Improving the health of rural populations around the country continues to lag behind urban areas, particularly when it comes to the leading causes of death.

Fresh air. Wide open spaces. Starry skies above.

Rural America has long claimed a reputation as a healthy place to live.

But the truth is that rural areas in the United States generally lag behind urban areas in many aspects of health.

A new study released this month by researchers at the Centers for Disease Control and Prevention (CDC) highlights the health situation for those living the country life.

Americans living in rural areas face a higher risk of dying from the five leading causes of death in the United States — heart disease, cancer, lower respiratory disease, stroke, and unintentional injuries — compared with their urban counterparts.

“This report confirms the findings that we’ve seen in previous studies about rural populations tending to be older, poorer, and sicker,” Dr. Daniel Derksen, director of the Arizona Center for Rural Health, told Healthline.

Using mortality data from the National Vital Statistics System, CDC researchers determined that these five leading causes accounted for almost 62 percent of all deaths in the country.

Between 1999 and 2014, death rates for heart disease and cancer dropped across the country, but both fell more slowly in nonmetropolitan, or rural, areas.

Urban and rural areas saw similar drops in the death rates for stroke.

Death rates for chronic lower respiratory disease — which includes chronic obstructive pulmonary disease (COPD) — decreased in urban areas, but increased in rural areas.

Researchers also estimated the percentages of “potentially excess deaths” by comparing the death rates in counties in states with the lowest rates.

These excesses for heart disease, unintentional injury, and chronic lower respiratory disease were higher in rural areas. They also are potential targets “for public health prevention efforts focused on rural populations,” the study authors wrote.

The rural-urban health gap, though, extends beyond disease mortality.

“It’s not just the increased death rate, which is concerning and unacceptable enough,” said Derksen, “It’s also the collateral damage that these diseases cause.”

Accidents and chronic diseases can lead to disability, which makes it harder for people to work.

This can snowball, with people not being able to afford doctor visits, lab tests, prescription medications, or even a car to get to their appointments.

Read more: COPD risk is higher in poor and rural communities »

In 2014, approximately 15 percent of Americans — or 46 million people — lived in nonmetropolitan counties, spread across 72 percent of the country’s land area.

Overall life expectancy in the United States has increased over the past decades, but more slowly in rural areas. One study found that the life expectancy gap between urban and rural areas has grown from 0.4 years in 1971 to 2.0 years in 2009.

Unhealthy behaviors may be dragging down the life expectancy and health of Americans living in rural areas.

According to the South Carolina Rural Health Research Center, Americans in rural areas are more likely to smoke, use alcohol or other substances, be physically inactive or overweight, or have poor access to healthy foods. They are also more likely to not wear car seat belts, a factor in motor vehicle deaths.

Childhood obesity is also a particular problem in rural areas, with 25 percent of children overweight in 2008, compared with 19 percent of urban children.

Certain types of substance abuse affect rural areas more than urban ones, as well.

“The opioid epidemic has been getting much attention in the press, and it’s certainly one that’s affecting rural areas more than urban areas, and rural areas have fewer resources to address it,” Carrie Henning-Smith, Ph.D., M.P.H., M.S.W., a research associate at the University of Minnesota Rural Health Research Center, told Healthline.

A 2012 study by the Maine Rural Health Research Center concluded that alcohol use and binge drinking were more common among 12- to 13-year-olds in rural areas, compared with youth of the same ages in urban areas.

According to the Rural Health Information Hub, abuse of prescription opioids in the past year was more common in adults in urban areas than those in rural area. But rates of deaths and injuries from misuse of these drugs was higher in states with high rural populations.

Read more: Babies born with drug withdrawal symptoms skyrocketing in rural areas »

In addition to the unhealthy behaviors identified by the authors of the CDC report, other factors lie behind the rural-urban health gap.

“A lot of rural health disparities are driven not by one particular health issue, but by differences in the social determinants of health,” said Henning-Smith.

Those include unequal access to jobs or education, transportation, social activities, recreational facilities, and even whether there are sidewalks to encourage people to walk more.

“All of those things that we think of as going with health and being part of this healthy lifestyle aren’t necessarily embedded into the fabric of rural communities in the way they are in urban communities,” added Henning-Smith.

Economic factors, in particular, drain the health of rural America.

According to the Kaiser Commission on Medicaid and the Uninsured, rural areas have higher rates of poverty and unemployment as well as lower household incomes compared with urban areas. They also have lower rates of college or university education.

These are all linked to an increased risk of death, unhealthy behaviors, poor access to healthcare, and inadequate quality of care.

Specific populations in rural areas may face their own unique problems.

Along the U.S.-Mexico border in Arizona, “there are not enough health providers that speak Spanish,” said Derksen. “Being able to communicate effectively in the language which they’re most comfortable with is an important factor” in accessing medical care.

