Rural mental health inequities are frequently produced not by an absence of services but by systemic designs that fail to align with the lived realities of local communities. Findings from the From the Ground Up project in Rocky View County, Alberta, demonstrate that farmers encounter barriers embedded in geography and institutional logics that reflect outdated models of care. This paper situates these findings within an anthropological framework, advancing the view that health systems are not neutral infrastructures but socially constructed and culturally mediated assemblages.

Employing ethnographic fieldwork, participatory engagement, and design-thinking methods, we collaborated with farmers, community partners, and health professionals to surface needs, expectations, and symbolic understandings of health and wellbeing. This process generated a set of sixty-six guiding principles that point toward both “hard” innovations (telehealth services, resource networks) and “soft” innovations (community-led initiatives, identity-affirming practices). Reflexive practice was central, enabling the research team to unsettle institutional assumptions and re-center rural voices as epistemic authorities.

The analysis reveals persistent misalignments between institutional access points and agricultural lifeways, including seasonal rhythms of labor and culturally embedded practices of care. These misalignments reinforced experiences of invisibility and mistrust, positioning farmers as passive recipients rather than active agents. By contrast, community-forward approaches foregrounded dignity and agency, offering a more responsive and sustainable path toward equity. This paper concludes by reframing rural health systems as lived, co-constructed, and entangled, calling for a paradigm shift from designing for rural populations to designing with them. This shift emphasizes context-sensitive, participatory innovations that respect rural culture and lifeways, thereby bridging the gap between lived experience and systemic response.