Older People in Rural Areas: Older Places, Thinner Services, Wider Gaps

Rural places are often older than cities, yet services for later life are often thinnest there. In the United States, death rates among people aged 65 and over have been higher in rural areas than in cities for two decades, and the gap has widened. Worldwide, rural populations have far fewer health workers than urban ones.

Growing older in a village, a farming district or a remote town is, for many people, a choice made gladly: a home of decades, neighbours who know you, land and landscape that mean something. The difficulty is not rural life itself. It is what happens when the nearest clinic is an hour away and the bus runs twice a week. Care workers become harder to find, a bank or a benefits office moves online, and younger relatives have moved to the cities for work. The evidence in this study, drawn from the United States, Europe, England, India and China, shows that these gaps are measurable, and that they are gaps in services and policy that can be closed.

Rural populations are older, and in Europe their older population is growing fastest

In the United States, the 2012–2016 American Community Survey found that 17.5% of the rural population was aged 65 or over, against 13.8% in urban areas. Of 46.2 million older Americans, 10.6 million lived in areas designated rural. In Vermont and Maine, most older residents lived in rural areas (65.3% and 62.7%)^[4].

Europe shows the same pattern, driven by people leaving as well as people ageing. Between 2015 and 2020, the total population of the EU’s predominantly rural regions fell by an average of 0.1% a year. Their working-age population (20–64) fell by 0.6% a year, and their population aged 65 and over grew by 1.8% a year. In urban and intermediate regions that older population grew by 1.6% a year^[5]. Across the whole EU, 22.0% of people were aged 65 or over on 1 January 2025^[6]. In England, 27% of people living in rural areas were 65 or over in mid-2024^[7].

In many lower- and middle-income countries, most older people are rural. India’s 2011 census found that, on average, 71% of older people lived in rural areas, ranging from 62–63% in the west and south to 78–80% in the east, north and north-east^[8]. The India Ageing Report 2023 notes that large parts of rural India “are still remote with poor road and transport access”^[8].

In the United States, older people in rural areas die sooner, and the gap has widened

The clearest long-run evidence comes from US death certificates. Between 2000 and 2019, the age-adjusted death rate for Americans aged 65 and over fell by 15% in rural areas, from 5,377.5 to 4,560.2 deaths per 100,000, and by 22% in urban areas, from 5,119.0 to 3,974.1. Rates were higher in rural areas for both men and women. The National Center for Health Statistics concludes that the gap between rural and urban older adults widened over the period^[1]. In 2019 the age-adjusted rate for rural men aged 65 and over was 5,216.5 per 100,000, against 4,571.4 for urban men. For women it was 4,023.6 against 3,519.8^[1]. These figures are from before the COVID-19 pandemic.

The difference shows in the years people can expect to live in good health, too. A microsimulation based on the Health and Retirement Study estimated that Americans aged 59–60 in 2014–2020 could expect 22.9 more years if they were urban men and 20.9 if rural men. For women the figures were 25.6 and 25.0. Adjusted for health quality, the expectations were 17.5 against 15.7 years for men and 19.3 against 18.7 for women. The urban–rural gap in quality-adjusted years for men had grown substantially since a 1994–2000 cohort^[9]. In the model’s scenarios, eliminating smoking and managing obesity and heart conditions would be particularly beneficial for rural healthy life expectancy. The authors add that interventions earlier in life may be needed to close the gap at older ages^[9].

Rural is not a single story, though. In England, official statistics report that life expectancy is higher in majority rural local authorities than in urban ones^[7]. The US pattern should not be assumed to hold in other countries without local data.

Fewer health and care workers, further away, and in the US a shrinking rural care workforce

Every country’s rural older people depend on health workers, and worldwide those workers are concentrated in cities. The International Labour Organization’s 2015 analysis of 174 countries found that 56% of people living in rural areas lacked access to essential health care, against 22% in urban areas. In Africa the rural figure was 83%. Only 23% of the global health workforce was deployed in rural areas, although nearly half the world’s people live there^[10][3]. WHO’s 2021 guideline on the rural health workforce puts the share of rural people without adequate access at 51–67%. In some countries, it says, rural populations have access to ten times fewer health workers than urban ones^[3]. These are figures for all ages, not for older people alone.

