Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1035 — Comparing Attitudes Toward Mental Health Service Use among Rural and Non-Rural Veterans: The Impact of Varying Definitions of Rurality

Lead/Presenter: Ellen Fischer, COIN - North Little Rock
All Authors: Fischer EP (HSR&D Center for Mental Healthcare & Outcomes Research) Bartnik MK (HSR&D Center for Mental Healthare & Outcomes Research) Curran GM (HSR&D Center for Mental Healthare & Outcomes Research) Fortney JC (HSR&D Center of Innovation for Veteran-Centered & Value-Driven Care) McSweeney JC (University of Arkansas for Medical Sciences) Williams DK (University of Arkansas for Medical Sciences) Williams JS (HSR&D Center for Mental Healthcare & Outcomes Research)

Objectives:
The literature and our previous research suggest that Veterans' attitudes contribute to rural/non-rural disparities in use of VA mental healthcare. We evaluated how a set of attitudes and beliefs related to mental healthcare utilization varied by rurality, and explored the impact of varying definitions of "rural" on observed associations.

Methods:
We interviewed a probability sample of 752 Veterans, aged 18-70, living in VISNs 1, 16, 19 or 23, who had screened positive for depression or PTSD. Three rurality indicators were used: distance between the Veteran's residence and the nearest VAMC, RUCA-B categories (urban, large rural, small and isolated rural), and place-identity (self-description as an urban, suburban or rural person). The relationship of each attitudinal measure to each of the rurality indicators was assessed separately using weighted regression models, adjusted for age, gender, ethnicity and VISN.

Results:
Patterns of statistically significant associations varied by indicator. Using place-identity as the indicator, Veterans identifying as rural were least willing to rely on others, most mistrusting of healthcare providers, scored highest on both physical and emotional stoicism, and were intermediate between suburban- and urban-identifying Veterans on perceptions of public stigma and in endorsing the efficacy of mental healthcare delivered by clergy. Two of these associations were significant when distance was the rurality indicator: as distance increased, willingness to rely on others and endorsement of the efficacy of treatment by clergy decreased. Only willingness to rely on others was significantly associated with RUCA-B categories. Regardless of indicator, no significant associations were observed for willingness to rely on those outside one's social network, trust in others, self-stigma, attitudes toward the VA and VA mental healthcare, the efficacy of mental healthcare, or the self-resolving nature of mental disorders.

Implications:
In this sample, the culture-based, place-identity measure was a better predictor of rural/non-rural differences in attitudes relevant to mental healthcare utilization than geography-based measures.

Impacts:
Given the many published definitions for "rural" it is likely that inconsistent findings regarding variation by rurality partly reflect differences in definitions. Clinicians endeavoring to engage Veterans in treatment may gain more insight into potential attitudinal barriers by asking about place-identity rather than residence.