key: cord-0725714-mcu4cyme
authors: Howren, M. Bryant; Higginbotham, John C.
title: Rural health in behavioral medicine: introduction to the special series
date: 2021-06-29
journal: J Behav Med
DOI: 10.1007/s10865-021-00240-y
sha: 28ea57beaa9a18f33407465debb807e15e5f4841
doc_id: 725714
cord_uid: mcu4cyme

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highlight some of these broader issues and is devoted to rural health research in health psychology and behavioral medicine which is of interest to researchers and clinicians alike.

The special series includes a pair of articles addressing issues in rural cancer survivorship. Bhuiyan et al., (2021) examined age-varying associations between physical activity and psychological outcomes in a sample of 219 rural cancer survivors in Pennsylvania. Participants were survivors of multiple different types of cancer including breast, prostate, and colorectal and completed measures of physical activity and symptoms of depression and anxiety. Analyses utilized intercept-only time-varying effect models (TVEM) to assess the prevalence of symptoms of depression and anxiety as a function of age and to assess the age-varying effects of moderate, vigorous, and total physical activity on symptoms of depression and anxiety. Bhuiyan et al. found that, as compared to older cancer survivors, younger survivors (aged 20-40) experienced a significantly higher prevalence of both depression and anxiety symptoms and advocate for more studies of factors associated with psychological distress in younger adult cancer survivors. Ratcliff et al., (2021) conducted a systematic review of 19 behavioral interventions for rural breast cancer survivors over the last two decades. As noted within the article, compared to urban breast cancer survivors, rural breast cancer survivors experience poorer mental and physical health outcomes and often lack knowledge about post-treatment care. The authors discuss the implications and need for interventions targeting psychosocial support, weight control, and education tailored to rural breast cancer survivors.

Four articles describe interventions for rural military veterans. Bernardy et al., (2021) mailed a direct-to-consumer educational product aimed at decreasing benzodiazepine use in PTSD care to over 1300 veterans in New England, half of which were rural; approximately two-thirds of veterans exhibited a dose reduction with significantly more rural veterans doing so than their urban counterparts. The authors suggest that their approach may have been particularly beneficial for rural veterans in that the educational product left decision-making power to the patient, which may have aligned with many rural individual's strong attitudes toward independence and is an interesting avenue for future research. Dindo et al., (2021) piloted a one-day acceptance and commitment therapy (ACT) group workshop for distressed rural veterans in community-based settings. In order to reach such veterans, the authors partnered with rural veteran-serving nonprofit organizations which often have a high degree of credibility within veteran communities. Results showed improvements in functioning, reintegration, meaning and purpose, as well as reductions in distress three months following workshop participation; the success of the project was a function of fostering collaborations with community-based veterans' organizations, suggesting that community partnerships with rural-serving health clinics and veteran-serving organizations may facilitate identification and engagement of rural veterans in research and care, an area that is receiving increased attention (Howren et al., 2020) . O'Hara et al., (2021) conducted a program evaluation of MomMoodBooster, a coachsupported internet-delivered cognitive behavioral therapy (CBT) program for the treatment of maternal depression in veteran women. Program participation was associated with decreased depressive symptoms, increased behavioral activation, and decreased dysfunctional automatic thoughts, with rural women doing as well as urban women in terms of participation and outcomes. Shiner et al., (2021) examined whether the rural-urban disparity in suicide risk among VA users decreased during a time of contemporaneous VA efforts to improve access to and services for mental health care for rural veterans using a retrospective cohort design. They found that the rural-urban suicide disparity persists, but was attenuated after adjustment for age, gender, and race. In particular, rates of suicide were much higher for White as compared to Black veterans, suggesting the need to explore variation in suicide risk by race and rurality.

Lastly, Fischer et al., (2021) conducted a review of sleep health in rural mothers using a social-ecological framework. The authors identified gaps in the literature, social determinants that interact to influence sleep health, and provide recommendations for targeting sleep health in rural mothers. Among other timely recommendations, they suggest incorporating brief and adaptable behavioral sleep interventions with flexible modes of delivery as well as increased screening for behavioral health problems in rural primary care. Research in sleep health continues to grow yet issues specific to rural areas have yet to be fully explored.

These papers represent only a tiny cross-section of the promising work being conducted in the area of rural health in health psychology and behavioral medicine. The intended scope of this series was broad but several important areas are not represented. These include rural care coordination efforts, prevention studies, initiatives to develop/advance population health strategies for rural behavioral health, moderators of treatment impact (e.g., patient, provider, and/or sociocultural factors), emerging or existing areas and populations deserving of greater attention in rural settings (e.g., migrant farm workers, indigenous peoples, persons with HIV, testing and vaccination for COVID-19), and sociocultural considerations related to rural populations in this context to name but a few. We also had hoped to see more research focused on translation and adaptation of existing evidence-based interventions into rural settings through community partnerships, perhaps using informal or paraprofessional delivery mechanisms to engage those hardest to reach. Moreover, as rural areas continue to become more diverse, more research must be also be conducted in underrepresented rural minority groups who disproportionately suffer from poverty and other socioeconomic impacts (Bolin et al., 2015) as well as understanding the challenges of recruiting and enrolling all rural residents into behavioral medicine research. The COVID-19 pandemic has exacerbated existing inequalities and has underscored the need to consider these issues in all behavioral medicine research. Lastly, much research focuses on outcomes and content areas in which rural residents fare worse, for good reason, as considerable existing evidence already demonstrates. However, work is needed which highlights things that rural does well, including study of protective factors and related assets and opportunities associated with living in a rural community. This will require a reframing to some degree away from de facto rural-urban comparisons and looking at pockets within rural which have found success and are doing as well or better than comparable rural areas and/or their urban counterparts.

In sum, several diverse patient populations and topic areas are represented in this series, but many other important areas are not, in part due to the nature of an open request for submissions. It is hoped that the included articles are timely, useful, and facilitate even more high quality, methodologically rigorous rural health research in health psychology and behavioral medicine. As rural health continues to rightfully take its place "centerstage" across many health-related disciplines, there will be increased opportunities to undertake impactful behavioral medicine research in this space.

Taking the message to the rural patient: Evidencebased PTSD care

Age-varying associations between physical activity and psychological outcomes among rural cancer survivors

Rural healthy people 2020: New decade, same challenges

Continuing challenges in rural health in the United States

Combination outreach and wellness intervention for distressed rural veterans: Results of a multimethod pilot study

Social-ecological considerations for the sleep health of rural mothers

Identification of military veterans upon implementation of a standardized screening process in a federally qualified health center

A systematic review of behavioral interventions for rural breast cancer survivors

Recent trends in rural-urban suicide disparity among veterans using VA health care

Treating postpartum depression in rural veterans using internet-delivered CBT: Program evaluation of MomMoodBooster

Barriers to medical research participation as perceived by clinical trial investigators: Communicating with rural and African American communities

Community-based participatory researchspeed dating: An innovative model for fostering collaborations between community leaders and academic researchers

One in five Americans live in rural areas

Healthy People 2020: Rural areas lag in achieving targets for major causes of death