Disparities in mental health between rural and nonrural cancer survivors: a preliminary study.

Cancer disparity research has focused primarily on identifying population-based characteristics linked to cancer incidence, survival, and treatment [1–4]. While the mental health (MH) of cancer survivors is of great significance [5–6], little research has examined the link between population-based characteristics and MH outcomes among cancer survivors. In particular, there is scant research examining whether geographic residence, that is whether an individual resides in a rural or nonrural area, has significant bearing on an individual’s MH following cancer diagnosis. Since over 10 million cancer survivors live in the United States (U.S.) [7], and roughly 20% of the population resides in rural areas, one can estimate the presence of approximately 2 million rural cancer survivors. With such a large number of rural cancer survivors, it is important to consider whether rural residence might be an important predictor of MH in cancer survivors. There are several reasons to believe residing in a rural area, characterized by low population density and geographic isolation [8–9], might influence adjustment after cancer diagnosis. First, disparate rates of comorbidity [9] and variation in cancer treatment received by rural and nonrural residents [10–11], may place rural cancer survivors at risk for poor physical functioning, which might have negative implications for MH. Second, few MH professionals (e.g., psychologists, psychiatrists), long travel distances to healthcare providers, low rates of insurance, and little anonymity for those seeking treatment from MH professionals in rural areas [8–9, 12–13], could contribute to rural residents consuming less MH treatment than nonrural residents [14–16]. Third, geographic isolation can make it difficult for rural cancer survivors to participate in cancer support groups and access information that could be helpful in coping with illness-related distress [17]. Fourth, a cancer diagnosis might be more difficult to discuss in rural areas [18–19] due to social norms regarding disclosure of one’s emotional or psychological problems to other individuals [19], including MH professionals [20]. In sum, unique aspects of rural residence may interact with the experience of cancer diagnosis, treatment, and recovery, such that rural cancer survivors experience poorer MH outcomes than nonrural cancer survivors. Despite the likelihood and potential importance of MH disparities between rural and nonrural cancer survivors, few studies have directly compared the MH of rural and nonrural cancer survivors [21–24]. In a sample of 191 female long-term cancer survivors, Kurtz and colleagues [21] found geographic residence was not a significant predictor of quality of life (QOL) outcomes, including “psychological state.” In contrast, in a study of 60 recently diagnosed breast and cervical cancer survivors, Lyons and Shelton [22] found rural survivors reported poorer QOL than nonrural survivors, despite no differences in the severity of depressive symptoms. Lancee and colleagues [23] reported rural residence was unrelated to the experience of distress among a sample of 1309 cancer survivors, the majority of whom were diagnosed with breast and genitourinary cancers. Finally, rural cancer survivors were not more likely than nonrural cancer survivors to report need for psychological assistance [24]. While these studies provide some information, they all evidence methodological limitations, including small sample sizes [22], not being designed to test for differences between rural and nonrural survivors [21, 23–24], examination of only 1 or 2 indices of MH [21–23], lack of any objective criterion for determining rural residence [21–23], and inclusion of only female participants [21–22, 24], most of whom were diagnosed with breast cancer. It could even be argued that some participants in Lyons and Shelton’s [22] sample are not cancer “survivors” per se, as many were still undergoing treatment. Considering all of the above, it is clear that no well-designed study of MH disparities between rural and nonrural cancer survivors currently exists. The present study aimed to identify the nature and magnitude of differences in MH outcomes in cancer survivors as a function of rural residence. Indices of both psychological distress and well-being were included to allow for a comprehensive assessment of participants’ MH functioning. It was hypothesized that rural cancer survivors would report poorer MH (i.e., greater psychological distress and less well-being) than nonrural cancer survivors.