Rural and nonrural racial variation in mentally unhealthy days: Findings from the behavioral risk factor surveillance system in North Carolina, 2015-2019

Rural-nonrural health disparities are well documented, yet researchers rarely consider how mental health is experienced across racial groups in rural areas. Black Americans frequently demonstrate better mental health than White Americans, which is puzzling, given their exposure to interpersonal and structural racism and discrimi-nation. To determine if this paradoxical mental health patterning occurs within the context of rurality, we used zero-inflated negative binomial regression to model 2015-2019 North Carolina Behavioral Risk Factor Surveil-lance System respondents' self-reported days with stress, depression, and problems with emotions ("mentally unhealthy days") in the past 30 days. The rate of mentally unhealthy days was 1.10 times as great for rural re-spondents than nonrural respondents (95% CI 1.04-1.17, p = 0.002), in the negative binomial portion of the model. However, this relationship was moderated by racial identity. Rural White respondents had 1.26 times as many mentally unhealthy days as rural Black, nonrural Black, and nonrural White respondents (95% CI 1.08-1.47, p = 0.003). Probing the interaction of rurality and racial identity indicated that rural residence was associated with more mentally unhealthy days for White respondents and fewer mentally unhealthy days for Black respondents. Because of expectations that are rooted in the social system of whiteness, we posit that White Americans' mental health could be more susceptible to the barriers to mental health that are associated with rural residence. Our findings also suggest that it may be insufficient to examine the association between rurality and mental health without documenting how health is experienced across racial groups. This study enhances un-derstanding of potential social determinants that could underlie Black-White racial patterning in mental health. To advance rural health promotion and health care delivery, future research should investigate which underlying determinants may facilitate mental wellbeing for rural Black Americans and identify which mechanisms influence rural White Americans' relative mental health deficit.