Abbreviated, the duties performed by public health nurses include investigating, surveillance/monitoring, diagnosing, and evaluating community health issues (e.g., environmental health hazards); mobilizing partnerships to resolve issues; promoting a competent workforce; promoting quality services and safety ideals; advocating for population health; enforcing policy and program goals; creating policy; and implementing and evaluating health and social policies related to population health needs [2,3]. The assessment skills of the public health nurse, in addition to their primary prevention focus and system-level perspectives, can "assure that local and state needs are met, services and programs are coordinated, and communities are engaged" [4].

Differing from acute care practice, the public health nurse aims to improve population health through prevention efforts and by attending to multiple determinants of health [4]. With a multi-level view of health, public health nursing action occurs through community applications of theory, evidence, and a commitment to health equity [4]. The Health Resources and Services Administration defines population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group. In this concept, the population as a whole is viewed as the patient" [3].

Public health in the United States has many functions. According to the Centers for Disease Control and Prevention (CDC), public health prevents epidemics and the spread of disease, protects against environmental hazards, prevents injuries, promotes and encourages healthy behaviors, responds to disasters and assists communities in recovery, and assures the quality and accessibility of health services [6]. It aims to promote physical and mental health, prevent disease, injury, and disability. The CDC has identified the following 10 vital services applied to all entities of public health—national, state, local, and tribes and territories [6]:

Public health in the United States has many functions. According to the Centers for Disease Control and Prevention (CDC), public health prevents epidemics and the spread of disease, protects against environmental hazards, prevents injuries, promotes and encourages healthy behaviors, responds to disasters and assists communities in recovery, and assures the quality and accessibility of health services [6]. It aims to promote physical and mental health, prevent disease, injury, and disability. The CDC has identified the following 10 vital services applied to all entities of public health—national, state, local, and tribes and territories [6]:

The U.S. Census Bureau has historically taken the lead in defining rural and urban. It uses statistical data to analyze population characteristics and changes in population distribution in the development of their definition. For more than 100 years, since 1910, the Bureau has provided an official definition of urban territory, population, and housing, but over time, they have changed the concept behind their definitions or the methods or classification schema. The U.S. Census Bureau first defines urban areas and defines rural areas as those that are not urban. Urban areas may be further classified as urbanized areas or urban clusters. Rural areas are further divided into three categories: completely rural, mostly rural, and mostly urban [10]. For the most part, the definition of urban is based on residential population density and a few other land-use characteristics (e.g., land cover, airports) used to identify densely developed territory [10]. Rural areas encompass a wide variety of settlements, from densely settled small towns and "large-lot" housing subdivisions on the fringes of urban areas, to more sparsely populated and remote areas [10]. Although some sources interchange the entities nonmetropolitan and rural, the U.S. Census Bureau states that these geographic entities are not identical and should not be used interchangeably [10]. Professionals working with public reports and agency data should familiarize themselves with the particular definition of rural and urban used in the report or data.

Frontier health professional shortage areas are also important to conceptualize. According to the U.S. Census Bureau, counties classified as frontier have a population density of fewer than seven people per square mile [15]. The 2010 Patient Protection and Affordable Care Act defines frontier health professional shortage area to mean an area "with a population density less than six persons per square mile within the service area; and with respect to which the distance or time for the population to access care is excessive" [16]. The health professional shortages of primary care, mental health, or dental health professionals, regardless of classification—frontier, rural, suburban, urban, or mixed—can limit service availability for a population. The designation of health professional shortage area may be based on a health professional shortage for a particular population group and/or a shortage for an entire population within a defined geographic area. In some cases, it may be facility-based, such as a Centers for Medicare and Medicaid Services-certified rural health clinic [17].

