Older Adults in Rural Areas Lag Behind on Key Health Outcomes and Behaviors

In the United States, 24.1% of adults age 65 and older lived in rural areas in 2023, and residents of rural areas are older

 than their metropolitan counterparts. While the population of older adults living in rural areas varies by state, there were six states in 2023 where the majority of their older adults lived in rural areas: Vermont (69.6%), Maine (63.5%), West Virginia (58.6%), Mississippi (58.4%), Montana (52.9%) and Arkansas (50.9%).

Older adults living in rural areas face many challenges to staying healthy, including unique economic and social factors,

higher rates of unhealthy behaviors and barriers to accessing care. As rural residents age and their health needs increase, their already-limited access to necessary services, such as specialist doctors that are often located in metropolitan areas, may be further complicated.

America’s Health Rankings^® examined the health of older adults living in nonmetropolitan (“rural”) areas* and how it differs from their metropolitan counterparts across several health behaviors — smoking, fruit and vegetable consumption and physical inactivity — and health outcomes like high health status, frequent physical distress and frequent mental distress. The analysis also explores how these health behaviors and outcomes differ from the national rate in the six states with the highest proportion of older adults living in rural areas.

Data from the America’s Health Rankings platform show that older adults living in rural areas are more likely to have less healthy behaviors and worse health outcomes compared with their counterparts in metropolitan areas.

The prevalence of cigarette smoking was 1.34 times higher among older adults living in rural areas (10.7%) compared with those living in metropolitan areas (8.0%) in 2023. However, smoking rates among older adults living in rural areas were lower than the overall national rate (10.7%) in three of the states with the highest proportion of older adults living in rural areas: Vermont (6.5%), Montana (8.0%) and Maine (9.1%).

The data showed a similar pattern in fruit and vegetable consumption, where 5.9% of older adults living in rural areas consumed two or more fruits and three or more vegetables daily compared to older adults living in metropolitan areas (7.8%) in 2021. Of the states with the largest relative populations of older adults living in rural areas, only Vermont (13.3%) had a higher rate of fruit and vegetable consumption among this population than the national rate (5.9%).

Physical inactivity was also worse among older adults living in rural areas. In 2023, 37.2% of older adults living in rural areas were physically inactive — defined as doing no physical activity or exercise other than their regular job in the past 30 days — compared to 30.5% of older adults in metropolitan areas.

Physical inactivity among older adults living in rural areas was higher in 2023 than the national rate (37.2%) in half of the states with the highest proportion of older adults living in rural areas and lower in half. It was higher in Mississippi (46.5%), Arkansas (43.9%) and West Virginia (43.9%) and lower in Vermont (25.3%), Montana (27.7%) and Maine (29.6%).

All three of these behaviors are critical to healthy aging and can contribute to health outcomes. Smoking cessation

has been shown to improve health outcomes among older adults, including lowering risk factors for chronic conditions. Consuming whole fruits and vegetables daily is important for older adults to meet nutrient recommendations and reduce the risk of developing chronic illness or other health conditions. Finally, older adults tend to be more physically inactive than younger people, increasing their susceptibility

to negative health outcomes and chronic conditions.

In addition to reporting more unhealthy behaviors, older adults living in rural areas also experienced poorer outcomes on some self-reported health measures that capture health-related quality of life

and overall wellness.

High health status — or the percentage of adults age 65 and older who reported their health was very good or excellent — was 1.15 times lower among older adults living in rural areas (36.0%) than those living in metropolitan areas (41.5%) in 2023. However, high health status has declined overall; both older adults living in rural areas (39.7% to 36.0%) and those living in metropolitan areas (44.4% to 41.5%) experienced a decline in high health status between 2020 and 2023.

Older adults living in rural areas had a lower prevalence of high health status than the national rate (36.0%) in Mississippi (27.0%), Arkansas (27.6%) and West Virginia (30.5%), while the same population had a higher prevalence in Vermont (48.8%), Montana (44.3%) and Maine (41.6%).

The prevalence of frequent physical distress— or self-reported poor physical health 14 or more days out of the past 30 days— was 1.18 times higher among older adults living in rural areas (19.4%) than older adults living in metropolitan areas (16.5%) in 2023. Since 2020, the rate increased among both older adults in rural areas (16.2% to 19.4%) and those in metropolitan areas (14.1% to 16.5%). This indicates a growing health challenge for all older adults in the U.S., who are more likely to struggle with poor physical health and lack of access to quality healthcare, putting them at greater risk for mental health issues.

Compared to the national rate (19.4%), in 2023, older adults living in rural areas had higher prevalence of frequent physical distress in West Virginia (24.4%) and Arkansas (23.0%) and lower prevalence in Vermont (14.8%).

The prevalence of frequent mental distress — which is based on self-reported poor mental health 14 or more days

out of the past 30 days, and can be associated with health conditions and risk factors for further poor health — was similar among older adults living in rural (8.8%) and metropolitan (8.7%) areas in 2023. However, rates increased among older adults living in rural areas (7.7% to 8.8%) between 2020 and 2023, reflecting a growing challenge for that population. Older adults living in rural areas in West Virginia (12.5%) had a higher rate of frequent mental distress than the national rate (8.8%) among that population in 2023.

Health behaviors and outcomes for older adults worsened in both rural and metropolitan areas, according to several measures in America’s Health Rankings. However, some of these challenges are more pronounced among older adults living in rural areas than their counterparts living in metropolitan areas.

The America’s Health Rankings platform offers insights into the distinct needs and characteristics of rural older adults, including data beyond the measures spotlighted in this piece. We encourage community and public health leaders across the country to use this data to better understand and support healthy aging in rural areas and beyond.

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