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Open Access

Essay

Climate change and health in the rural context: Vulnerability, capacity and outlook

Abstract

On a global scale, climate change is resulting in negative impacts to human health. As temperatures rise, morbidity and mortality rates continue to climb. While the health effects of climate change are experienced across regions, the burden is unevenly distributed. Rural communities in particular are disproportionately impacted. This essay aims to draw attention to the climate-health nexus from a rural perspective, emphasizing the necessity of centring the rural context at the forefront of the climate response. In this paper we showcase the unique characteristics of rural communities that increase their social and physical vulnerability to climate-health impacts, then discuss the constraining factors that reduce their capacity to respond to these impacts. In doing so, we highlight both the importance of ensuring rural populations are prioritized in the climate response, and suggest that efforts to do so are currently inadequate. We call attention to the dearth of climate-health research framed within the rural context, which further compounds the issue. Given the intersecting challenges that increase risk in rural communities, we argue that this perspective warrants further research attention.

Citation: Rose D, Birchall SJ (2026) Climate change and health in the rural context: Vulnerability, capacity and outlook. PLOS Clim 5(7): e0000974. https://doi.org/10.1371/journal.pclm.0000974

Editor: Stefan Wheat, University of Washington, UNITED STATES OF AMERICA

Published: July 23, 2026

Copyright: © 2026 Rose, Birchall. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was conducted with financial support from the Social Sciences Humanities Research Council (SSHRC) of Canada.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

On a global scale, climate change is resulting in widespread impacts to human health [1,2]. In nearly all greenhouse gas emissions scenarios and modelled pathways, temperatures will continue to increase in the near term [3]. With every increment of warming, projected human morbidity and mortality rates grow rapidly [4–6].

The health effects of climate change are experienced across all regions; however, the burden is unequally distributed. Rural communities in particular are disproportionately impacted [7]. This is the result of characteristic features such as remote geography, reduced access to health and emergency services, and factors related to the social determinants of health (Box 1) [8,9].

Box 1. Climate-health impacts in rural communities.

The health risks posed by climate change are extensive and vary widely, threatening a range of body systems and processes [10]. Within the literature, these climate-health impacts are categorized into three distinct pathways: primary, secondary, and tertiary effects [11]. The primary pathway refers to the direct effects of climate impacts; secondary effects result from changes to the environment that indirectly impact health; and, tertiary effects relate to the environmental changes that modify the social determinants of health, subsequently affecting health outcomes [9].

Within rural communities, the primary effects of climate change include increased respiratory disease as a result of drought; unintentional injury related to fire, flooding and storms; and, heat-related illness resulting from extreme heat events [9,12]. Secondary effects in rural communities largely consist of mental health challenges, food and water insecurity, and increased incidence of disease [12]. For instance, extreme weather events modify environmental conditions and subsequently affect disease pathogens, resulting in increased rates of infectious disease such as Dengue and Q-fever [9]. Climate impacts also produce tertiary effects, which include increased risk of maternal mortality, malnutrition, and domestic violence. For example, intense flooding in rural communities may disrupt access to medical services, resulting in poor health outcomes in an emergency event [9].

With approximately 43% of the global population living in rural settings [13], its essential that these communities are adequately prepared to face the impacts associated with climate change. Adaptation – which can be understood as the process of adjusting to the effects of climate change in order to moderate harm – has been recognized in the literature as a key strategy for safeguarding health [14]. Adaptation strategies targeted to protecting health (henceforth referred to as ‘health adaptation’) can include improving access to potable water, reducing exposure of sanitation systems to flooding, strengthening surveillance and early warning systems, and developing heat health action plans [3].

Local governments have an important role to play in health adaptation; they are the level of government closest to the impacts, and are equipped with the ability to implement local-scale plans/ policy [15–18]. Urban planning is the mechanism through which local governments can effectively implement health adaptation within their communities. Urban planning tools, such as strategic plans/ policy, zoning, and regulations, are key governance devices that guide local-scale decision-making [19]. These tools can be leveraged to address climate-health impacts, and are noted within the literature to facilitate the delivery of a health-adaptation agenda [17,20,21]. For instance, a recent study from Sheehan et al. [22] exploring highly health adaptive communities identified substantial involvement of urban planning in the implementation of health-adaptation strategies, particularly those related to extreme heat management, climate hazard mapping, and preparedness/ response.