Care at home, where many older people prefer to grow older, faces the same shortage. In the United States in 2021 there were on average 32.9 home health aides per 1,000 people aged 65 and over in rural areas, against 50.4 in urban areas. There were 20.9 nursing assistants per 1,000 against 25.3^[11]. The trend is moving the wrong way. Between 2015 and 2024 the supply of home care workers serving older people with functional impairments rose by 6.0% nationally and by 7.3% in metropolitan areas. In rural areas it fell by 10.3%, even though potential demand rose everywhere^[2].

When a care facility closes, rural residents travel further for what remains. In US ZIP codes where a nursing home closed between 2008 and 2018, the nearest nursing home offering long-term care was on average 7.2 miles away in rural areas, against 1.1 miles in urban ones. Between 6.1% and 15.7% of rural ZIP codes with a closure, or with no nursing home at all, had no post-acute or long-term care provider within 25 miles^[12]. Distances like these also affect older partners and family members who visit, which is one reason support for older unpaid carers matters so much in rural areas.

Getting there: transport and distance shape who reaches care

Distance is only a barrier when there is no way to cover it. In England, the more rural the area, the more likely people are to travel by car or van than by public transport or on foot^[7]. That leaves a rural older person who stops driving with few alternatives. A survey of 580 older people who needed help with transport, drawn from 92% of rural counties in Wisconsin, found that 67.6% faced at least one barrier. Most still travelled, but 12.8% had stopped using transport because of those barriers. The commonest problems were service hours, the areas services covered and the destinations they reached^[13].

In India, support meant to help older people travel reaches fewer of them in villages. In the Longitudinal Ageing Study in India, 24.9% of older people in rural areas were aware of any government concession for older people, against 36.7% in urban areas. Only 11% of rural older people had used a travel concession, against 23% in cities^[8]. The India Ageing Report concludes that income insecurity, lack of access to quality healthcare and isolation “are, therefore, more acute for the rural elderly than their urban counterparts”^[8].

Transport is something policy can change, and there is evidence that it helps. A quasi-experimental study using the China Health and Retirement Longitudinal Study (2011–2018) found that a national transport-driven poverty alleviation policy had a positive effect on whether older people in rural areas sought health care. It also found that their medical spending rose, which the authors say needs attention^[14]. Cost travels with distance in richer countries too: in England, the average depth of fuel poverty is greater for rural households than for urban ones^[7]. Our study of older people on low incomes looks at money in later life more broadly.

Digital services can bring care closer, but only where broadband and skills reach

Telehealth and online services are often presented as the answer to rural distance. The evidence says they can help, but that the digital divide follows the same rural lines. In England, decent, superfast and gigabit-capable broadband is less available in the most rural areas, and mobile “not-spots” are proportionally more common in majority rural constituencies^[7]. In a US study of mental health care, access to any telehealth service was 8–9 percentage points lower for people living outside metropolitan areas. That held even after allowing for differences in mental health care use and internet access, so telehealth alone may not close rural gaps^[15]. That study covered adults of all ages.

Among rural older people specifically, the divide can be wide. In a 2022 cohort of 3,242 older people in rural Shandong, China, 71.01% reported experiencing a digital divide, and experiencing it was associated with lower health-related quality of life^[16]. A 2026 systematic review of digital and remote health for people aged 60 and over in rural or underserved settings found 14 studies. Of these, 10 (71%) reported improvement in at least one clinical outcome, such as blood pressure or blood sugar, and 11 (79%) improved behavioural or psychosocial outcomes. Digital literacy and broadband access were the most consistent barriers, and nurse-supported models achieved higher adherence. The review notes that small samples, differences between studies and the absence of cost-effectiveness analyses limit certainty^[17]. Digital care works best as an addition to people, not a replacement for them.