According to the U.S. Census Bureau, and based on the 2016–2020 American Community Survey, there are differences between rural and urban America in terms of demographic, social, and economic determinants (e.g., age, education, income, health insurance) [20,78]. Rural residents are more likely to be older, married, and not living alone. They tend to have completed less education and have lower civilian employment, lower health insurance coverage, and less Internet access compared with urban residents [20,78]. The CDC reports that rural Americans tend to show higher rates of cigarette smoking, higher rates of hypertension and obesity, and less access to healthcare services [21]. Negative determinants (e.g., lower employment) place residents at a higher risk for certain public health conditions, such as chronic disease. All these factors can lead to poor health outcomes [21].

Although some claim that rural America has a higher poverty rate compared with urban areas, U.S. Census Bureau data show that the urban poverty rate is higher than the rural rate [26,78]. Poverty is defined as "any individual with income less than that deemed sufficient to purchase basic needs of food, shelter, clothing, and other essential goods and services" [27]. Based on the American Community Survey, all four regions of the United States (Western, Midwestern, Southern, and Northeastern) showed consistently lower poverty rates in rural areas compared with urban areas [26,78]. The poverty rate for rural adults is 15.4%, compared with 11.9% for urban adults. The poverty rate for rural children (younger than 18 years of age) is 18.9%, compared with 22.3% for urban children [20,78]. In total, 42 states report lower poverty rates for their rural areas than for their urban areas [26].

The median household income for rural areas is $52,386, while the median household income for urban areas is $54,296 [20]. Rural household income is led by younger householders (44 years of age and younger) whereas urban median household income is greater for households led by an older householder (45 years of age and older). There are 32 states with greater median household incomes for rural households than for urban households [26]. Between 2007 and 2014, rural incomes were highest in rural recreation counties, and incomes were also high in the farming and mining counties [28]. Incomes were lowest in the government-dependent and non-specialized job category for rural counties; these counties have the highest rural poverty rates [28].

Chronic lower respiratory disease is a risk factor for long-term disability and a leading cause of rural mortality, with 11,000 deaths reported in 2014 [34]. Rural populations have a higher incidence than urban areas. Chronic lower respiratory disease encompasses a group of respiratory disorders, including asthma, pulmonary hypertension, occupational lung disease, and, perhaps most significantly, chronic obstructive pulmonary disease [39]. Rural economic sectors have specific work-related lung problems. Agricultural workers may develop hypersensitivity pneumonitis and/or idiopathic pulmonary fibrosis after repeated exposures to mold/fungi, animal feed, dust, and pesticides [40]. Exposure to chemicals in manufacturing work can lead to bronchiolitis obliterans (also known as obliterative bronchiolitis or "popcorn lung"), and rural construction and mining industries are at increased risk for pneumoconiosis from inhalation of dust (e.g., silica, coal). Major risk factors for the development of chronic lower respiratory disease include tobacco exposure, occupational and environmental toxin exposures, respiratory infections, and genetic predisposition. Among youth, asthma is one of the most prevalent chronic health conditions [41,42]. Exposing youth and parents early to prevention programs on respiratory disease can help offset disease.

Psychoeducational groups were first used in families with members who had schizophrenia; however, they have been adapted for use with other clinical populations. Psychoeducational groups typically involve a didactic and support component, whereby family members (i.e., caregivers) convene (in-person or remotely) for 10 to 12 structured sessions, on a biweekly basis [56]. It assumes that the caregivers are experts and each member can help each other [57]. The didactic component focuses on both cognitive information and behavioral change. Caregivers, for example, listen to a series of mini-lectures that focus on disease etiology, treatment, and management [56]. Problem-solving skills and coping strategies are often discussed. Caregivers are encouraged to use these newly learned skills and apply them at home. The support component of the psychoeducational groups provides a forum for family members to talk about various issues that may come up in the caregiving situation. Facilitators and other family members provide validation and recognition of feelings. Ultimately, when family members feel confident about providing care, their quality of life improves [46]. In terms of the research evaluating the effectiveness of psychoeducational groups for caregivers, the findings are mixed. In one study, nurse-facilitated psychoeducational groups for caregivers resulted in no improvements in perceived caregiver burden [58]. But a separate study found participation in distance or in-person psychoeducational groups was associated with improved caregiver distress and burden [59].