Despite this, however, health adaptation lags [15]. Local governments often struggle to make progress on their health adaptation agendas [20] as a result of several constraining factors, such as a lack of capacity, climate change awareness, and political will [17,23,24]. Importantly, these challenges are frequently exacerbated in the rural context [25,26].

Thus, rural communities are both disproportionately at risk of experiencing climate-health impacts, and increasingly constrained in their ability to implement health adaptation strategies.

Given these intersecting and compounding challenges, there is an evident need to centre the rural context at the forefront of the climate response. Yet, scholarly attention remains focused on the urban (city) perspective, leaving rural communities largely understudied [10,27,28].

The purpose of this essay-style article is to demonstrate the importance of directing greater research attention towards the rural climate-health nexus. We showcase (i) vulnerability to climate-health impacts in rural communities; (ii) capacity to adapt; and, conclude with (iii) the current outlook on health adaptation, in order to justify the ramping up of rural-focused health adaptation research. Various definitions of the term ‘rural’ exist within the literature [12,29]. In this article, we employ the broad, inclusive definition used by Dewi et al. [9], which is simply “not urban”. Moreover, this article discusses rural communities primarily within the context of OECD countries; importantly, the experience of rural communities in high-income versus low-come countries differs greatly.

2. Factors affecting vulnerability in rural communities

According to scholars, populations that experience heightened vulnerability to climate impacts must be prioritized in the health adaptation response, particularly in the allocation of health resources and targeting of adaptation strategies [28]. As such, attention to the rural context is critical. There is a multitude of social and physical factors that modify vulnerability to health impacts in rural communities. Social vulnerability encompasses factors related to the social determinants of health, such as demographics and socio-economic indicators, while physical vulnerability relates to the environment, and includes factors such as geography and infrastructure [30]. Importantly, these factors intersect, compound and amplify each other, and are experienced differently by each individual.

2.1. Social factors

Researchers have identified several factors related to the social determinants of health that increase vulnerability in rural communities, often using the term “socio-vulnerability” to describe these elements [28,31]. Residents of rural communities are often older, have completed less formal education, and possess lower levels of health literacy [8,28,32]. They are also generally less affluent, experiencing lower income levels and higher rates of unemployment [33]. These social determinants of health have a significant influence on health outcomes, as they limit their ability to prepare for and recover from climate impacts [30,34,35].

The population health status of rural communities is also generally lower than that of urban communities [33]. A higher burden of disease persists in rural communities, with rural residents often characterized as being “sicker” than their urban counterparts [9,33]. Rural communities have increased rates of chronic illness, such as diabetes, hypertension, and hyperlipidemia, with residents often experiencing more than one of these conditions concurrently [32,36,37]. Further, rural residents are less likely to have health insurance, which reduces their access to medical care [28,38]. Ultimately, those with a lower baseline health status are increasingly susceptible to climate-health impacts, with effects generally being more severe [14,27,34].

On the other hand, social capital is often quite high in rural communities, which can decrease their vulnerability to climate-health impacts. Research suggests that residents of rural communities commonly have strong social bonds and social networks [39]. These social networks are often small, dense, and cohesive; when leveraged effectively, they can contribute to the sharing of resources and knowledge, and facilitate adaptation progress [24,12].

2.2. Physical environment factors

Rural communities are frequently characterized as being small, remote, and often challenged by a lack of infrastructure [8]. These factors have substantial implications for climate-health vulnerability. For instance, remoteness can limit resident access to social supports and community services [8]. Within rural communities, there is often large physical distances between parents and children, greater separation between neighbours, and less opportunity for social interaction, which has been noted to increase risk for social isolation [8,40,41]. During a climate event, this can heighten vulnerability to health impacts [42]. Research has identified remoteness, and by extension social isolation, as a key risk factor for mortality during periods of extreme heat [43,44]. This is largely due to the fact that socially isolated individuals are less likely to seek timely medical treatment.

