Researchers at Harvard University and the Robert Wood Johnson Foundation found that rural Americans identified drug addiction and economic concerns as the most serious problems facing their communities.

The open-ended survey of 2700 rural adults aimed to identify the major concerns of rural voters, and found that 25 percent of rural Americans said drug addiction was their biggest concern for their community, and 21 percent said the same about economic concerns. The striking results illustrate the dramatic toll of addiction on rural communities, which have generally struggled to recover from the 2009 recession.

A higher share of Appalachian respondents, about four in 10, ranked opioid addiction as the most serious problem facing their community. Separate research from 2017, which found that the rate of overdose deaths per 100,000 people is higher in rural places than in metro areas.

“When you ask an open-ended question like that, the idea that four in 10 people would say the same thing is unheard-of,” said lead researcher Mary Gorski.

The findings suggest that in rural parts of the United States, which have struggled to recover from the 2009 recession, drug addiction has emerged as a significant problem on par with economic concerns.

The findings come as rural communities across the country reckon with the consequences of the opioid epidemic. In 2015, 1.5 million people living in rural areas misused prescription opioids and heroin, and 5,000 rural Americans died of overdose that year. The Ohio Valley ReSource reported recently that schools are adapting to higher rates of children with neonatal abstinence syndrome, and Ohio Valley communities are at the forefront of creative programs for addiction recovery.

Affordable healthcare was also identified as a problem in rural areas, with nearly a third of respondents saying they had trouble paying medical bills.

Interestingly, respondents said they felt that outside help was necessary to solve their communities’ problems.

“Rural communities have been traditionally characterized as very self-reliant, so we asked people, ‘Do you see a need for outside help?’” Gorski said. “A majority of respondents said they did see a need for outside help, including a major role for government to play.”

The survey comes as the 2020 presidential election kicks into high gear, and both Democratic and Republican candidates are eager to win rural votes.

“In this partisan era, opioids are one of the big bipartisan issues out there. Solving the opioid epidemic and bringing funding and treatment and some major policy solutions to rural areas is something that both parties will do something about,” Gorski said.

President Donald Trump recently named the opioid epidemic a public health emergency, and the Department of Health and Human Services has awarded $1 billion to address the crisis.