The use of smokeless tobacco is also a greater issue for rural adolescents and adults than for their urban counterparts. Smokeless tobacco is defined as tobacco products that are sucked or chewed (not burned) and includes chewing tobacco, snuff, and dissolvables. An estimated 8.6% of rural adults use smokeless tobacco, compared with 6% of urban adults [63]. Rates of smokeless tobacco use are greatest in states with large rural areas: Wyoming, West Virginia, Mississippi, and Kentucky [64]. Results of studies suggest that factors other than age, gender, poverty level, and region are driving urban-rural differences in tobacco use. In one study, the most likely reasons given for smokeless tobacco use were affordability, choice of flavors, ability to use in public places (as opposed to smoking), and safety to persons around the user (i.e., no secondhand smoke) [65]. While there may be a perception that these products are safer than smoked tobacco, they contain nicotine, are highly addictive, and have been linked to oral, esophageal, and pancreatic cancers [66].

Although cancer rates are lower in rural areas than urban areas, cancer-related mortality is greater [34,72]. In particular, higher death rates have been reported for lung, colorectal, cervical, and prostate cancers in rural areas. The highest mortality rates are typically in the rural South. Geography alone cannot predict cancer risk, but it can have an impact on prevention measures, diagnosis, and the treatment opportunities. As such, some cancer cases can potentially be mitigated with public health intervention [72]. Certainly, mortality rates could be improved by ensuring adherence to screening guidelines and access to optimal care.

The rate of opioid misuse and related fatalities are considered public health emergencies in the United States. The general rate of drug use in urban and rural areas rural areas are similar (10.4% and 10.9%, respectively), with the rate of opioid and methamphetamine misuse being roughly the same among the two groups [75]. The rate of drug overdose deaths is greater in rural areas, with the rural overdose rate (unintentional injury) 50% higher than the urban rate [76]. Between 1999 and 2015, the rural opioid death rate quadrupled among those 18 to 25 years of age and tripled for women [76]. Socioeconomic factors, behavioral factors, and access to services contribute to these rural-urban differences. An understanding of how rural areas are different when it comes to drug use and drug overdose deaths, including opioids, can help public health professionals identify, monitor, and prioritize their response to the opioid epidemic [76]. To develop this understanding, ongoing data collection, analysis of data, and reporting of findings are critical to staying ahead of the drug crisis in public health.

Methamphetamine users in rural areas, especially areas designated as frontier regions, are likely to experience great difficulty in accessing medical, psychiatric, or substance abuse services. Even self-help groups are likely to be nonexistent in these areas, and when they are available, the degree of anonymity in a 12-step group in a small town may be compromised. The nearest available small city often serves as the population center for the region. Social services in these cities may be overwhelmed by numbers of transient persons from the surrounding rural areas needing services in addition to the inhabitants of the city [81].

Suicide rates have been increasing across the United States, led by areas considered less urban, with the gap in rates between less urban and urban areas widening between 1999 and 2016; furthermore, suicide with a firearm is two times higher among rural residents than those in urban areas [86,87,160]. While White men are at highest risk for suicide nationally, in rural areas American Indians/Alaska Natives (AI/ANs) are the most affected [86,87]. Geographic disparities in suicide rates might reflect risk factors known to be prevalent in less urban areas, such as limited access to mental health care, social isolation, and opioid misuse [89]. Addressing the opioid crisis in rural areas is one way of reducing suicide rates.

A large national study found that lifetime intimate partner violence victimization rates in rural areas (26.7% in women, 15.5% in men) are similar to the prevalence found among men and women in nonrural areas [99]. In 2020, a national review was published confirming the similarity in prevalence of intimate partner violence; however, it was found that emergency department visit rates were higher in rural areas (15.5 per 100,000 population) than in nonrural areas (11.9 per 100,000 population) [96]. In addition, there is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [100]. This disparity is thought to be a result of fewer preventive and medical services [96,99,100].

