse or nursery. Indeed, the Journal of Rural Health already states that authors can use a definition of “rural” that is not based upon area-based measures. Author guidelines read, “All submissions should include the rural definition (e.g., US Office of Management and Budget, Rural Urban Commuting Area, or Rural Urban Continuum Codes) applied in the study.”¹¹ This approach would allow researchers to include populations with strong rural socioeconomic and cultural characteristics to be participants in rural health research in the 21st century.

Rural health research in the 21st century should understand and examine the complexity of rural life and culture as it occurs in specific locations. A definition of “rural” based solely upon a geopolitical unit may limit the representativeness of rural health research. Extending the definition to include those who share the socioeconomic and cultural characteristics prominent in rural areas would improve representativeness and extend an investigator's “understanding of the study population.”¹ In addition, socioeconomic issues, such as the regional economic base in agriculture, may be studied in relation to the economic viability of farms and other businesses in rural areas. The present commentary is focused upon agriculture in the Commonwealth of Pennsylvania; however, other researchers should draw specificity from their own experience in rural health and from the specific characteristics of the location of their studies. One Health, and more specifically One Rural Health, research can be an integrated approach to rural health research in the 21st century.

No funding was received for this work.

I declare that there are no conflicts of interest in this material.