Use of formal and informal mental health resources by cancer survivors: differences between rural and nonrural survivors and a preliminary test of the theory of planned behavior.

Cancer diagnosis, treatment, and recovery entails a challenging and diverse set of stressors for most individuals. Individuals differ in their response to these challenges with consequent diversity in mental health (MH) outcomes evidenced across cancer survivors. Understanding of the many factors contributing to the heterogeneity in MH outcomes among cancer survivors is a critical, yet difficult, task. In general, MH outcomes in cancer survivors might be viewed as resulting from the balance of two broad classes of factors: (a) the stress and burden posed by the cancer experience, and (b) the various resources the individual can bring to bear to cope with their cancer stress and burden [1-2]. Similar to any individual confronted by a significant adaptational challenge, cancer survivors might access various formal and informal MH resources as a means of coping with the stress and burden posed by their cancer experience. Formal MH resources that might be available to survivors include MH professionals (e.g., psychologists, psychiatrists, social workers), professionally-led cancer support groups, or prescription medications to manage distress. Survivors might also access informal MH resources such as religious leaders (e.g., ministers, priests, rabbi), other cancer survivors, or a sympathetic and caring friend or family member. In general, better MH is fostered not simply by the availability of MH resources but by the appropriate access to and utilization of available MH resources. Consequently, understanding and identification of factors that influence access to and utilization of MH resources in cancer survivors is an important goal. In general, MH resource use in all its various forms can be viewed as a type of health behavior. A variety of models for understanding the performance of various health behaviors have been proposed [3-7]. Among them, the Theory of Planned Behavior (TPB) [8-9] has found empirical support in its ability to account for performance of a variety of physical and psychosocial health behaviors [10-14]. The TPB posits performance of a particular health behavior is a function of three broad classes of variables: (a) personal attitude toward performance of that behavior, (b) perceived behavioral control over performance of that behavior (akin to self-efficacy for performing a health behavior), and (c) social norms regarding performance of that behavior [8-9]. Recently, we reported evidence suggesting significant disparities might exist between cancer survivors residing in rural and nonrural areas with regard to their reported MH outcomes [15]. Specifically, survivors residing in rural areas reported more anxiety and depressive symptoms, greater global distress, more emotional problems, and poorer mental functioning than survivors residing in nonrural areas. These differences existed even after controlling for differences between rural and nonrural respondents in education and physical functioning. In part, such disparities in MH outcomes might result from differences in access to and utilization of various formal and informal MH resources. Indeed, research has shown lower use of various MH resources among individuals in rural areas [16-17]. Reasons for this are several. Rural areas are likely to be medically underserved [18] with consequently poorer availability of various MH resources. Practical barriers, such as long travel distances to professionals, low rates of insurance coverage, unreliable transportation, and limited financial resources, may further contribute to rural residents’ perception that some MH resources are not accessible [19]. In addition, personal attitudes and social norms regarding MH problems [18, 20-21] and MH help-seeking [19, 21-23] might differ between rural and nonrural areas. Indeed, research has shown individuals residing in rural areas are more likely to stigmatize individuals with MH difficulties, profess some wariness of MH professionals, and endorse a policy of “keeping one’s problems to oneself” relative to individuals residing in nonrural areas [21-23]. The aims of this study were to: (1) identify differences in use of formal and informal MH resources between cancer survivors residing in rural and nonrural areas; (2) identify differences between rural and nonrural survivors in personal attitudes, social norms, and perceived behavioral control regarding MH resource use for cancer-related emotional difficulties; and (3) test the utility of the TPB for understanding differences between rural and nonrural survivors in utilization of various MH resources. We hypothesized rural cancer survivors, relative to their nonrural counterparts, would report less utilization of a variety of MH resources for addressing emotional difficulties following their cancer diagnosis, and would report less favorable personal attitudes, social norms, and perceived behavioral control regarding such MH help-seeking. In addition, based on the TPB, we hypothesized reported utilization of MH resources would be positively associated with more positive personal attitudes and social norms regarding use of various MH resources for addressing emotional difficulties, as well as greater perceived behavioral control to access those MH resources if desired.