Parents of children (birth to 18 years old) in rural communities face different inequities and health disparities than urban parents (The Cecil G. Sheps Center for Health Services Research, 2017; Centers for Disease Control and Prevention [CDC], 2017; Zahnd, Rodriguez, & Jenkins, 2018).
Most adults in rural communities, compared with urban communities, have lower median household incomes, less education, and are more likely to be uninsured (The Cecil G. Sheps Center for Health Services Research, 2017). The rates for the five leading causes of death—heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and stroke—are higher for adults living in rural communities (CDC, 2017). Opioid overdose deaths are 45% higher in rural communities (CDC, 2015). In addition, adults in rural communities are more likely to have cancers correlated with modifiable risks, such as lack of human papillomavirus vaccines and preventive colorectal or cervical cancer screenings, and higher incidence of tobacco use (CDC, 2017; Zahnd et al., 2018). The rate of suicide for adults in rural communities, when compared with urban communities, is also higher (Fontanella et al., 2015).
A shortage of health care providers exacerbates many of these rural health disparities. Most rural communities lack primary care providers and specialists, including substance misuse and mental health providers (U.S. Department of Veterans Affairs [VA], 2016).
Depression is a common mental health problem in rural communities (Fontanella et al., 2015). Suicide rates of parents and children, opioid addiction of parents, and poverty have been increasing steadily since the mid-1990s in rural areas (Fontanella et al., 2015; VA, 2016). Depression in parents is associated with sub-optimum parenting of children (Berger & Langton, 2011; Davis, Davis, Freed, & Clarke, 2011; Searle, 2011; Weitzman, Rosenthal, & Liu 2011; Yogman & Garfield, 2016). Researchers have found associations between parental depression and impaired parenting for children from birth through adolescence (Beeber, Perreira, & Schwartz, 2008; Chang, Halpern, & Kaufman, 2007; Davé, Petersen, Sherr, & Nazareth, 2010; Davis et al., 2011; Luthar & Ciciolla, 2016; Yogman & Garfield, 2016). Beeber et al. (2008) and Davis et al. (2011) found depression in parents is associated with poorer well-being and physical health of infants and toddlers. For older children and adolescents, adverse health outcomes of adolescent tobacco and substance use, childhood asthma, accidents, and child maltreatment occur more often when a parent is depressed (Berger & Straub, 2008; Davis et al., 2011; Weitzman et al., 2011; Yogman & Garfield, 2016). Some mental health information related to the negative impact of depression in parents associated with parenting children is based on evidence, some is not, and some mental health information related to depression in parents needs to be further studied by nurses.
Using theoretical models, Miklush and Connelly (2013) have shown that the association between depression and parenting is complex and needs to be understood in the context of a larger set of mediators and moderators. For example, depression in parents is more likely to be associated with adverse outcomes in children with the presence of additional risk factors (e.g., poverty, comorbidities, substance use disorders, family structure). Unfortunately, current theoretical models to support improved mental health for parents were developed for primarily urban and suburban White samples and are therefore limited in other populations (Miklush & Connelly, 2013).
Currently, there is little nursing research on gender differences in depression associated with parenting children in rural communities as well as parenting from different cultural or ethnic groups living in rural communities. In addition, no nursing research was found on depression in lesbian, gay, bi-sexual, transgender, transsexual, queer, questioning, intersex, asexual, ally, pansexual parents associated with parenting children in rural communities.
The complex tapestry of families in rural communities in the United States has become progressively diverse across cultures, sexual orientation, race, and ethnicity within the past 100 years. For instance, communities in rural America are becoming a complex mixture of families from various cultures, ranging from factory workers who have been laid off in West Virginia, to Middle Eastern Muslim engineering students moving to rural Missouri to study petroleum engineering in university towns, to immigrants from Latin America relocating to work at beef processing plants in Kansas. Fewer children are living in households with married heterosexual parents of the same ethnicity; more children are being parented by same-sex parents and non-traditional caregivers, such as grandparents, and living with parents of different racial backgrounds or with single parents (Child Trends Databank, 2015).
Evolving technological, economic, demographic, and social landscapes in rural U.S. communities have created new opportunities and challenges with respect to ways providers can support parents with depression (and other mental health problems) while parenting children. Providers need to increase their clinical understanding of parents' concerns and their perspectives on the challenges, demands, and resources needed for parenting children in rural communities, especially among diverse groups of people. Providers should consider barriers to use of mental health services for parents from rural communities. These barriers may include being uninsured, the inability to recognize depression, and lack of internet access (The Cecil G. Sheps Center for Health Services Research, 2017; Greenberg, Haney, Blake, Moser, & Hesse, 2017). Providers also need to consider the generational impact of parental depression on children (Beeber et al., 2008; Chang et al., 2007; Davé et al., 2010; Davis et al., 2011; Luthar & Ciciolla, 2016; Yogman & Garfield, 2016).
Future nursing research should include how the opioid epidemic has impacted depression in parents associated with parenting children in these communities. Nursing research should also explore the impact of rising poverty and depression associated with parenting children related to the stress and demands of parenting in the context of diminishing family and community resources. Mental health of parents affects the health of their children living in the United States and is a critical investment for the health of our country now and in the future.
Sarah Oerther, MSN, MEd, RN, FRSPH
Jonas Policy Scholar, Psychiatric, Mental Health
& Substance Abuse Expert Panel, 2017–2019
Saint Louis University School of Nursing
St. Louis, Missouri
Mona Shattell, PhD, RN, FAAN
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