Infrastructure challenges can also increase vulnerability to climate-health impacts [42]. Rural communities are often equipped with less of the infrastructure necessary to cope with climate impacts, such as spaces for public cooling zones (e.g., churches, senior centres, community halls) [8]. Transportation infrastructure is also generally limited, which can reduce access to emergency and essential services [12]. Research from Spitalar et al. [45] found that injury and mortality occur more frequently in US rural communities during flash floods, due in part to a lack of adequate transportation infrastructure (e.g., bridges). Further, rural communities must often contend with stressed and degraded infrastructure, and as climate impacts intensify, critical infrastructure disruption becomes increasingly likely. This poses major risks to health and safety [12].

Both remoteness and a lack of infrastructure limits access to healthcare, which reduces resident ability to mitigate health impacts during a climate event [9]. Rural communities generally have fewer healthcare facilities, and offer limited services [8]. Healthcare worker shortages are also more dire, with remote facilities facing increased challenges attracting and retaining personnel [46]. These shortages can trigger hospital closures, further reducing access to medical services [47]. Not only does a lack of health infrastructure increase travel time to care, patients are also less likely to seek out medical attention if they must travel long distances [29,47]. This delays treatment for both emergent climate-health issues, such as myocardial infarction related to extreme heat, and non-emergent issues, such as increased anxiety following a flood event [10]. According to Alanazy et al. [48], delayed treatment can substantially increase negative health outcomes.

Importantly, there are physical factors that decrease rural vulnerability to climate-health impacts. Rural communities are less impacted by the urban heat island effect, and maintain cooler temperatures overall [8]. This is the result of more green space and vegetation, greater ventilation, and a lower concentration of buildings, asphalt and concrete [8]. Despite these factors, however, some studies suggest that rural communities still experience poorer health outcomes related to extreme heat in comparison with urban communities, likely due in part to reduced access to healthcare, and lack of air conditioning in rural households [49,50].

3. Rural capacity to respond to climate-health impacts

Communities with lower capacity are more likely to experience a greater range, severity, and complexity of climate-health impacts [35]. Research points to several factors that constrain the capacity of rural communities to effectively prepare for and respond to climate impacts.

3.1. Resources

Rural communities face significant issues with resourcing [51]. Lack of funding is key challenge commonly described in the literature [25,39]. A small local tax base and less diversified local economy creates chronic financial burdens, limiting the ability of rural communities to allocate funds toward climate-health issues and prioritize health adaptation initiatives [24,12]. According to Fungfeld et al. [24], this results in “one-off”, short-term adaptation actions, rather than the mainstreaming of long-term initiatives into local policy. Further, these actions are often reliant on receiving external financial support [24,39].

Lack of administrative staff (i.e., planners) and time can also reduce the capacity of rural communities to develop and implement climate-health policy in response to impacts [25,52]. With fewer staff and departments, each unit must undertake a broader range of tasks [24,53]. As staff work to balance competing responsibilities, “optional” activities such as health adaptation are often relegated to a lower priority [25]. Moreover, rural communities frequently lack specialized staff with the expertise necessary to tackle climate-health challenges, and planners often lack the time necessary to develop a strong understanding of relevant climate hazards [25,54]. However, as previously indicated, rural communities do benefit from resources such as increased social capital, which can bolster capacity to address climate risks [39].

3.2. Knowledge

A lack of knowledge also reduces the capacity of planners and decision-makers in rural communities to adequately prepare for climate-health impacts. Locally-focused climate studies are often constrained due to limited financial resources. Decision-makers in rural communities must also contend with decreased access to sources of knowledge like research institutions and universities, as well as consulting firms [24]. As a result, rural planners frequently lack the necessary climate data and information to guide and inform the development of effective health adaptation policy [55].

Further compounding this issue is a lack of climate awareness within rural communities. Research demonstrates that public perception of climate change differs between rural and urban areas; risk perception is often lower in rural settings, with residents less likely to believe that climate change is a serious issue [56,57]. Rates of climate skepticism and climate denialism are also noted to be higher overall in rural communities [56]. These attitudes can act as a barrier to effective health adaptation action, reducing support for strategy development and policy mobilization [56,57].

