Health outcomes in rural America: A prevention-to-crisis view on determinants of health, chronic diseases, and economic consequences

Key insights

Participants highlighted the following as foundational elements for evaluating and improving rural health care outcomes:

• Rural mortality and disease disparities are shaped not only by health care infrastructure gaps, but by social determinants such as housing, transportation, food access, poverty, job benefits, education, and social infrastructure. These factors operate across individual, community, institutional, and economic levels, often before clinical care begins.
• Transportation emerged as one of the most persistent and difficult social determinants of rural health. Dependence on private vehicles, poor road conditions, longer travel distances, and limited alternatives especially affect older adults, people with disabilities, lower-income residents, and those in remote areas.
• Social infrastructure supports civic engagement, social cohesion, trust, and personal well-being in rural communities. Yet the discussion also emphasized that the presence of “third places” is not enough; residents must be able to meaningfully use them for connection.
• Rural chronic disease and mortality patterns are uneven across both rural-urban and within-rural geographies. While deaths of despair draw much public attention, a wider set of conditions—including cardiovascular disease, obesity, tobacco use, and infectious diseases—all contribute to the rural mortality burden.
• Health behaviors and interventions often spread through trusted community networks. Social ties can diffuse harmful behaviors or skepticism but also accelerate peer recovery support, chronic disease care, and other positive interventions and new treatments. Peer-supported programs can use low-barrier entry points to reach residents earlier, connect them to broader health services, and support recovery over time.
• While technology can reduce distance and improve the efficiency of health care services, there is no substitute for local trust. Relationship-centered care and social infrastructure remain essential to making rural interventions usable and acceptable.
• Improving health outcomes requires more than making services available. Participants emphasized that people facing chronic illness, addiction, trauma, or disconnection from work also need trusted support networks, motivation, and ongoing assistance to succeed.
• Poor health outcomes and limited economic opportunity form a self-reinforcing cycle in many rural communities. Chronic disease, disability, mental health challenges, and premature mortality can reduce workforce participation, limit business growth, weaken tax bases, increase outmigration, and further erode local support systems.
• Rural populations are disproportionately older and less healthy than those in other geographic areas, but often face fewer providers, longer travel distances to care, thinner caregiving networks, shrinking tax bases, and limited child care and aging-in-place supports. These services are part of rural social infrastructure: when they are unavailable, under-resourced, or located too far away, they strain families and caregivers and make it harder for residents to remain in the workforce.
• Workforce development can function as health infrastructure when it is designed around the real barriers workers face. The Coalfield Development example showed how training, employment, health navigation, recovery, and civic participation can be integrated into a place-based support system that strengthens labor force participation and the broader community, overcoming long-term health and addiction challenges.
• The farmers’ mental health crisis shows how rural health challenges can be tied to the nature of the work, social isolation and stigma, and economic uncertainty. It also exemplifies how the culture of rural work shapes help-seeking behavior and health outcomes.
• Rural health programs should be evaluated with metrics that reflect rural conditions, not only standard service-delivery measures. Program evaluation frameworks should account for health outcomes, implementation capacity, and effects on workforce and community vitality.

Ongoing debates and research priorities

Symposium participants reached broad agreement on the insights above, but several tensions remain unresolved.

1. Rural transportation barriers and policy design failures

Issue. A recurring tension was whether rural transportation barriers are unavoidable features of distance, density, and scale, or whether they are created, reinforced, or exacerbated by policy and program designs with a structural urban bias. Distance, density, and scale create real constraints, but policy and programs that take urban conditions as their starting point can result in designs that exacerbate those constraints or even create new barriers, making limitations mutually reinforcing rather than strictly one-directional. Transportation was the clearest example: Rural residents rely more heavily on private vehicles, have less access to comprehensive public transportation, and face road, bridge, weather, and distance barriers that make access difficult even when the services they need technically exist. The unresolved question is whether rural transportation can be “solved,” or whether policy should instead prioritize linked-service models that reduce the need for repeated long-distance travel.

Research needed. Which infrastructure and transportation barriers are inherent to rural distance, density, and scale, and which are reinforced or made more difficult to address by policy and program design? Which models reduce travel burdens most effectively—transportation services, mobile delivery, community health workers, school-based care, telehealth, pharmacy access, or multipurpose service hubs? How do these answers vary across different kinds of rural communities and geographies?