In addition, Derksen added, “some chronic diseases tend to be more prevalent in certain populations,” including higher rates of type 2 diabetes in Hispanic adults.

Older people in rural areas — because of the larger distance from family and neighbors — are especially at risk of social isolation.

“A person might go longer without someone noticing that they’re not doing well,” said Henning-Smith. “So they might go longer without screening or treatment than someone who is in really close contact with people.”

Then there are the wide open spaces to contend with.

Some of the counties in Arizona are bigger than many New England states. And New England’s population is more than double that of Arizona.

People may have to travel hours to get to the doctor or hospital. Without a car — or services like Uber or Lyft, which are not common in rural areas — this can be daunting.

According to a 2005 USDA Information Bulletin, Americans living in rural areas without cars are more dependent on public transportation. But only 60 percent of rural counties offer any services.

“It’s not as though people in urban areas don’t also live in poverty or struggle to afford a car,” said Henning-Smith. “But there’s the infrastructure to get to the doctor if they need to. There are public transportation options — albeit not perfect — but they exist. In a lot of rural communities, they don’t exist at all.”

And when older adults are placed in long-term care facilities, they may end up far from home.

“That’s really disruptive for someone who’s lived their whole life, or a good portion of their life, in a community,” said Henning-Smith, “to suddenly find themselves somewhere else just to get the care that they need.”

Read more: Labor, delivery rooms closing at rural hospitals »

Some of these issues may be easier to address than others.

In a related commentary, CDC authors call for improved public health prevention efforts focused on rural populations.

These would target risk factors for the leading causes of death through increased screenings for high blood pressure, cholesterol, and cancer, as well as smoking cessation programs. It would also include educating people about eating better, exercising more, and motor vehicle safety.

Others see a need for a broader approach.

“How do we really transform lives and communities, not only within the doctor’s office, but throughout every aspect of their lives?” said Henning-Smith. “We know this impacts health much more than what happens just in the doctor’s office.”

Part of the challenge again is the fabric of rural America.

“These are very large areas, often considered frontier in terms of population density,” said Derksen. “How do you get the information out to those folks who really need it?”

Public health and education efforts alone will not reduce rural health disparities.

Compared to cities, rural areas suffer from two factors that continue to widen the health gap.

“The combination of not enough providers, not enough clinics, not enough hospitals — along with a high rate of uninsured — is a kind of a recipe for health system failure,” said Derksen.

These issues can limit people’s access to healthcare — and to the screenings, vaccinations, and treatments that can improve a person’s health or reduce the severity of a disease.

According to the Rural Health Information Hub, less than 10 percent of doctors set up practice in rural areas.

“There are often not the number or array of specialty physicians, clinics, and hospitals readily available for people to access primary care, preventive, and specialty services,” said Derksen.

Rural demographics play a role, too, as seen with a shortage of caregivers for older adults.

“There’s not the same workforce, partly because the population structure is different,” said Henning-Smith “You don’t have the same number, or proportion, of younger folks there to help take care of older folks.”

Programs like the National Health Service Corps, which offers loan forgiveness to providers who practice in rural areas, take a financial incentive approach to luring providers to these more remote locations.

But sometimes exposing people to the best of rural America is enough to keep them there.

“When we educate our health professionals in these types of areas,” said Derksen, “they tend to go into those areas to practice more often.”

Read more: Turning rural doctors into multidisciplinary specialists »

One of the biggest successes for rural America in recent years was the Affordable Care Act (ACA) — in particular, provisions for the expansion of Medicaid in states, and subsidies to offset the cost of health insurance for many people.

“Those two factors halved our uninsured [in Arizona],” said Derksen. “Before these coverage provisions of the Affordable Care Act went into place, of our 6.5 million total population, 1.2 million were uninsured. We halved that.”

These factors also revitalized small, rural hospitals — known as Critical Access Hospitals. These hospitals, which have 25 beds or less and are 35 miles or more from another facility, serve a sparse population.

If someone without insurance shows up at a hospital needing care, most hospitals will treat them. This “charity care” is a drain on all hospitals, but more so on small ones that you find in rural areas.

Increased insurance coverage through Medicaid and federal insurance subsidies relieved some of this burden.

“Rural and critical access hospitals across the country have been closing at a very disturbing rate,” said Derksen. “That decline was certainly stabilized with the sharp reduction in uncompensated care, as more people were covered.”

With the Republican-controlled Congress already dismantling the ACA, the future health of people living in rural areas — like the healthcare system itself — remains uncertain.

“A lot of us in public health are apprehensive,” said Derksen. “I think ‘repeal and replace’ is a catchy phrase. It has a nice alliteration, but it’s not a health plan. It’s not a public health intervention in itself.”

However, rural voters played a big part in President Donald Trump’s election in November.

“Any politician would be prudent to pay attention to the constituents that got them into office,” said Derksen. “What I’m hopeful for is that there will be more health policy attention paid to rural populations.”