Importantly, however, rural communities do possess strong local and place-based knowledge systems [12]. Residents tend to live with a close connection to their environment, often depending on it for their livelihood, wellbeing, and way of life [12]. When leveraged, these knowledge systems strengthen rural capacity, by providing extensive insight into climate-health impacts, and helping to inform the development of effective health adaptation policy [12]. Further, local knowledge is more easily accessed and integrated into planning processes within these smaller communities [24,54].

3.3. Politics

Diminished political will is another key factor that can reduce capacity to respond to climate-health impacts. An absence of strong climate leadership reduces the resources available to planners to effectively address the issue [55]. Within rural communities, decision-makers often hold conflicting beliefs with regard to the urgency of the climate crisis, and the extent to which it should be prioritized. Research from the United States shows that rural elected officials tend to demonstrate less support for federal environment policies, largely due to distrust in government oversight, thus creating an unfavourable political environment for health adaptation activities [25]. Further, rural communities are generally considered to be more conservative than their urban counterparts [58]. Studies show that conservative populations are less likely to believe in anthropogenic climate change, agree with scientific consensus, and see climate change as a serious risk [59].

4. Outlook and conclusion

Research demonstrates that progress on health adaptation in rural communities has been minimal thus far [25,39]. Some rural communities have begun to develop and implement health adaptation plans; for instance, in Canada, various communities have initiated efforts to improve health surveillance and monitoring programs, increase awareness of impacts, and build the capacity of the health sector [12]. Overall, however, scholars describe health adaptation efforts in rural communities as fragmented, underdeveloped, and ultimately inadequate [15,26]. When health adaptation does occur, strategies are generally reactionary responses to emergency situations, rather than long-term, ongoing, anticipatory efforts [9,24]. Moreover, adaptation efforts frequently stall in the planning/ policy development phase, with implementation significantly less common [20,24].

The past decade has seen a surge in climate-health scholarship [27]. However, the majority of this research has been framed in the urban context, while the rural perspective has received comparatively little attention [8,9,28]. Indeed, scholars emphasize that the rural perspective remains a prominent gap in the research [25]. For instance, in their systematic review exploring the health effects of climate change, Rocque et al. [10] found that only 1 of 94 articles was situated within the rural setting. Harper et al.’s [27] research likewise reveals a trend towards urban research, with 3 times as many climate-health studies conducted in urban settings, in comparison with the rural/ remote context.

Thus, as climate impacts continue to intensify, we argue that rural communities are at imminent risk of experiencing a “perfect storm”, in which heightened social and physical vulnerability, limited capacity, an underdeveloped adaptation response, and lack of research attention converge to create the conditions for crisis. To avoid this outcome, greater focus must be directed towards strengthening the rural health adaptation response. The first step in doing so is to devote increased scholarly attention towards this understudied perspective. A robust body of rural-focused research will support decision-makers in their efforts to mobilize effective health adaptation efforts. Directions for future research include investigating how key actors in rural communities perceive, prepare for, and respond to climate-health impacts. Addressing research gaps related to the development, implementation and efficacy of health adaptation interventions in a rural context is also a key priority [25,34]. Additionally, the application of a planning lens is an important avenue for inquiry, given that planning is the mechanism through which health adaptation is operationalized at the community level [22]. There is a need to better understand how the climate-health nexus is considered and integrated within local plans/ policy in rural communities.

This essay-style article emphasizes the importance of centering rural communities at the forefront of the health adaptation response. Given the myriad of intersecting factors that heighten risk for climate-health impacts in these communities, health adaptation uptake here is critical. Yet, little progress has been made thus far. Efforts must be significantly bolstered in order to ensure rural residents are adequately prepared and protected.

Highlights

  • Climate change poses an increased risk to health in rural communities, as a result of physical and social factors that compound and amplify vulnerability, and reduced capacity for response.
  • Despite initial progress being made, health adaptation efforts are currently inadequate in rural communities. Health adaptation initiatives are generally fragmented and underdeveloped, and implementation lags.
  • In order to better support local rural decision-makers in mobilizing effective health adaptation action, greater research must be directed towards the rural context.

