Mental health status among rural women of reproductive age: findings from the Central Pennsylvania Women's Health Study

Objectives. We sought to examine variables associated with mental health among rural women of reproductive age, with particular attention given to rural area type and farm residence.Methods. We analyzed data from the Central Pennsylvania Women’s Health Study, which included a random-digit-dialed survey of women aged 18 to 45 years. Hierarchical multiple linear and logistic regression models were estimated to predict 3 mental health outcomes: score on a mental health measure, depressive symptoms, and diagnosed depression or anxiety.Results. Mental health outcomes were associated with different factors. Farm residence was associated with higher mental health score, and the most isolated rural residence was associated with less diagnosed depression or anxiety. Elevated psychosocial stress was consistently significant across all models. A key stress modifier, self-esteem, was also consistently significant across models. Other variables associated with 2 of the outcomes were intimate partner violence exposure and affectionate social support.Conclusions. Farm residence may be protective of general mental health for women of reproductive age, and residence in isolated rural areas may decrease access to mental health screening and treatment, resulting in fewer diagnoses of depression or anxiety.Research on the mental health of rural women in the United States is sparse.1 Although some aspects of rural life—such as a slower pace and smaller, more tight-knit communities—are thought to be conducive to mental health, other aspects of rural life are stressful, especially for women. For example, women in rural areas may have fewer opportunities to participate in paid employment, may have restricted social contacts, or may have less access to social services and health care compared with women in more urbanized areas. In this study, we examined the variables associated with the mental health status of rural women of reproductive age, for whom mental morbidity could be important both for their own health and for the well-being of their children and families.Although rural areas vary with respect to population size, sociodemographic composition, cultural context, and socioeconomic factors, several generalizations can be made. First, because rural residents are disproportionately poor,2 rural women are likely to experience numerous stressors related to mental health problems. These stressors include economic deprivation, lack of job benefits such as health insurance, and social isolation in the smallest rural communities. Other aspects of small rural communities that might affect women’s mental health include the reinforcement of traditional gender roles, which can result in limiting women’s participation in employment or higher education and in creating barriers to women’s access to shelters or other social services for victims of intimate partner violence.3Some literature suggests that farm residents are at higher risk for health and mental health problems compared with nonfarm residents. Although some of these studies focus on the risk of suicide and farm-related injuries among men, it is noteworthy that many women who reside on farms are involved in farm work to some degree, and all women who reside on farms are involved in caregiving of family members engaged in farm work. The mental health risks to women of living on a farm and direct involvement in farming might include stressors such as the economic uncertainty of farming, low levels of job demand and control, lack of external recognition for their work, fatigue, emotional and social isolation, and the trauma associated with injuries and functional impairments.3^–5Although some studies have suggested that rural residence generally is not associated with higher levels of mental health problems compared with urban residence, with the exception of suicide among males,2^,6^,7 depression prevalence has been found to be slightly higher among residents of rural areas compared with residents of urban areas.8 Studies also showed that women consistently report higher levels of mental distress compared with men, regardless of place of residence. Also, to the extent that rural women, compared with urban women, have higher rates of some chronic conditions, such as obesity, and more limitations of activity caused by chronic conditions,2 they might be expected to experience greater levels of comorbid depression. A better understanding of the determinants of rural women’s mental health problems is needed to identify appropriate targets for interventions.Furthermore, because rural areas are often medically underserved, access to screening and treatment services for mental health problems is lower in rural areas, reducing the likelihood of diagnosis and receipt of needed care.9^–12 In particular, rural areas compared with urban areas have less availability of specialty mental health services, including mental health providers such as psychiatrists, child psychiatrists, and psychologists as well as inpatient psychiatric services.13Little research has focused on women’s mental health in various types of rural communities, comparing isolated areas with more populous rural areas. In this study, we examined 3 mental health outcomes among rural women of reproductive age living in these types of communities, with a focus on aspects of psychosocial stress and potential stress modifiers. Psychosocial stressors included acute or chronic demands or challenges as appraised by women, such as living in poverty or being exposed to domestic violence or discrimination on the basis of race/ethnicity or gender, which may affect their mental health and functioning. Stress modifiers included factors that have been found in previous research to buffer or exacerbate the individual’s response to stress, including religiousness or spirituality,14 self-esteem,15 and social support.16 We examined the following 3 research questions: (1) What are the correlates of mental health status among rural women of reproductive age? (2) Do modifiers of psychosocial stress, including religiousness, self-esteem, and social support, alter the effects of other predictors on mental health outcomes? (3) Does the type of rural residential setting or residence on a farm affect women’s mental health status after we controlled for other variables?On the basis of findings from previous mental health research, we hypothesized that rural women’s mental health status would be adversely affected by psychosocial stressors. We also expected that stress modifiers would reduce the effect of these stressors on mental health outcomes. In view of rural women’s potentially reduced access to social, economic, and health care resources, as well as the limited literature linking farm residence to mental health problems among rural men, we hypothesized that residing in more isolated rural settings and on farms would be associated with less optimal mental health outcomes among women in our sample.