Access to Mental Health Care in Rural Communities Among Women Diagnosed with Breast Cancer

To the Editor: Access to health care among rural populations is limited. Residents of rural areas have less access to a regular primary care provider and to specialty physicians (1). Although the rural United States has 20% of the national population, it has less than 11% of its physicians (1,2). In addition, mental health care professionals are substantially underrepresented in rural areas (3). According to the 2001 Surgeon General Report, persons living in rural communities are likely to be underserved and have difficulty accessing needed treatment (4). The problem of accessing health care is severe in the Intermountain Region of northern California, which spans approximately 30,000 square miles. A majority of the towns in this region are located between 50 and 150 miles from the nearest urban area, a characteristic that contributes to reduced treatment rates (5). Furthermore, 83% of its residents live in areas designated as “frontier”—defined as fewer than 11 people per square mile, compared to the average of 217.2 per square mile in California (6). Research indicates that the availability of health care resources declines as population density declines and geographic isolation increases (3,5). In addition, the majority of counties in our study have been designated as Health Professional Shortage Areas in mental health services (7). This research focused on women with a diagnosis of breast cancer who live in the Intermountain Region. Women diagnosed with breast cancer often suffer from symptoms of emotional distress that may be ameliorated through accessing psychosocial services (8). Approximately one third experience significant distress, and 10–25% have major depression (9,10). Although receiving psychosocial services is becoming the standard practice for cancer patients (11), residents of rural communities have far less access to such services as a result of geographic isolation and scarcity or complete lack of health care services (12). This study examined the prevalence of depression among 63 women diagnosed with breast cancer from 12 rural counties of northern California and their ability to obtain mental health treatment. Data were drawn from a parent study, conducted from 2008 to 2010 that examined the efficacy of providing breast cancer support groups via videoconferencing for improving emotional support and reducing distress. Prior to randomization, participants completed a shortened version of the 2008 Adult Access to Health Care and Utilization section of the National Health Interview Survey to assess the availability and site of a usual source of care, indications of delayed care, and the inability to obtain care (13). Participants also completed the Center for Epidemiologic Studies Depression scale (CES-D) to assess depressive symptomatology (14). Analyses explored the direction of and relationship between access to mental health care and (a) depression and (b) educational level, as research has found a positive association between educational level and receiving mental health services (15). This study used the more conservative approach of simultaneous binary logistic regression to test two hypotheses in the same model. The age of the women ranged from 37 to 80 years (M = 58.7, SD = 9.1). More than half (60.3%) had some college or less, and 47.6% were unemployed. The majority (73.1%) had to drive more than 30 miles and 17.4% had to drive more than 100 miles, for breast cancer treatment. In the past 12 months, 14.3% of the sample needed medical care specifically related to breast cancer and 17.5% needed some type of other health care service, but were unable to obtain it. More than a third of the sample (38.1%) met criteria for depression––determined by a score of greater Address correspondence and reprint requests to: Alexandra Aylward, BA, Metropolitan Center for Urban Education, Steinhardt School of Culture, Education, and Human Development, New York University, 726 Broadway, 5th floor New York, NY 10003, or e-mail: aga218@nyu.edu. This research was supported by funds from the California Breast Cancer Research Program of the University of California, Grant Number 13BB2400.