2. Poor rural versus poor urban communities, and variation within rural America

Issue. A key assumption tested in the first panel was whether social determinants of health have a greater effect in rural places, or whether they operate differently because rural communities have different infrastructure, labor markets, housing conditions, transportation systems, and social networks. The discussion suggested that poverty matters in both rural and urban settings, but the pathways through which poverty shapes health may differ. It also reinforced that rural America itself is highly varied by region, race, ethnicity, age, occupation, local economy, and state policy context.

Research needed. How do social determinants of health operate differently by type of geography, and how does that inform the variation that exists within rural America by region, race, ethnicity, age, occupation, local economy, and state policy? How do we determine what makes a rural community “wealthy,” or well-resourced? Which rural-specific assets contribute the most to improved health outcomes, and how should these findings change program design, targeting, eligibility, delivery models, and evaluation?

3. Defining and measuring rural social infrastructure

Issue. There was broad agreement that social infrastructure matters, but less clarity on what should count as social infrastructure in rural places. “Third places” such as libraries, parks, coffee shops, religious organizations, grocery stores, and community centers are part of the picture, but informal spaces such as homes, porches, schools, faith networks, and multipurpose gathering places may play similar roles. The deeper tension is that availability alone may not matter unless people meaningfully use those spaces for interaction, trust-building, and support.

Research needed. What is the full picture of social infrastructure in rural America? How can researchers measure not only availability but also meaningful use? What facilitates or prevents the use of third places in rural communities? What evidence is needed to link investments in third places, informal gathering places, and multipurpose community spaces to public health outcomes including loneliness, mental health, preventive care, chronic disease management, and civic participation?

4. Technology, trust, and implementation capacity

Issue. Technology was discussed as a possible way to reduce rural distance barriers, including drone delivery, telehealth, and remote treatment models. But the discussion repeatedly qualified that technology does not succeed on its own. In several examples, technology appeared most promising when it acted as an extension of trusted local relationships, rather than replacing them.

Research needed. When and how can technology reduce rural health barriers? What conditions are necessary for it to succeed rather than fail, particularly related to local trust, human relationships, broadband access, pharmacy access, and community-based implementation capacity? Which services can be meaningfully and effectively delivered through technology, and which require in-person or peer-supported models?

5. Interpreting low uptake of rural health interventions

Issue. Low uptake of rural health interventions can be interpreted in several ways: low demand, poor design, lack of trust, stigma, transportation barriers, cost, limited anonymity, or the wrong entry point. There is also the challenge of who in the community knows about the intervention, how active a role they play in promoting it, and to whom. The discussion complicated the assumption that making a service available is enough. Examples from addiction treatment, hepatitis C treatment, GLP-1 medications, telehealth, and peer recovery support suggested that uptake often depends on whether an intervention begins from a need residents already recognize, whether the messenger is trusted, and whether the service is socially and financially accessible.

Research needed. How should policymakers interpret low uptake of rural health interventions? What would it take to identify which barrier is operating in a given community? How can programs test whether different entry points, messengers, or delivery models improve participation?

6. Appropriate metrics for rural health programs

Issue. Conventional metrics may miss the conditions that shape rural health outcomes. Standard measures of access, utilization, or cost may not fully capture transportation burdens, housing quality, social isolation, trust, informal caregiving, implementation capacity, or whether a program is reaching the people it was designed to serve. The measurement problem is especially acute when county-level data obscure local variation, or when the most important outcomes are long-term changes in health, social connection, and community stability.

Research needed. What metrics are effective in evaluating rural health programs when standard measures may miss underlying social determinants and long-term health outcomes? At what geographic scale should rural need be measured? How should programs account for differences in access to, and familiarity with, technologies that are important for successful program implementation? How can evaluation frameworks account for transportation, social infrastructure, implementation capacity, meaningful uptake, and local variation across rural America?

7. Health support as workforce development

Issue. Workforce development becomes more complicated when health barriers are a major reason people cannot enter or remain in the labor force. The discussion suggested that employment programs may need to connect participants to behavioral health, recovery, transportation, primary care, caregiving support, and civic infrastructure. The unresolved boundary is how far workforce development programs should go in addressing health-related barriers without being treated as substitutes for broader health care access. At the same time, policymakers should ensure that workforce development programs do not negatively affect health care access programs in the community.

