A narrative review of factors associated with drink driving and drug driving in rural areas from a socioecological perspective

Drink and drug driving continue to be significant public health concerns, and this holds on rural roads. While few review studies focus specifically on drink or drug driving in rural areas, individual studies identify key factors associated with these behaviours in rural regions. Review studies can provide a synthesised understanding of rural risk, integrating single factors to offer a clearer picture of patterns of influence, including contrast with urban settings. We undertook a systematic search of research examining factors associated with drink and drug driving in rural areas. We searched databases of PubMed, PsycNet, SCOPUS, Web of Science, and TRID. We used a socioecological model as a framework to categorise, synthesis, and compare factors associated with drink and drug driving. We included 35 studies from 2010 to 2025 to identify factors associated with rural drink or drug driving. Studies used administrative datasets, surveys (typically with teens or young adults), and interviews with very specific samples. Analysis revealed factors associated with different socioecological layers, but with a relative absence of factors capturing connections between systems. Patterns of risk and protective factors showed multilayered dynamics shaping rural drink and drug driving, with heterogeneity evident both by substance type and across rural areas themselves. Thus, multiple interrelated factors likely need to be addressed for a safer road use experience. There is scope to continue to understand factors associated with drink and drug driving in rural areas. Opportunities exist to expand and use data linkage to better understand rural behaviour and help tailor approaches with a theory-guided framework to address identified risk and protective factors. Policy level factors may serve as key focal points for initiating change efforts. Further research is warranted to explore differences among various rural populations and the different substances used.