News Release

​​​​​Black people in rural areas have greater mental health resiliency than white people

Finding in North Carolina is one of the first to explore this relationship and has implications for other areas of the country

Peer-Reviewed Publication

Georgetown University Medical Center

WASHINGTON (March 4, 2023) — Black people living in rural areas of North Carolina were found to have better mental health than white people despite their exposure to various forms of racism and discrimination. This paradoxical finding was reported by researchers at Georgetown University and their colleagues online in the journal Social Science & Medicine: Mental Health on March 4, 2023.

“Studies have examined the greater health burdens experienced between people living in rural versus non-rural areas, yet few, if any, have looked at how mental health is experienced across racial groups in rural areas,” says the study’s lead author Caroline Efird, PhD, MPH, a postdoctoral research fellow in Georgetown’s Racial Justice Institute and its Center for Men’s Health Equity. “White Americans commonly report worse mental health than Black Americans, but we wanted to know if this pattern would occur in rural areas, where all residents experience barriers to mental health and wellbeing. Interestingly, when white Americans’ expectations of advantage go unmet, they are potentially susceptible to poor health outcomes, and this is what we think could be going on with rural white residents’ relatively worse mental health.”

Nearly 20% of people over the age of 18 in the United States live with a mental illness, yet rural adults are at an increased risk of being undiagnosed, according to a report by the Centers for Disease Control and Prevention (CDC) in 2018. Nearly 62% of places in the U.S. that are classified as mental health care shortage areas are located in rural or partially rural regions, which suggests that rural residents have less access to mental health care resources than nonrural residents.

Using data from the CDC’s 2015-2019 Behavioral Risk Factor Surveillance System (BRFSS) in North Carolina, survey respondents self-reported how many days a month they typically experience stress, depression, and problems with emotions (i.e., mentally unhealthy days). Those days were 10% greater for rural respondents than nonrural respondents. However, this relationship was moderated by racial identity, with rural white respondents reporting 26% more mentally unhealthy days than rural Black people, nonrural Black people, and nonrural white people.

“People who live in rural areas should not be thought of as a homogenous group who have uniform experiences and mental health needs, which is important because policy makers, researchers, and health care providers need to consider how mental health needs may differ for white and Black residents of rural communities,” says Efird. “Documenting the mechanisms that facilitate mental wellbeing for Black rural residents could support efforts to sustain and promote their mental health. We also need to determine which mechanisms contribute to rural white residents’ relative mental health deficit so that we can tailor culturally relevant options to improve everyone’s mental health.”

While the scientists did not find significant variation in self-reports by gender or social class, they suggest that future studies should help to affirm the importance of examining mental health in rural areas for people whose identities intersect across race, class, gender and other constructs.

Efird also noted that the researchers are interested in looking at community-based studies in rural areas to help them better determine how the COVID-19 pandemic has impacted rural residents from all racial and ethnic backgrounds. The scientists could potentially use the BRFSS data from the year’s following the peak of the COVID-19 pandemic to determine if trends in mental health differences have shifted or remained the same.


Additional study authors are Derrick D. Matthews, Clare L. Barrington and Alexandra F. Lightfoot at the University of North Carolina at Chapel Hill, Kathryn E. Muessig at Florida State University, Tallahassee, and Jonathan M. Metzl at Vanderbilt University, Nashville.

The authors report no competing interests related to the study. Funding for Efird’s role in the study was partially provided by an Agency for Healthcare Research and Quality predoctoral traineeship, sponsored by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The funding source was not involved in any part of the research study.

About Georgetown University Medical Center
As a top academic health and science center, Georgetown University Medical Center  provides, in a synergistic fashion, excellence in education — training physicians, nurses, health administrators and other health professionals, as well as biomedical scientists — and cutting-edge interdisciplinary research collaboration, enhancing our basic science and translational biomedical research capacity in order to improve human health. Patient care, clinical research and education is conducted with our academic health system partner, MedStar Health. GUMC’s mission is carried out with a strong emphasis on social justice and a dedication to the Catholic, Jesuit principle of cura personalis -- or “care of the whole person.” GUMC comprises the School of Medicine, the School of Nursing, School of Health, Biomedical Graduate Education, and Georgetown Lombardi Comprehensive Cancer Center. Designated by the Carnegie Foundation as a doctoral university with "very high research activity,” Georgetown is home to a Clinical and Translational Science Award from the National Institutes of Health, and a Comprehensive Cancer Center designation from the National Cancer Institute. Connect with GUMC on Facebook ( and on Twitter (@gumedcenter).





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