Fewer rural older people live alone, but loneliness and families moving away still weigh

Rural older people are not always more isolated by household. In the United States, 22.3% of rural older people lived alone in 2012–2016, against 27.6% in urban areas, and fewer lived in skilled nursing facilities (1.4% against 3.1%)^[4]. Living with others is not the same as feeling connected, though. In China’s 2018 Chinese Longitudinal Healthy Longevity Survey of 13,735 older people, 27.77% of rural older people reported loneliness, against 24.27% of urban older people; being widowed was among the rural risk factors^[18].

Migration matters as well. A 2026 study in China used historic ties between cities and villages to estimate the effect of younger people moving to cities. Its results suggest that this rural–urban migration negatively affected the physical, cognitive and emotional health of the older adults who remained^[19]. Europe’s shrinking rural working-age population, falling by 0.6% a year in 2015–2020^[5], may put similar pressure on family care there. Our study of older people living alone covers loneliness and its links with health in more depth.

What the evidence asks of us

The figures point to gaps in provision, not in rural older people. They suggest five priorities for governments, health systems, commissioners and funders:

• Plan the rural health workforce deliberately. WHO’s 2021 guideline on health workforce development, attraction, recruitment and retention in rural and remote areas sets out how countries can develop, attract, recruit and retain health workers where rural people live^[3]. With only 23% of the world’s health workforce in rural areas^[10], rural recruitment and retention need their own plans and budgets.
• Treat home care workers as essential rural infrastructure. A rural care workforce that shrank by 10.3% in a decade while demand grew^[2] needs investment in pay and job quality. Researchers who measured the US rural–urban gap in direct care workers call for exactly that, especially in rural areas where the need for direct care is greater^[11].
• Count distance when care facilities close. When a rural nursing home closes, the nearest alternative can be many miles away^[12]. Decisions to close or merge services should measure the effect on travel for older residents and on how they reach care.
• Fund transport that fits older people’s lives. Rural older people in Wisconsin asked for longer service hours, wider service areas, more destinations, door-to-door help and fares on a sliding scale^[13]. Concessions only help if people know about them and can use them^[8].
• Build digital care on broadband, skills and people. Remote health can improve outcomes for rural older people, but literacy and connection are the barriers, and nurse-supported models do better^[17]. Offline routes to every service should remain.

WHO’s guideline puts it plainly: “Leaving no one behind means ensuring that health workers are available in rural and remote areas”^[3]. For rural older people, that means measuring access to care by where people live, and closing the gaps the data reveal.

Language: this piece says “older people” rather than “the elderly” (quotations keep their source’s wording), and “older people in rural areas” or “rural older people”, describing people by where they live rather than as a single group. “Rural” is defined differently in each country; we use each source’s own definition.

Why we're publishing this

Rural older people are often described as hard to reach. The evidence suggests that it is services which have become hard to reach. Rural community organisations, village halls, community transport schemes and rural older people’s groups work to fill these gaps every day. We have brought together official statistics and peer-reviewed research from several countries so that they, and the people they support, have clear, sourced figures to put in front of funders and decision-makers. The case is theirs; our job is to set out the data cleanly.

How to read this data

There is no single international definition of “rural”. The United States figures use Census Bureau rural areas or nonmetropolitan counties; the EU figures use Eurostat’s urban–rural typology of regions; England uses its own rural–urban classification; India and China use their own census and survey definitions. Figures from different countries are therefore not directly comparable. The US death rates are age-adjusted, so they allow for rural areas having older populations, and they come from death registrations before the COVID-19 pandemic. The healthy life expectancy figures are modelled projections from survey data, not observed outcomes. Several figures (the ILO and WHO access estimates, and the US telehealth gap) cover people of all ages, and we say so where they appear. Many studies here are cross-sectional and show associations, not causes. The Chinese migration study uses a quasi-experimental design to estimate cause and effect, but it rests on its own assumptions. The evidence for rural older people is strongest in the United States and China and thinnest in Africa, Latin America and much of Asia. Australian national data could not be accessed for this study.

Use this data

Free to cite with attribution to Understanding Aging. Rural community organisations, older people’s groups, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research and statistics for general information. It is not medical, care or financial advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else’s health, please speak to a GP or another qualified health professional.

Sources

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