Motor vehicle crash-related injuries are the leading cause of death among people 5 to 34 years of age [104]. Motor vehicle crash fatality rates are especially high in rural areas and for residents of tribal lands, in part because of poor road maintenance, higher rates of alcohol-impaired driving, lower rates of seat belt and child safety seat use, and less access to emergency response and trauma care [104]. The federal government has committed to supporting state, tribal, local, and territorial agencies in implementing, strengthening, and enforcing transportation safety policies and programs.

In the United States, those who live in rural areas are more likely to reporting owning a gun (46%) than those who live in the suburbs (28%) or urban areas (19%) [107]. Gun owners in rural areas are less likely to cite protection as a motivator of gun ownership (62%), compared with suburban and urban residents (both 71%), though it is the most cited reason. They are more likely to report having a gun for hunting or collecting purposes. Regardless of the reasons for owning a gun, the presence of a firearm in the home increases the risk of fatality from suicide, domestic violence, and homicide [108,109]. For providers devoted to preserving life and promoting health, this can make advising patients in risk situations to remove guns from their home seem ethically self-evident [109,110].

Intermittent explosive disorder is included under the general category of disruptive, impulse-control, and conduct disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [130]. Approximately 2.7% of the general public meets the diagnostic criteria for this disorder, but it is much more common among military veterans. In one study of nondeployed U.S. Army personnel, 11.2% of participants met the criteria for intermittent explosive disorder in the past 30 days; it was the most prevalent mental disorder, surpassing PTSD and attention deficit hyperactivity disorder [131].

Mouth and throat diseases, including tooth decay, periodontal disease, and oral cancers, cause pain and disability for millions of Americans each year [38]. Poor dental health is associated with impaired intake and systemic disease. As compared to decades ago, dental health has improved across the United States, which is primarily attributed to fluoridation of water and toothpaste and greater awareness of optimal oral hygiene. However, rural areas have a variety of factors that contribute to poor oral health [132]:

Ground ambulance transport is an efficient and appropriate method of transport for most ill and injured patients in this country. The number of ground transports increases annually and the appropriateness of these transports is unquestioned. However, there are instances in which ground transport is at a disadvantage. Adverse weather conditions can impact the vehicle's ability to traverse certain terrain. At the same time, this adverse weather can prevent air ambulances from flying, leaving ground transport as the only viable option. Time-in-transit is another drawback of ground transport. Some critically ill or injured patients cannot withstand the stressors of transport and the shorter the out-of-hospital time, the better that patient's chance for survival. Finally, when choosing to utilize a ground ambulance, the needs of the community should be examined. Some isolated rural areas have only a single ground ambulance to service a largely scattered population base. If this vehicle is taken out of service for an interfacility transport, the people of the community are temporarily left without the medical coverage they have come to expect.

Air transport should be considered an adjunct to, not a replacement for, ground transport. There are inherent dangers in transporting by air, and it is an expensive alternative. Many third-party providers are withholding reimbursement for flights, which are considered nonemergent. The advantage of fixed-wing transport is the ability to travel long distances at speeds between 250 and 570 miles per hour. Care is usually provided in a pressurized cabin with sophisticated on-board medical equipment. Many aircraft utilized for air transport of patients have the capability of transporting multiple patients, and in some instances, family members are allowed to accompany the patient. All-weather navigational equipment allows for the transfer of patients during inclement weather. Many of the dedicated aircraft utilized in air transports have been referred to as "flying ICUs."

Fixed-wing transport requires suitable airfields to ensure the safety of the crew and patient. Accessibility to such fields may be a problem in isolated areas. Optimally, a 5,000-foot paved runway located near the site of the patient would erase the disadvantages of air transport. However, because hospitals are located a considerable distance from most airfields, ground transport is utilized at the beginning and the end of the air transport. (Note: A unique situation exists in Anchorage, Alaska, where a regional referral medical center is located on the edge of an appropriate airfield and the patient can be off-loaded from the plane and wheeled directly into the hospital. This is far from the norm.) The patient should be moved in and out of the aircraft to a waiting ground ambulance and then transported from the referring hospital or to the receiving hospital. This increases the likelihood of the dislodgement of tubes, lines, etc. There is an additional cost associated with this supplemental ground transport.