References

  1. 1. Campbell-Lendrum D, Neville T, Schweizer C, Neira M. Climate change and health: three grand challenges. Nat Med. 2023;29(7):1631–8. pmid:37464036
  2. 2. Murray EC, Montgomery H. The “climate emergency”, and how we respond. Future Healthc J. 2025;12(1):100228. pmid:40236930
  3. 3. Intergovernmental Panel on Climate Change. (2023). Climate change 2023: Synthesis report [PDF]. Available from: https://www.ipcc.ch/report/ar6/syr/downloads/report/IPCC_AR6_SYR_SPM.pdf
  4. 4. García-León D, Masselot P, Mistry MN, Gasparrini A, Motta C, Feyen L, et al. Temperature-related mortality burden and projected change in 1368 European regions: a modelling study. Lancet Public Health. 2024;9(9):e644–53. pmid:39181156
  5. 5. World Health Organization. Climate change [Web page]. 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
  6. 6. van Daalen KR, Romanello M, Rocklöv J, Semenza JC, Tonne C, Markandya A, et al. The 2022 Europe report of the Lancet Countdown on health and climate change: towards a climate resilient future. Lancet Public Health. 2022;7(11):e942–65. pmid:36306805
  7. 7. Kennedy AM, Tsakonas K, Berman-Hatch F, Conradi S, Thaysen M, Gillespie MA, et al. Promoting community health and climate justice co-benefits: insights from a rural and remote island climate planning process. Front Public Health. 2024;12:1309186. pmid:38532965
  8. 8. Fastl C, Arnberger A, Gallistl V, Stein VK, Dorner TE. Heat vulnerability: health impacts of heat on older people in urban and rural areas in Europe. Wien Klin Wochenschr. 2024;136(17–18):507–14. pmid:39158652
  9. 9. Dewi SP, Kasim R, Sutarsa IN, Hunter A, Dykgraaf SH. Effects of climate-related risks and extreme events on health outcomes and health utilization of primary care in rural and remote areas: a scoping review. Fam Pract. 2023;40(3):486–97. pmid:36718099
  10. 10. Rocque RJ, Beaudoin C, Ndjaboue R, Cameron L, Poirier-Bergeron L, Poulin-Rheault R-A, et al. Health effects of climate change: an overview of systematic reviews. BMJ Open. 2021;11(6):e046333. pmid:34108165
  11. 11. Butler CD, Higgs K. Climate Change and Global Health: Primary, Secondary and Tertiary Effects. Cabi; 2024.
    • 12. Vodden K, Cunsolo A, Harper S, Kipp A, King N, Manners S, et al. Rural and remote communities: National issues report. 2021. Available from: https://changingclimate.ca/site/assets/uploads/sites/3/2021/01/Chapter-3_Rural-and-Remote-Communities_Final_EN-1.pdf
    • 13. World Bank Group. Rural population (% of total population) [Web page]. 2023. Available from: https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS
    • 14. Berry P, Blagden P, Campagna C, Egyed M, Enright P, Gosselin P, et al. Health of Canadians in a changing climate: Advancing our knowledge for action. 2022. Available from: https://changingclimate.ca/site/assets/uploads/sites/5/2022/02/CCHA-REPORT-EN.pdf
    • 15. Romanello M, Di Napoli C, Drummond P, Green C, Kennard H, Lampard P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. Lancet. 2022;400(10363):1619–54. pmid:36306815
    • 16. Araos M, Austin SE, Berrang-Ford L, Ford JD. Public health adaptation to climate change in large cities: a global baseline. Int J Health Serv. 2016;46(1):53–78. pmid:26705309
    • 17. Austin SE, Ford JD, Berrang-Ford L, Biesbroek R, Ross NA. Enabling local public health adaptation to climate change. Soc Sci Med. 2019;220:236–44. pmid:30472516
    • 18. Roser-Renouf C, Maibach EW, Li J. Adapting to the changing climate: an assessment of local health department preparations for climate change-related health threats, 2008-2012. PloS One. 2016;11(3).
    • 19. Smith G, Martin A, Wenger DE. Disaster Recovery in an Era of Climate Change: The Unrealized Promise of Institutional Resilience. Handbooks of Sociology and Social Research. Springer International Publishing; 2017. pp. 595–619. https://doi.org/10.1007/978-3-319-63254-4_28