Research needed. How can workforce development programs be integrated with health care, behavioral health, and recovery support in ways that strengthen participation and stability without becoming a substitute for care itself? Which partnerships between employers, providers, community organizations, and training programs show measurable results? How can different but linked outcomes be tracked in a meaningful way: employment, retention, health stability, recovery, and civic participation? How can workforce development programs address the needs of sandwich-generation participants who are caring for both children and parents?

Relevant resources

Davis, Alison F. Review of Rural U.S. Economic and Health Care Trends. Center for Economic Analysis of Rural Health, University of Kentucky, September 2022. https://cearh.mgcafe.uky.edu/articles/review-rural-us-economic-and-health-care-trends.

Dennison, Brandon M. “Rebuilding the Appalachian Economy From the Ground Up: Towards a Holistic Organizational Framework for Community and Economic Development in Rural Extractive Areas.” PhD diss., West Virginia University, 2023. https://doi.org/10.33915/etd.12269.

Henning-Smith, Carrie. “Rural Health in the United States.” In Meeting the Health Needs of Rural America, edited by Alan R. Weil, 29–56. Washington, DC: Aspen Institute, 2026. https://healthmedicineandsociety.org/wp-content/uploads/2026/03/Meeting-the-Health-Needs-of-Rural-America-FINAL.pdf.

Hoffman, Kim, Gillian Leichtling, Sarah Shin, et al. “Peer-Assisted Telemedicine Hepatitis-C Treatment for People Who Use Drugs in Rural Communities: A Mixed Methods Study.” Addiction Science & Clinical Practice, February 8, 2025.https://link.springer.com/article/10.1186/s13722-025-00541-6.

Hung, Peiyin, Sophia N. D. Negaro, Rachel M. Hantman, Emma K. Boswell, Christina M. Andrews, Cassie L. Odahowski, and Elizabeth L. Crouch. “Access and Quality of Mental Health Services in Rural and Urban America.” Policy brief. University of South Carolina Rural Health Research Center, July 2025.https://www.ruralhealthresearch.org/mirror/17/1722/access-quality-mental-health-services.pdf.

Kowalkowski, Jennifer, Danielle Rhubart, and Yiping Li. “Mental Health Status and Third Places Use Among Rural Working-Age Adults in the United States.” Rural Society 34, no. 1 (2025): 1–19. https://www.tandfonline.com/doi/full/10.1080/10371656.2025.2465169.

Kozhimannil, Katy Backes, and Carrie Henning-Smith. “Improving Health Among Rural Residents in the US.” JAMA, March 16, 2021.https://jamanetwork.com/journals/jama/fullarticle/2777476.

Monnat, Shannon M. “Demographic and Geographic Variation in Fatal Drug Overdoses in the United States, 1999–2020.” The ANNALS of the American Academy of Political and Social Science 703, no. 1 (September 2022): 50–78. First published online March 20, 2023. https://doi.org/10.1177/00027162231154348.

Monnat, Shannon M., and Tim Slack. “Population Health in Rural America: Changes, Challenges, and Opportunities.” In Meeting the Health Needs of Rural America, edited by Alan R. Weil, 59–92. Washington, DC: Aspen Institute, 2026. https://healthmedicineandsociety.org/wp-content/uploads/2026/03/Meeting-the-Health-Needs-of-Rural-America-FINAL.pdf.

NORC at the University of Chicago and East Tennessee State University. Appalachian Diseases of Despair: Update 2025. Appalachian Regional Commission, July 2025. https://www.arc.gov/wp-content/uploads/2025/07/Appalachian-Diseases-of-Despair-Update-2025.pdf.

Probst, Janice, Jan Marie Eberth, and Elizabeth Crouch. “Structural Urbanism Contributes to Poorer Health Outcomes for Rural America.” Health Affairs 38, no. 12 (December 2019): 1976–1984. https://doi.org/10.1377/hlthaff.2019.00914.

Rhubart, Danielle, Megan Henly, M. Aaron Guest, Carrie Henning-Smith, and Mary Anne Powell. “Social Infrastructure and Health Among Mid-Life and Older Adults in Rural America: An Environmental Scan of Existing Data.” Aging and Health Research 4, no. 2 (June 2024): 100186. https://doi.org/10.1016/j.ahr.2024.100186.

Rhubart, Danielle, and Yiping Li. “Loneliness and Social Infrastructure in Rural America: A Cross-Sectional Analysis of Existing Relationships.” Wellbeing, Space and Society 8 (June 2025): 100262. https://doi.org/10.1016/j.wss.2025.100262.