OBJECTIVE: This analysis determines the importance of geography and spatial behavior as predisposing and enabling factors in rural health care utilization, controlling for demographic, social, cultural, and health status factors. DATA SOURCES: A survey of 1,059 adults in 12 rural Appalachian North Carolina counties. STUDY DESIGN: This cross-sectional study used a three-stage sampling design stratified by county and ethnicity. Preliminary analysis of health services utilization compared weighted proportions of number of health care visits in the previous 12 months for regular check-up care, chronic care, and acute care across geographic, sociodemographic, cultural, and health variables. Multivariable logistic models identified independent correlates of health services utilization. DATA COLLECTION METHODS: Respondents answered standard survey questions. They located places in which they engaged health related and normal day-to-day activities; these data were entered into a geographic information system for analysis. PRINCIPAL FINDINGS: Several geographic and spatial behavior factors, including having a driver's license, use of provided rides, and distance for regular care, were significantly related to health care utilization for regular check-up and chronic care in the bivariate analysis. In the multivariate model, having a driver's license and distance for regular care remained significant, as did several predisposing (age, gender, ethnicity), enabling (household income), and need (physical and mental health measures, number of conditions). Geographic measures, as predisposing and enabling factors, were related to regular check-up and chronic care, but not to acute care visits. CONCLUSIONS: These results show the importance of geographic and spatial behavior factors in rural health care utilization. They also indicate continuing inequity in rural health care utilization that must be addressed in public policy.