      • 20. Rose D, Birchall SJ. Bolstering community resilience through health-focused climate change adaptation: moving from talk to action in Western Canadian communities. Climate Policy. 2024;24(9):1225–41.
      • 21. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: The public health response. Am J Public Health. 2008;98(3):435–45.
      • 22. Sheehan MC, Khudairi F, Swaich GS, Hines W, Mehta S, Fox MA. Urban climate-health governance: Charting the role of public health in large global city adaptation plans. PLOS Clim. 2022;1(3):e0000012.
      • 23. Susskind L, Kim A. Building local capacity to adapt to climate change. Climate Policy. 2021;22(5):593–606.
      • 24. Fünfgeld H, Fila D, Dahlmann H. Upscaling climate change adaptation in small- and medium-sized municipalities: current barriers and future potentials. Curr Opin Environ Sustain. 2023;61:101263.
      • 25. Vo MV, Ebi KL, Busch Isaksen TM, Hess JJ, Errett NA. Addressing capacity constraints of rural local health departments to support climate change adaptation: action is needed now. Int J Environ Res Public Health. 2022;19(20):13651. pmid:36294229
      • 26. Arnold JL, Cangelosi E, Beyea WR, Shaaban A, Kim S-K. Rural climate resilience through built-environment interventions: modified deliberation with analysis as a tool to address barriers to adaptive capacity. Region Stud Region Sci. 2020;8(1):1–24.
      • 27. Harper SL, Cunsolo A, Babujee A, Coggins S, De Jongh E, Rusnak T, et al. Trends and gaps in climate change and health research in North America. Environ Res. 2021;199:111205. pmid:33961824
      • 28. Kearney GD, Jones K, Bell RA, Swinker M, Allen TR. Climate change and public health through the lens of rural, Eastern North Carolina. N C Med J. 2018;79(5):270–7. pmid:30228131
      • 29. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–20. pmid:26025176
      • 30. Rolfe MI, Pit SW, McKenzie JW, Longman J, Matthews V, Bailie R, et al. Social vulnerability in a high-risk flood-affected rural region of NSW, Australia. Nat Hazards. 2020;101(3):631–50.
      • 31. Flanagan BE, Gregory EW, Hallisey EJ, Heitgerd JL, Lewis B. A social vulnerability index for disaster management. J Homeland Security Emerg Manage. 2011;8(1).
      • 32. Eddy E, Musser M, Kahle R. Transforming education for rural health equity: lessons from a rural and underserved health scholars program. Curr Pharm Teach Learn. 2025;17(1):102213. pmid:39426013
      • 33. Houghton A, Austin J, Beerman A, Horton C. An approach to developing local climate change environmental public health indicators in a rural district. J Environ Public Health. 2017;2017:3407325. pmid:28352286
      • 34. Smith GS, Anjum E, Francis C, Deanes L, Acey C. Climate Change, environmental disasters, and health inequities: the underlying role of structural inequalities. Curr Environ Health Rep. 2022;9(1):80–9. pmid:35338470
      • 35. Bailie R. Climate-related natural disasters: reflections on an agenda for rural health research. Int J Environ Res Public Health. 2023;20(8):5553. pmid:37107834
      • 36. Nielsen M, D’Agostino D, Gregory P. Addressing Rural Health Challenges Head On. Mo Med. 2017;114(5):363–6. pmid:30228634
      • 37. Disler R, Glenister K, Wright J. Rural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: a systematic integrative review. BMC Public Health. 2020;20(1):770. pmid:32448173
      • 38. Sven T. Rural health inequities: data and decisions. Lancet. 2015;385(9980):1803. pmid:25987137
      • 39. Miller ZJ, O’Brien C, Canfield C, Sullivan L. Show-me resilience: assessing and reconciling rural leaders’ perceptions of climate resilience in Missouri. Environ Manage. 2023;72(4):771–84. pmid:37253850
