Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. Objective: Health department accreditation is a crucial strategy for strengthening public health infrastructure. The purpose of this study was to investigate local health department (LHD) characteristics that are associated with accreditation-seeking behavior. This study sought to ascertain the effects of rurality on the likelihood of seeking accreditation through the Public Health Accreditation Board (PHAB). Design: Cross-sectional study using secondary data from the 2013 National Association of County & City Health Officials (NACCHO) National Profile of Local Health Departments Study (Profile Study). Setting: United States. Participants: LHDs (n = 490) that responded to the 2013 NACCHO Profile Survey. Main Outcome Measures: LHDs decision to seek PHAB accreditation. Results: Significantly more accreditation-seeking LHDs were located in urban areas (87.0%) than in micropolition (8.9%) or rural areas (4.1%) (P <.001). LHDs residing in urban communities were 16.6 times (95% confidence interval [CI], 5.3-52.3) and micropolitan LHDs were 3.4 times (95% CI, 1.1-11.3) more likely to seek PHAB accreditation than rural LHDs (RLHDs). LHDs that had completed an agency-wide strategic plan were 8.5 times (95% CI, 4.0-17.9), LHDs with a local board of health were 3.3 times (95% CI, 1.5-7.0), and LHDs governed by their state health department were 12.9 times (95% CI, 3.3-50.0) more likely to seek accreditation. The most commonly cited barrier was time and effort required for accreditation application exceeded benefits (73.5%). Conclusion: The strongest predictor for seeking PHAB accreditation was serving an urban jurisdiction. Micropolitan LHDs were more likely to seek accreditation than smaller RLHDs, which are typically understaffed and underfunded. Major barriers identified by the RLHDs included fees being too high and the time and effort needed for accreditation exceeded their perceived benefits. RLHDs will need additional financial and technical support to achieve accreditation. Even with additional funds, clear messaging of the benefits of accreditation tailored to RLHDs will be needed.