Rural counties are also historically disadvantaged in terms of mental health services [136]. According to the CDC, more than 85 million Americans live in areas with an insufficient number of mental health providers; this shortage is particularly severe among low-income rural communities [86]. Rural Americans with mental health needs typically enter care later, have more serious symptoms, and require more costly and intensive treatment [141]. Patients in rural care settings are also more likely to be given pharmacotherapy for psychiatric illness due to a shortage of professionals qualified to provide psychotherapy.

Frontier and rural communities have a greater likelihood of experiencing a nurse shortage than urban areas for multiple reasons. Most rural areas cannot compete economically with the urban areas for nurses, and urban nurses may not have the training preparation to cross over into rural health care [147,148]. Policy solutions aimed at reducing nursing shortages in frontier and rural communities should consider that it is a different nursing context than an urban environment. Solutions that emphasize improving competitiveness may be short-lived and draw nurses away from and exacerbate the shortage elsewhere—possibly other rural and frontier areas [147,148]. To improve the healthcare workforce capacity in rural communities, stakeholders should focus on community-based development approaches. Approaches failing to address the well-being of the community in a holistic sense will not improve nursing shortages over the long term. Building the capacity of the public health workforce is a priority policy solution [136]. An adequate rural workforce supply is expected to offset the shortage of preventive services and to prevent hospitalizations [145].

Emergency response services are a vital part of the rural healthcare system. The goal of the EMS system is to provide a coordinated, timely, and effective response to medical emergencies. As discussed, the distances between population centers and the need to transport patients from hospitals and nursing homes in small communities to larger facilities make these services essential in rural areas [151]. Advanced life support units respond to life-threatening events requiring immediate attention (e.g., stroke) and aim for an immediate response time. Rural factors such as difficult geographic terrain, a longer travel time to patient and/or facility, and weather-related factors can be potential barriers for an optimal response time. For prehospital EMS, travel time and distance to the patient location alone can far exceed an eight-minute threshold [152].

Persons living in rural areas have an increased need for prehospital care and emergency transport. Rural residents tend to be older, poorer, and sicker than those living in urban areas [32]. The death rates for rural unintentional injuries (e.g., motor vehicle crashes, drug overdose) are about double that of urban areas [151]. Residents not able to access emergency or prehospital services (e.g., for an acute cardiac event or stroke) are more likely to experience an unfavorable clinical outcome. Furthermore, patients with restricted access to medications, equipment, or special care they need (more common among rural patients) are at increased risk of complications and death during an emergency [151].

Of the many federal agencies involved in public health, the CDC guides health promotion, prevention, and preparedness actions. The CDC provides public health resources, including the Division of Scientific Education and Professional Development, to strengthen and develop the public health workforce through historical literature, reports, guidelines, global and local health data for research, legislation, and policy [156].

The USDA also provides financial support and guidance for rural communities through its Rural Development program. This program supports loans to businesses, technical aid to agriculture producers, affordable housing, home safety and health repairs, public safety services, first responder equipment, and a spectrum of infrastructure assistance that addresses the social determinants of rural health [157].

The U.S. Environmental Protection Agency (EPA) is also an important part of the federal infrastructure to improve the health of rural communities. It protects the health and environment with guidance, oversight, and programs that ensure clean air, land, and water, making community life safer and healthier [155].

The role of these community-based and patient-directed organizations is to provide comprehensive, culturally competent, high-quality services, many times integrating access to pharmacy, mental health, substance use disorder, and oral/dental health services in areas where economic, geographic, or cultural barriers limit access to affordable healthcare services [162]. Compared with other primary care facilities, community health centers provide more screening for diabetes, hypertension, and breast and cervical cancer, and 80% of centers outperform benchmarks on diabetes control [163]. Even while serving more complex patients and more chronic illness than other primary care providers, community health center patient outcomes are reported to be the same or better than the outcome levels of outside providers [163]. One in seven people served by a community health center are rural residents, and because these community health centers are locally governed, the services they provide are more likely to be tailored to meet the needs of the local population. A common element across rural hospitals, clinics, and community health centers is their focus on the local community [138].

