Statement of Purpose This study sought to determine the influence of rurality on the relationship between lifetime history of TBI with loss of consciousness (LOC) and unhealthy alcohol use or mental health problems.

Methods/Approach Measures of lifetime history of TBI with LOC, location of living (rural vs. urban), unhealthy alcohol use (binge drinking and heavy drinking in past 30 days), and mental health (depression diagnosis, number of poor mental health days in past 30 days) and demographics were sourced from the 2016, 2017, 2018, and 2019 Ohio Behavioral Risk Factors Surveillance System. We conducted multivariable logistic regressions to determine odds ratios for each outcome between individuals living in rural vs. urban areas and individuals with vs. without lifetime history of TBI with LOC.

Results A total of 16,941 survey responses were included. Of these, 22.9% were living in rural areas and 16.9% had experienced a TBI with LOC. No interaction between location of living and lifetime history of TBI with LOC was observed for any outcomes, indicating rurality did not modify these relationships. Rural respondents were less likely to report binge or heavy drinking than urban respondents, but not mental health outcomes. Lifetime history of TBI with LOC was associated with increased risk of unhealthy alcohol use and mental health problems.

Conclusion Our findings support the need for TBI screenings as part of mental health intake evaluations and behavioral health screenings. Though rurality did not influence mental health outcomes, rural areas may have limited access to quality mental health care. Therefore, future research should address access to mental health services following TBI among rural residents.

Significance To our knowledge, this is the first study to address rurality as a possible modifying factor of relationships between TBI and behavioral health outcomes and contributes to improve understanding of health disparities among understudied rural populations.