URBANA, Ill. (U.S.A.) — Back in the late 1990s, a distressing trend took hold for rural America. At that time, rural and urban mortality rates started to diverge, with rural populations experiencing 9% higher mortality in working-age adults. Unfortunately, the divide has only grown over time. As of 2019, working-age adults in rural areas were 43% more likely to die from natural causes than their urban counterparts, but researchers have struggled to explain this gap.

In a first-of-its-kind study, University of Illinois Urbana-Champaign and USDA Economic Research Service researchers help explain the rural mortality disadvantage by combining a place-based analysis with health biomarkers from over 66,000 people across a 20-year span.

“We find that chronic stress, nicotine use, obesity, and diet are major factors likely contributing to the growth of the rural-urban mortality gap,” said study author Sarah Low, professor and head of the Department of Agricultural and Consumer Economics, part of the College of Agricultural, Consumer and Environmental Sciences at Illinois. “But we find that the rural-urban gaps are really disparities associated with place, rather than as causal effects of rural residence.”

Low and her co-authors leveraged the National Health and Nutrition Examination Survey, a nationally representative survey administered annually, which gave them access to anonymized blood biomarkers, records of physical exams, and county of residence.

The research team analyzed health measures based on whether individuals lived in large metropolitan, small/medium metropolitan, or nonmetropolitan (rural) counties.

“We found rural health disadvantages exist across the overall adult and prime working-age (25-54) populations and are likely linked to the growing gap between urban and rural natural cause mortality rates documented by USDA,” Low said. “Specifically, chronic stress appears to be contributing to rural-urban health gaps.”

Chronic stress is manifested in a cardiometabolic index that measures metabolic health with blood pressure, cholesterol, pulse rate, diabetes, and obesity, and, in this study, serves as a proxy for allostatic load (i.e., the wear and tear on an individual’s organs over time).

“These metrics are a combination of factors we got from the survey, such as whether an individual is diabetic, has cotinine in their blood (evidence of nicotine use), high blood pressure, just a whole host of things,” Low explained. “The more of those things you have, the higher the cardiometabolic index and the higher the overall stress on the body.”

Low says there are various factors that could increase chronic stress among working-age adults in rural America. Farming is an inherently stressful occupation, and the rural nonfarm economy has struggled since the U.S. manufacturing crisis began in the late 1990s. Working-age adults in rural areas are also more likely to be caring for children and elderly parents.

Combining individual health metrics like the cardiometabolic index, health behaviors like smoking, and place-based data like access to full-service grocery stores, hospitals, or gyms is what makes the study unique.

“It's this wicked mess to untangle,” Low said. “But the data told us we can’t blame rural-urban health disparities on rurality alone. By digging into the data, we found that it is the characteristics of rural communities rather than the fact that they are rural that is driving the place-based results.”

Low says this nuance points to gaps in healthcare access, healthy food options, gyms, and other amenities in certain rural areas compared to urban areas.

“Our results can help inform policies and programs aimed at improving rural health and rural workforce productivity, which both impact the rural economy,” Low said. “Communities with workforce shortages may consider how improving the food environment and health behaviors might improve health outcomes. For example, educational programming to improve diets, decrease obesity, and eliminate cigarette use may have tangible effects on rural health outcomes.”

The study, “Rural health disadvantages in the United States: Evidence from nationally representative data,” is published in Economics & Human Biology [DOI: 10.1016/j.ehb.2026.101623].

Research in the College of ACES is made possible in part by Hatch funding from USDA’s National Institute of Food and Agriculture. This study was also supported by the USDA Economic Research Service.