A MIXED METHODS EXAMINATION OF BLACK-WHITE RACIAL DIFFERENCES IN PERCEPTIONS OF MENTAL HEALTH IN RURAL NORTH CAROLINA

Background: Rural-nonrural health disparities are well documented, but less is known about how mental health is experienced across racial groups in rural areas. Termed the Black-White mental health paradox, some Black Americans report better mental health than White Americans, despite chronic exposure to the negative effects of racism and discrimination. Yet, it is unclear if this paradox exists within the context of rurality and mental health. Methods:Grounded in the whiteness and health framework, Intersectionality Theory, and the Transactional Model of Stress and Coping, this dissertation draws on the strengths of both quantitative and qualitative research methods to investigate the relationship between rurality and self-reported mental health in North Carolina (NC). Study 1 was a secondary analysis of NC data from the 2015-2019 Behavioral Risk Factor Surveillance System, an annual random digit dialed telephone survey. I used zero-inflated negative binomial (ZINB) regression to model Black and White rural and nonrural residents’ self-reported days with stress, depression, and problems with emotions (i.e., “mentally unhealthy days”) in the past 30 days, with statistical controls for theoretically related demographic factors. Study 2 involved a critical discourse analysis of 29 previously collected health related oral history interviews from Black and White rural NC residents. Results:In Study 1, the rate of mentally unhealthy days was 1.10 times as great for rural respondents than nonrural respondents (95% CI 1.04 - 1.17, p = 0.002), in the negative binomial portion of the ZINB 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. Study 2 revealed racial patterning in how interviewees described the topics of depression, drug misuse, stressors, and coping. White interviewees’ beliefs about mental health were rooted in the meritocratic assumption that individual choice and personal responsibility are the primary determinants of mental illnesses. Conversely, Black interviewees considered how macro-level determinants and a personal relationship with a higher power can influence mental health. Conclusion:The social system of whiteness can disparately affect how living in a rural area relates to mental health for Black and White North Carolinians. Future mental health related research, interventions, and policies should not conceptualize rural residents as a homogenous population with universal mental health needs.