Journal of Rural Mental Health, Vol 50(2), Apr 2026, 86-96; doi:10.1037/rmh0000332
Poverty is a known risk factor for poor mental health in rural areas, where limited resources exacerbate challenges like food insecurity, housing instability, discrimination, and inadequate mental health care, though the specific mechanisms remain underexplored. This study aims to examine the mediating role of social determinants of health, including food insecurity, housing instability, mental health care access, stress, social support, and discrimination, in the relationship between poverty and poor mental health in Southern Appalachia. Repeated cross-sectional data from two waves of the Community Health Needs Assessment panel survey in 2021 and 2024 were analyzed. Mediators included food insecurity, housing instability, mental health care access, stress, social support, and discrimination. A counterfactual four-way decomposition mediation model assessed the direct and indirect effects of poverty on mental health for each mediator and relevant covariates. Stress emerged as a key mediator, with a controlled direct effect (CDE) risk ratio (RR) of 1.11, potentially eliminating 48.6% of poverty–mental health disparities. Food insecurity (CDERR = 1.13) could mitigate 37.3% of disparities, while housing insecurity (CDERR = 1.12) could reduce 42.6%. Mental health care access (CDERR = 1.14) could lower disparities by 33.4%. Discrimination (CDERR = 1.13) and a lack of social support (CDERR = 1.15) also significantly mediated the poverty–mental health link, with potential disparity reductions of 27.1% and 32.1%, respectively. Targeting food security, housing stability, and mental health care access through community and health care infrastructure represents a critical pathway for reducing poverty-related mental health disparities in Southern rural Appalachia, offering actionable strategies for policymakers and clinical practice. (PsycInfo Database Record (c) 2026 APA, all rights reserved)