Dissertation Title: “Pride, Pressures, and Politics of Place: Essays on the Influence of Rurality and Geography on Group Identity, Health Care Access, and Health Communications”

Place matters. Where individuals reside has a substantial impact on their life experiences, their values systems, the way they view and respond to major policy issues, their ability to access health care services, and myriad other aspects of life. This dissertation explores how geography is intrinsically tied to dynamics of group identity, how perceptions of rural Americans influence how providers engage with and coordinate care with rural patients, and how politicians differentially communicate major health policy issues across states and geopolitical boundaries.

In Chapter 1, I conduct an empirical analysis of the association between strength of place-based identity and rural Americans’ policy preferences and political values. A growing body of work has examined the political behavior of rural Americans; however, uncertainty remains about how scholars should operationalize rural identity and how the manifestation of this identity is associated with rural Americans’ views on health and social policy issues salient to the rural experience and important to both major political parties’ national agendas. Using 2020 American National Elections Survey data, this paper presents novel evidence that rural social identity is a unique predictor of several health and social policy views, above and beyond other established affinities and group identities, and that rural identity is distinct from rural residence and rural resentment.

In Chapter 2, my co-authors and I explore how health providers perceive barriers to cancer prevention and care coordination in rural communities. Rural Americans are at disproportionate risk for numerous adverse health outcomes and face barriers to accessing quality health care, including cancer care. Through a thematic analysis of semi-structured interviews with health providers, nurse navigators, and community health workers serving rural midwestern communities, we evaluate how provider beliefs about barriers facing rural patients influence care recommendations and provider perceptions of patient interactions. We find that provider beliefs and subsequent interactions affect providers’ perception of trust between themselves and their patients, which providers also perceive as influencing whether rural patients are willing to believe providers, adherence to care recommendations, and the information patients are willing to share with providers.

Chapter 3 explores how state and candidate characteristics matter for politicians’ decisions to incorporate substance use issues in campaign advertising. Campaign advertisements serve as a major avenue for candidates to communicate their values, positions, and issue priorities with voters. In recent years, the opioid epidemic and rising rates of substance use more broadly have emerged as a major public health issue across the United States. These issues have gained increased salience in voters’ minds and as policy priorities for elected officials and political candidates. Using Senate and House campaign advertising data across five election cycles (2012 – 2020), I find that congressional candidates running in states with higher overdose mortality rates are more likely to incorporate substance use-related issues into their advertising strategies. I also find that incumbent candidates are more likely to address substance use issues in their campaign advertisements, while at the same time, unlike other major health policy issues, the amount of candidate attention given to substance use issues in campaign advertisements doesn’t clearly fall along partisan lines.