The Moderating Role of in-Person and Online Social Connectedness in the Association between Geographic Isolation and Depressive Symptoms Among Adults Living in the Black Belt Region of Alabama

Background and Purpose: Geographic isolation, defined as having limited mobility due to lack of transportation, is a major risk factor for depression. However few studies have examined the association between geographic isolation and depression among individuals living in the Black Belt region in Alabama, one of the most under-resourced regions in the US. Despite facing increased structural challenges, rural-living individuals may have greater in-person social connectedness (SC), a factor associated with better mental health outcomes, than their urban-living counterparts. In addition to in-person SC, the COVID-19 pandemic highlighted the usefulness of online SC to reduce depression. Very few COVID-19 studies, however, have included rural-living individuals. We aimed to examine the association between geographic isolation and depressive symptoms and test the moderating effects of in-person and online SC.

Methods: Using cross-sectional data collected from 116 participants living in the Black Belt region of Alabama in 2019–2020, we tested adjusted linear regression models to examine the association of geographic isolation and depressive symptoms. Fully adjusted models included sex, age, income, educational attainment, marital status, and racial discrimination as covariates. We conducted moderation analyses using cross-products in fully adjusted models. Stratified analyses by level of SC were conducted for statistically significant moderation coefficients. Geographic isolation was measured dichotomously. If participants reported difficulty conducting at least one everyday task due to lack of transportation, they were categorized as geographically isolated. Depressive symptoms were assessed using the Personal Health Questionnaire-9 (PHQ-9). In-person SC was calculated summing the frequency with which individuals reported socializing at in-person events. Online SC was assessed using the number of social media platforms with which participants engaged.

Results: Most participants were African American/Black (93.97%) and women (79.31%). Participants had a Mage=56.40 (SD=14.32). Most participants were not geographically isolated (78.45%). The average PHQ-9 was 5.78 (SD=6.60), indicating mild depressive symptoms. The average in-person and online SC scores were 5.74 (SD=1.76) and 0.81(SD=0.91), respectively. Geographic isolation was associated with a 0.61 unit increase in PHQ-9 compared to no geographic isolation (b=0.61, SE=0.01, p=0.007) in fully adjusted models. While in-person SC was not a statistically significant moderator (b=-0.15, SE=0.11, p=0.17), online SC did moderate this relationship (b=-0.64, SE=0.32, p=0.04). For individuals with no online SC, being geographically isolated was associated with a 0.89 unit increase in PHQ-9 when compared to those who were not geographically isolated (b=0.89, SE=0.33, p=0.01).

Conclusion: Geographic isolation is a robust predictor for increased depressive symptoms among individuals living the Black Belt region of Alabama. Lacking online SC may exacerbate the effects of geographic isolation on depressive symptoms in this population. Multi-level interventions focused on increasing access to transportation and promoting online SC may help reduce the burden of depression among those living in under-resourced regions of Alabama. Furthermore, expanding access to Internet service in rural areas is critical given that a substantial portion of Alabama has limited to no access to Internet services. Future studies should replicate the current models in larger samples across other rural regions in the US.