Community Context 

North Central Nebraska covers 15 percent of the state’s land but is home to only 3 percent of its population. The landscape is dominated by the Sandhills, ecologically fragile grass-covered sand dunes that support a highly agricultural regional economy: Large, mostly family-owned ranches dominate the western part of the region and farms, feedlots, and small towns (O’Neill, Atkinson, Spencer) characterize the eastern part. 

The region is predominantly White, though Knox County includes part of a reservation for the Santee Sioux tribe and Latino residents make up a small percentage of the population. Overall, like many other rural, agricultural communities, the region’s population is aging and shrinking.

In March 2019, heavy rainfall and rapid snowmelt caused catastrophic flooding, and 75 percent of Nebraska’s counties declared states of emergencies (including all of the counties in North Central Nebraska). Many communities took over a year to recover. 

Historically, the region has also struggled with a lack of convenient access to healthcare providers (particularly specialty care), transportation options, safe and affordable housing, healthy foods, and broadband internet. 

The region is a longstanding conservative stronghold at the state and local levels. The tax structure and spending priorities in the community have resulted in limited funding for health and well-being, education, and social services. However, Medicaid was expanded in Nebraska in 2020. Key health issues prioritized by local stakeholders have not evolved much over the past five years, with chronic disease prevention, mental wellness, and substance abuse prevention topping the list. 

Recently, public surveys have further highlighted a need for mental health resources and support for the aging population. COVID-19 did not reach the region until the summer of 2020, after initial business closures and other mitigation efforts had been established. Respondents theorized that early efforts in the absence of COVID-19 outbreaks led to residents discounting mitigation and precipitated backlash against ongoing restrictions and recommendations.

North Central Nebraska’s Journey to Promote Health, Well-Being, and Equity

Five years into the Sentinel Communities Surveillance Project, North Central Nebraska’s capacity to promote health, well-being, and equity has remained relatively stable under the leadership of the North Central District Health Department (NCDHD) and critical access hospitals.

Regional and state organizations, a small set of social service agencies, economic development organizations, and nonprofits also contribute capacity. NCDHD continues to coordinate most of the efforts around health and well-being in the community, though social services agencies also help to support healthy housing and food access, and stakeholders concerned specifically with mental health have expanded their efforts. Considering the role of healthcare access and health in general in their future economic viability, regional stakeholders have continued efforts to build the local healthcare workforce and promote economic development (with health as a piece of that). The rugged individualism that pervades the ranching and farming culture in the region has meant that health has been viewed as an individual responsibility by many. Stakeholders in the region have not historically prioritized health equity, though some social service and public health stakeholders have started to label their efforts to provide access to healthcare and health-promoting resources (food, income support) as health equity activities over the past five years.

Lessons Learned: Where is North Central Nebraska Five Years Later?

North Central Nebraska is illustrative of many rural communities struggling to remain viable as economic and generational shifts challenge existing structures and paradigms. 

Crises, such as the 2019 floods and the COVID-19 pandemic, have revealed the strong community ties in the region, but also the tendency to resist government intervention in favor of individual action. 

Non-health stakeholders are beginning to put effort and investment into well-being, recognizing that things such as good mental health, access to childcare, and healthy, affordable housing, access to healthy food options, and opportunities for physical activity are critical to the community’s future viability. 

Other communities can learn from North Central Nebraska’s approaches to make these changes, as well as the challenges they 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, North Central Nebraska has leveraged external resources to supplement a lack of local funding and organizational capacity. Strong interpersonal connections and a desire to sustain their communities into the future have motivated community engagement for health and well-being. Yet, barriers remain in the vast, rural, aging community. Service areas are large, and health is seen as an individual responsibility and is thus underfunded, inhibiting collaboration, innovation, and impact.


  • State-level interest in rural futures

  • External data capacity

  • Access to health information in the media

  • Strong ties between residents

  • Positive, future-orientation inspires community engagement


  • Large service areas for regional organizations

  • Health as an individual responsibility

  • No formal cross-sector health collaboratives

  • Limited state and county funding for health

  • Within-region variability in activity for health

  • Lack of engagement of individuals with low incomes, populations of color