ABSTRACT
Research on urban community effects on health has considered a range of collective social processes as potential links between economic disadvantage and health. We extend this focus to deaths of despair (DoD; drug overdose mortality and suicide) in rural counties by examining the association between a novel indicator of economic cynicism (perceptions that local communities have been ‘left behind’ economically) and DoD. We also consider a range of other aspects of social climate potentially relevant to health, including social network ties, collective efficacy and social and physical disorder. We draw on data from the 2018 Ohio Community Resilience Study to estimate county-level social process measures. Multilevel models of 2018–2022 age-adjusted DoD rates in 39 rural Ohio counties indicate that economic cynicism is associated with prepandemic rates of DoD and COVID-19 pandemic-associated increases in drug overdose mortality. Generalised structural equation models indicate that economic cynicism attenuates the association between economic disadvantage and drug overdose mortality by roughly 27% and the association with suicide by 50%. We discuss the importance of community-level social processes as factors in understanding rural area vulnerability to DoD.