Compared with other Americans, AI/AN populations have long experienced lesser health and quality of life, having a greater proportion of disease burden and a lower life expectancy [168]. For example, AI/AN individuals are more likely than other Americans to die from chronic liver disease and cirrhosis, diabetes, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases [168]. Across all racial/ethnic groups in the United States, AI/ANs have the highest percentage of type 2 diabetes, which can lead to many complications and exacerbation of other chronic illnesses. As compared with the general population and other racial/ethnic groups, AI/AN children are disproportionately affected by dental disease, and oral health for school-aged children 6 to 9 years of age did not change significantly between 2012 and 2017 [169]. The compromised health of this population is believed to be rooted in historic economic adversity and poor social conditions [168].

A person may be regarded as eligible and within the scope of the IHS health care program if he or she is of AI/AN descent and belongs to the Indian community served by the IHS program, as evidenced by such factors as [158]:

In addition, care and treatment of non-Indians shall be provided for children, spouses, and pregnant women meeting certain requirements. This includes any individual who is 18 years of age or younger; is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and is not otherwise eligible for health services provided by the IHS [158]. Any spouse, including a same-sex spouse, of an eligible Indian who is not an Indian, or who is of Indian descent but is not otherwise eligible for the health services provided by the IHS, is eligible for such health services if the governing body of the Indian tribe or tribal organization providing such services deem them eligible by an appropriate resolution as a class. In addition, a non-Indian woman pregnant with an eligible Indian's child may receive IHS services for the duration of her pregnancy and through the postpartum period (usually six weeks after delivery) [158].

Nurses working in or with the IHS play a vital role in improving the health and well-being of AI/AN populations. The IHS conceptualizes its public health nursing program as autonomous—flexible and individualized. For those in the IHS, the primary focuses of the public health nurse are on prevention of illness; promotion and maintenance of health through the provision of therapeutic services, counseling, and education; and advocacy [158]. This is accomplished through assessment and identification of individual, family, and community needs; consumer participation; and the planning and coordination of community health programs and services. In this environment, the public health nurse takes into account the prevailing economic, cultural, social, and geographic characteristics of his or her patients. Nursing actions are considered dependent, interdependent, and intradependent with other disciplines, and nurses are part of an interprofessional team of providers [158]. Many of the IHS sites throughout 35 states are in rural remote areas, and IHS nurses have connections with patients, the greater community, clinics, and hospitals.

Adequate sanitation facilities are lacking in approximately 38,000 AI/AN homes (or 9.5%). Of these homes, approximately 7,100 (or 1.8%) lack access to a safe water supply and/or waste disposal facilities, compared with less than 1% of homes for the U.S. general population [178]. Unregulated and unsafe water sources and poor waste disposal practices increase individuals' risk for infectious diseases (particularly waterborne disease). Lack of potable drinking water may also result in individuals relying on high-calorie drinks for hydration, which has been linked to overweight/obesity and diabetes.

Medicaid is a federal-state joint public program providing health services to children, pregnant women, parents, seniors, and disabled persons, and it is considered the largest U.S. healthcare insurance provider [191]. It is administered by the states, and states have a good amount of discretion on the Medicaid program they provide, resulting in interstate variation in programs. Skilled long-term care that is largely used by disabled seniors is covered under Medicaid, and this coverage was expanded by the 2010 Affordable Care Act, giving consumers the choice of traditional care at a long-term care facility or receiving services in a community-based setting, including home. Although the federal law has authorized community-based services, not all states and their locales offer this option, instead limiting covered care to state-run nursing homes for long-term care [191]. According to the National Conference of State Legislatures, "rural seniors with unmet personal and healthcare needs may be prematurely forced into assisted living or nursing homes because they are unable to live independently in their own home or community. The shift to institutionalization not only restricts consumer choice and satisfaction, but it is a major cost driver for state Medicaid programs" [141]. In rural communities, there are fewer support services for elderly patients and fewer options for long-term care services. Rural health clinics certified to give home health services are an option when there is no home health agency in the area. These clinics can supply visiting nurse services to home-bound patients in areas with shortages of certified home health agencies [192].

