Abstract CN11-01: Disparities in mental health outcomes between rural and nonrural cancer survivors
Authors: Andrykowski Michael , Burris Jessica 
Published: May 2012

Abstract
CN11-01
Considerable research has sought to identify disparities in cancer screening, incidence, treatment, and survival associated with race and ethnicity. Less research has sought to identify cancer-related disparities associated with geographic area of residence. No research has examined disparities in mental health outcomes due to whether a cancer survivor resides in a rural or nonrural area. This, despite the fact that there are a variety of social, psychological and structural reasons to believe such disparities might exist. Mental health outcomes were assessed in 116 survivors of a breast, colorectal, or hematologic malignancy. All study participants were 1 to 5 years post cancer diagnosis at time or study participation. All participants were recruited from the statewide, population-based Kentucky SEER cancer registry. Participants were classified as either rural or nonrural based on county of residence at time of cancer diagnosis using 2003 USDA rural-urban continuum codes (i.e., Beale codes). Participants residing in counties with codes 7-9 were classified as “rural” (n=54) while those residing in counties with codes 1-6 were classified as “nonrural” (n=62). All study participants completed a structured telephone interview and a mailed questionnaire packet. One-way ANOVA and ANCOVA comparing the rural and nonrural groups comprised the primary data analytic strategy for continuous measures while binary logistic regression analysis was used to analyze dichotomous measures. Effect sizes (ES) for continuous measures were calculated by dividing the mean group difference on a measure by the standard deviation in the entire sample. ES’s exceeding .33 SD were considered to be clinically significant or important differences between the rural and nonrural groups. Results indicated rural survivors evidenced significantly higher distress ratings on the National Comprehensive Cancer Network (NCCN) Distress Thermometer (p&lt;.05; effect size (ES) = .39 SD) and endorsed more total problems (p&lt;.05; ES=.50 SD) as well as more emotional problems (p&lt;.02; ES=.46 SD) on the NCCN Distress Thermometer. Rural survivors also evidenced greater anxiety (p&lt;.01; ES=.49 SD), depression (p&lt;.02; ES=.46 SD), and total scores (p&lt;.01; ES=.52) on the Hospital Anxiety and Depression Scale (HADS), and reported poorer status on MOS Social Functioning (p&lt;.01; ES=.49 SD) and Mental Health (p&lt;.02; ES=.44 SD) subscales. Rural survivors were more likely to meet criteria for clinically significant distress on the NCCN Distress Thermometer (OR=2.3; p&lt;.05) as well as meet criteria for clinically significant levels of both anxiety and depression symptoms on the HADS (OR=9.5; p&lt;.05). Rural and nonrural survivors did not significantly differ in the likelihood of being diagnosed with an anxiety or depressive disorder after cancer diagnosis (both p’s &gt;.10) nor did they differ with regard to measures of benefit-finding or life satisfaction/well-being (both p’s &gt; .10) As the rural group was less educated (p&lt;.05) and reported poorer status on the MOS physical function subscale (p&lt;.05), all analyses were repeated using education and physical function score as covariates. Results were largely unchanged. Additional analyses designed to identify potential reasons for the observed disparities in mental health outcomes found the rural and nonrural groups did not differ with regard to actual uptake or perceived ability to access various formal (e.g, psychologist, psychotropic medication) or informal (e.g., support groups, religious leader) mental health resources after their cancer diagnosis. However, rural survivors reported poorer personal attitudes regarding talking to a friend or family member about emotional difficulties (p&lt;.05; ES=.47 SD) and reported poorer perceived social norms regarding talking to a psychologist (p&lt; .05; ES=.37 SD) or friend/family member (p&lt;.05; ES=.37) about emotional difficulties, or participating in a cancer support group (p&lt;.05; ES=.39). In conclusion, rural cancer survivors evidence both statistically and clinically significant disparities on a variety of mental health indices. Significant disparities remained even after controlling for group differences in education and physical functioning. Despite these disparities, rural survivors are no more likely to receive a formal psychiatric diagnosis or access various mental health resources. However, rural cancer survivors do appear to hold less favorable attitudes and perceive less favorable social norms toward use of various formal and informal mental health resources for addressing mental health difficulties.
Citation Information: Cancer Prev Res 2008;1(7 Suppl):CN11-01.