      • 40. Henning-Smith C, Moscovice I, Kozhimannil K. Differences in social isolation and its relationship to health by rurality. J Rural Health. 2019;35(4):540–9. pmid:30609155
      • 41. Vogelsang EM. Older adult social participation and its relationship with health: rural-urban differences. Health Place. 2016;42:111–9. pmid:27755999
      • 42. Li A, Toll M, Bentley R. Mapping social vulnerability indicators to understand the health impacts of climate change: a scoping review. Lancet Planet Health. 2023;7(11):e925–37. pmid:37940212
      • 43. Kafeety A, Henderson SB, Lubik A, Kancir J, Kosatsky T, Schwandt M. Social connection as a public health adaptation to extreme heat events. Can J Public Health. 2020;111(6):876–9. pmid:32180181
      • 44. Yardley J, Sigal RJ, Kenny GP. Heat health planning: the importance of social and community factors. Glob Environ Change. 2011;21(2):670–9.
      • 45. Špitalar M, Gourley JJ, Lutoff C, Kirstetter P-E, Brilly M, Carr N. Analysis of flash flood parameters and human impacts in the US from 2006 to 2012. J Hydrol. 2014;519:863–70.
      • 46. Russell D, Mathew S, Fitts M, Liddle Z, Murakami-Gold L, Campbell N, et al. Interventions for health workforce retention in rural and remote areas: a systematic review. Hum Resour Health. 2021;19(1):103. pmid:34446042
      • 47. Mills CA, Yeager VA, Unroe KT, Holmes A, Blackburn J. The impact of rural general hospital closures on communities-A systematic review of the literature. J Rural Health. 2024;40(2):238–48. pmid:37985431
      • 48. Alanazy ARM, Wark S, Fraser J, Nagle A. Factors impacting patient outcomes associated with use of emergency medical services operating in urban versus rural areas: a systematic review. Int J Environ Res Public Health. 2019;16(10):1728. pmid:31100851
      • 49. Mendrinos A, O’Brien J, Davis M, Baldwin A, Zaitchik BF, Britton A, et al. Association between summertime emergency department visits and maximum daily heat index in rural and non-rural areas of Virginia (2015-2022). Sci Total Environ. 2024;948:174753. pmid:39025140
      • 50. Ahn M, Keith L, Brown HE. Rural heat health disparities: Evidence from the U.S. National Emergency Medical Services Information System (NEMSIS). J Clim Chang Health. 2025;22:100432. pmid:41646237
      • 51. Bausch T, Koziol K. New policy approaches for increasing response to climate change in small rural municipalities. Sustainability. 2020;12(5):1894.
      • 52. Birchall SJ, Bonnett N, Rose D, Gilchrist E. Factors contributing to climate adaptation lag in practice: Insights from local and territorial government interactions. Environ Sci Policy. 2025;170:104097.
      • 53. Taylor JE, Poleacovschi C, Perez M. Evaluating the climate change adaptation barriers of critical infrastructure in rural Alaska. Clim Dev. 2022;15(7):553–64.
      • 54. Jeff Birchall S, Bonnett N. Thinning sea ice and thawing permafrost: climate change adaptation planning in Nome, Alaska. Environ Hazards. 2019;19(2):152–70.
      • 55. Hamin EM, Gurran N, Emlinger AM. Barriers to municipal climate adaptation: examples from coastal Massachusetts’ smaller cities and towns. J Am Plann Assoc. 2014;80(2):110–22.
      • 56. Lachapelle PR, Albrecht DE. Addressing climate change at the community level in the United States. Routledge; 2018.
        • 57. Purcell R, McGirr J. Rural health service managers’ perspectives on preparing rural health services for climate change. Aust J Rural Health. 2018;26(1):20–5. pmid:28815911
        • 58. Dasgupta A, Ramirez E. Explaining rural conservatism: political consequences of technological change in the great plains. Am Polit Sci Rev. 2024;119(1):277–99.
        • 59. Tranter B. It’s only natural: conservatives and climate change in Australia. Environ Sociol. 2017;3(3):274–85.