Public health services, particularly preventive health services (e.g., screenings for chronic disease, immunization programs, health counseling services) are important for maintaining the quality of life and wellness of older adults [193]. However, rural seniors are often disadvantaged in regard to social services and health care due to lack of financial resources in rural areas [190]. Rural residents may find it difficult to access healthy food, with some rural households or residents considered "food insecure," which is defined as having limited access to nutritious and affordable foods. Food insecurity has been associated with chronic disease and poor health, and in the long term, it can affect learning, development, productivity, physical and mental health, and family life [194]. The USDA reports food insecurity rates for rural areas to be 11.6% in 2020 [194]. The factors underlying community-level food security issues are complex and include social, economic, and institutional factors. Households with limited resources use a variety of methods to help meet their food needs. Some participate in federal food and nutrition assistance programs or obtain food from emergency providers in their communities to supplement the food they purchase [195]. There are food assistance programs specifically available for elderly persons living in rural areas. Nutrition services made available by the Older Americans Act include the Congregate Nutrition Program and the Home-Delivered Nutrition Program, which provide healthy meals in group settings, such as senior centers and faith-based locations, as well as in the homes of older adults who live alone [195]. The USDA administers the Senior Farmers' Market Nutrition Program, which awards grants to states, territories, and federally recognized Indian tribal governments to provide low-income seniors with coupons that can be exchanged for eligible foods (i.e., fruits, vegetables, honey, and fresh-cut herbs) at farmers' markets, roadside stands, and community supported agriculture programs. The goal of this program is to provide better access to fresh foods to older adults with poor access to a healthy diet. More information on government nutrition programs for older individuals is available online at https://www.nutrition.gov.

Health promotion and disease prevention are important objectives for the U.S. public health system. As discussed, there are many key players working in partnership to improve the system. Among them is the CDC, which maintains several campaigns for healthier lives, including those focused on smoke-free environments, healthy daily nutrition, physical activity, and health-friendly communities [202]. The CDC promotes a cross-cutting intervention and multi-stakeholder collaboration approach that can be used to mitigate chronic conditions and related risk factors. The CDC offers four areas of intervention for offsetting chronic disease and promoting population health [203]:

Healthcare system interventions to improve clinical preventive services are necessary in order to more effectively deliver clinical and other services to prevent, detect early, and mitigate diseases in all populations, including those in rural communities [203]. System enhancements can have effect on the organization, the people engaged in the healthcare system, the population being served, and other parties (e.g., insurance carriers). Telehealth and electronic health records are examples of initiatives aimed at enhancing the health system. Federal laws have been enacted largely supporting health technology and more are being passed on the state level, laying a legal foundation to make technology in healthcare work better.

A key government agency working toward eliminating disparities and improving access to care is the Health Resources and Services Administration. This is the primary federal agency responsible for improving health care for people who are geographically isolated and/or economically or medically vulnerable [219]. In an effort to strengthen the healthcare workforce, the Health Resources and Services Administration is aiming to advance professional competencies of health workers and to improve the diversity of the workforce, which will improve the ability of providers to meet the needs of underserved populations and correct the maldistribution of the workforce [220].

The original goal for telehealth was to improve consumer access to healthcare professionals for persons living in federally designated professional shortage areas and the other underserved areas [136]. Most rural states have historically used telehealth for this purpose.

An early form of Internet use in public health was information sharing or using technology to disseminate health information to the general public. Agencies place information on their websites to educate the public on outbreaks, preventive medicine recommendations, health plans, providers, and health insurance [228]. The CDC uses their website, social media accounts, and listservs to disseminate information to providers and the public, including information on disease outbreaks and pandemics, food recalls, travel health, and health statistics. The Internet can make tracking disease, gathering data, and administrative decisions on population health issues more efficient and reliable. It has the potential to enhance the detection of disease outbreaks by enabling the efficient sharing of surveillance data. In a public emergency, effectively sharing data may influence a better response for outbreak coordination and management [229].

