Community Context 

Rural Monona County, Iowa, is bordered on its western edge by the Missouri River and is part of the Siouxland region of the U.S. Two of its larger towns are Onawa (the county seat) and Mapleton. Most of the county is made up of unincorporated farmland and open space and recreation areas in the Loess Hills. 

In more populated areas, the Burgess Health Center (in Onawa), the school systems, and the town and county governments are the major sources of employment. 

A devastating tornado hit Mapleton in 2011, destroying roughly 60 percent of the town and resulting in some disaster recovery funding flowing to the community. 

The county is aging and declining in population: 25 percent of residents are over 65 years old and the total number of residents decreased by almost seven percent between 2010 and 2019. A perceived lack of economic opportunity has driven some of these changes in the county, where the poverty rate is higher and the median income is lower than state averages. 

Politically, the area has leaned conservative in recent years, and local government has taken a “hands off” approach to health and well-being issues. Persistent health issues in the county include alcohol abuse, child maltreatment, and chronic disease, and Burgess Health has committed to improving problematic health indicators around poor mental health days, physical health and inactivity, and low access to dental health providers. 

COVID-19 peaked in the community in the late fall and winter of 2020, but also surged in fall 2021 due to the Delta variant and relatively low vaccination rates in the county.

Monona County’s Journey to Promote Health, Well-Being, and Equity

Monona County’s efforts have shifted with the consolidation of public health services under the authority of the local health system and transitions within local coalitions.

Regional and state organizations also provide important capacity to promote health and well-being, as do a small set of social service agencies and nonprofits. Burgess Health coordinates most of the efforts around health and well-being in the community, though local nonprofits and social services agencies also help to support healthy housing and food access, and some organizations have begun to address mental health more concertedly. Some progress has been made on walkability, and there are initiatives spearheaded by individual residents with personal interests in particular sectors, such as child care, health education, and mutual aid. For years, health has been viewed as an individual responsibility by many in Monona County, though there is a growing focus on mental health issues and access to food and recreation opportunities. Given the racially homogeneous population in Monona County, racial equity has traditionally not been a part of the conversation, although there has been somewhat more acknowledgement of income, age, and disabilities as determinants of access to resources for health over the past five years.

Baseline research started in 2016 to track community programs and initiatives. The most recent report, from 2022, provides more in-depth insights and analysis into the community's efforts to build a Culture of Health.

Lessons Learned: Where is Monona County Five Years Later?

Many of the well-being and equity priorities in Monona County—including substance use, chronic disease, and poverty—are deeply entrenched in the county. Public health leaders have been working over the past five years to establish a strategic direction within the healthcare system to address these health priorities. 

The community will likely continue to be challenged by a prevailing mindset that individuals are responsible for their own health and by a hands-off, risk-averse approach on the part of local government officials. 

Economic development goals that are taking root in downtown revitalization efforts and projects to improve walkability may have spill-over effects for residents with low incomes, though improving equity is not at the heart of these efforts. 

Other communities can learn from Monona County’s efforts, as well as the challenges encountered, to inform their own journeys. And, as COVID-19 recovery continues, with historic funding flowing to local communities, future research could consider the ways in which momentum around health, equity, and well-being influences community health narratives and decisions moving forward.

In its efforts to improve health and well-being, Monona County has leveraged personal connections between residents and leaders in this very rural community. External resources have supplemented a lack of local funding and organizational capacity. Yet, barriers remain in the rural, aging community, particularly since leadership for public health has transitioned and local leaders face disengagement and mistrust from community residents.


  • Community-oriented, pitch-in culture

  • State and regional capacity to support local partners 

  • Funding requirements encouraging coalition-building

  • Data made available by state and national partners 


  • Dissolution of Monona County Public Health

  • Extreme rurality: Transportation, food access, health care providers

  • Aging population

  • “Risk averse” elected officials

  • Denial about community challenges