Educating communities is an important component of public health nursing, and the Internet is a health-education medium that can be used to empower patients with knowledge, expose them to information covering a spectrum of health and wellness programs, and link them with providers and services [231]. The Southern Nevada Health District created an Internet and social media educational campaign regarding the health risks of cigarette smoking and e-cigarette use in teens. This online nicotine prevention campaign is reported to have reached at least 2,400 people on social media, 27,130 people via online campaign videos, and 287,000 via online messaging; a reported 1,113 teens took the educational campaign's online training to learn how they can help promote nicotine-free living among their peers using social media [231].

Federal and state governments have passed incentive-type laws to improve the workforce capacity in health professional shortage areas. As discussed, an example of these incentives is loan repayment programs for practitioners who work in shortage areas [239]. The Nurse Corps Loan Repayment Program helps with nursing education debts in return for the registered or advance practice nurse working in an eligible critical shortage facility in a high-need area [240]. A critical shortage facility is defined as a public or private nonprofit healthcare facility located in, designated as, or serving a health professional shortage area having shortages in the primary care or mental-health workforce [240]. As of 2018, 36 states and the District of Columbia have implemented state loan repayment programs and receive grants from the National Health Service Corps to help fund these programs. Some states have expanded the program to other regions. Nevada and New Hampshire, for instance, expanded the criteria for health workers receiving financial support or loan forgiveness to include those who provide services to medically underserved populations and in other needy locations [134]. In all, the majority of states have passed laws providing an incentive for practitioners to seek work in professional shortage areas and other underserved needy areas.

Another initiative to build workforce capacity is the community health worker. Community health workers have a strong understanding of their communities and serve as a liaison between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery [243]. Providing invaluable support to public health and private care, they are found in public health departments, community locations, primary care settings, and hospitals, and are generally well-positioned to reach patients in rural settings [244]. The role of the community health worker is broad and includes conducting outreach for community health promotion programs, providing community education, and collecting assessment data on community health needs [245]. Community health workers have a long history of service in the United States and are known by many titles, such as community health advisors, lay health advocates, outreach educators, community health representatives, peer health promoters, and peer health educators [244]. Some states have passed laws defining the role of the community health worker, developing standards or credentials, defining their training and certification needs, and collecting community health worker workforce data [141].

Educating children early regarding healthy lifestyle habits (e.g., good nutrition, physical activity) can promote school performance and help mitigate unhealthy living and disease later in life. In 2012, the CDC introduced the early care and education concept to promote healthy practices early in life, bringing "good habits" into early care facilities and schools. This idea of teaching healthy habits early is based on the belief that it is easier to influence children's food and physical activity choices when they are young, before habits are formed. Developing healthy habits for physical activity and diet early in life can influence daily practices as individuals grow and can favorably influence a child's cognitive development [254]. Early care and education programs promote social, emotional, cognitive, and motor skill development for the very young (up to 3 to 4 years of age). In addition to healthy physical activity, some programs include nutritious meals, support for parents, health screening, and social services. Early care and education programs may be delivered in a variety of ways and settings, including state and district programs (available to all children), federal Head Start programs for low-income children and families, and other programs targeting low-income children at risk. These early childhood education programs are reported to lessen the chance for obesity, improve child cognitive development, reduce the incidence of child abuse and neglect, lessen youth violence, and limit use of emergency department services [255].

The CDC framework for promoting classroom health is called the Whole School, Whole Community, Whole Child (WSCC) model. It is a student-centered model that emphasizes the role of the community in supporting the school, the connections between health and academic achievement, and the importance of evidence-based school policies and practices [260]. The WSCC model aligns the goals of education, public health, and school health. Because school education and public health give service to the same population and in the same setting, the WSCC model depends on collaboration between the sectors interested in promoting youth cognitive, emotional, physical, and social development. The elements of WSCC create a model for promoting a whole-child approach to education and include [260]: