Historically, rural residents have used fewer mental health services than urban residents, despite equal or greater need. VA has made provision of high quality, accessible mental health services to Veterans living in rural areas a high priority. Although structural barriers (geographic barriers and limited service availability) explain some of the rural-urban gap in mental healthcare use, structural barriers rarely completely explain rural-urban disparities. Indeed, in the VA, offering local services like community-based outpatient clinics (CBOCs) has not fully resolved rural-urban disparities in mental health service use. Relatively little research has addressed factors other than structural barriers that may influence help-seeking behaviors and service use and especially little has addressed these issues for Veterans living in rural areas. To better understand service use by underserved populations, investigators are increasingly focusing on the influence of attitudinal/cultural variables. A fuller understanding of such influences is needed to allow VA to effectively tailor interventions to engage rural Veterans in mental healthcare.
The primary objective of this study has been to understand how attitudinal characteristics associated with rural culture operate to influence mental health service-use among Veterans. We hypothesized that (1) specified personal beliefs and attitudes (e.g., self-reliance, stoicism) would be more common among rural Veterans, (2) Veterans endorsing those attitudes and beliefs would be less likely to have initiated mental healthcare, and (3) and less likely to have sustained engagement in mental healthcare.
We used mixed quantitative/qualitative methods in this 3-phase project. In Phase 1, qualitative interviews were conducted with 25 purposefully selected Veterans and 11 mental healthcare providers from 4 VISNs with high proportions of rural Veterans to elicit their perspectives on how various attitudinal characteristics interact to influence engagement in mental healthcare. Qualitative data were analyzed using content analysis and constant comparison techniques. Findings informed development of the questionnaire to be administered in Phase 3. In Phase 2, 5 Veterans were interviewed to assess the clarity of survey questions and verify that questions were being understood as intended. In Phase 3, we used stratified probability sampling to recruit 752 Veterans to take part in a telephone survey of attitudes and mental health service use. Eligible Veterans were aged 18-70, had screened positive for depression and/or PTSD in FY10-12, and lived in VISNs 1, 16, 19 or 23. Sampling was stratified by VISN, gender, and distance between a Veteran's home and the nearest VAMC. Trained interviewers used computer-assisted technology to conduct a structured interview with participants (33.5% of eligible Veterans contacted). Survey data were analyzed using linear and logistic regression.
Phase 1 (qualitative interviews): Rural Veterans and their mental healthcare providers reported the same major attitudinal barriers to Veterans' mental health treatment-seeking. Pre-eminent among them was the importance rural Veterans place on independence and self-reliance. The centrality of self-reliance was attributed variously to rural, military, religious and/or gender-based belief systems. Stoicism, the stigma associated with mental illness and healthcare, and a lack of trust in the VA as a caring organization were also frequently mentioned. Perceived need for care and the support of other Veterans were critical to overcoming attitudinal barriers to initial treatment-seeking whereas critical facilitators of ongoing service use included "warm handoffs" from medical to mental healthcare providers, perceived respect and caring from providers, as well as provider accessibility and continuity.
Phase 3 (telephone survey): Apart from a higher proportion of women (25%) arising from purposeful oversampling of women Veterans, survey participants were representative of the study population. Average age was 51.5 years. Most participants were non-Hispanic White (69.3%); 11.4% were non-Hispanic Black and 19.3% were Hispanic or Other.
Hypothesis 1: In general, attitude score patterns supported the hypothesis that attitudes would differ by distance from one's home to the nearest VAMC. As distance increased, respondents scored higher on measures of mistrust of providers, self-stigma, public stigma, physical stoicism and emotional stoicism. They scored lower on measures of willingness to rely on one's social network, belief in the efficacy of mental healthcare and belief in the efficacy of religious counseling for mental health problems. Findings not consistent with the hypothesis were (1) that as distance increased, mistrust in others decreased, and (2) there were no differences by distance re willingness to rely on providers/those outside the social network, mistrust of the VA system, trust in the VA for mental healthcare, or beliefs about the self-resolving nature of mental disorders. Exploring two other measures of rurality (RUCA-B categories and place-identity (rural, urban, suburban)), we found place-identity to be the most robust predictor of attitudes after adjustment for age, gender, ethnicity and VISN.
Hypotheses 2 and 3: While analysis is still ongoing, preliminary results suggest these hypotheses will be supported as well.
The ultimate goal of this project is to improve outcomes of mental healthcare for the 3 million Veterans (36% of all VHA-enrolled-Veterans) living in rural areas. Reducing the knowledge gaps that impede effective tailoring of mental health programs to the needs and preferences of rural Veterans will improve the health and well-being of this growing, high-priority segment of the Veteran population. Analysis is ongoing, however, findings are beginning to inform clinical care, VACO surveys, and research. Publication of Phase 1 qualitative findings offered useful guidance for clinicians/CBOCs trying to engage and retain rural Veterans in mental healthcare; these findings were also shared directly with the Mental Health Leads and collaborating CBOCs in VISNs 1, 16, 19 and 23. Although not an explicit aim of the project, in March 2017, we had an opportunity to share some Phase 3 survey findings with SHEP; our data on the frequency with which participants used various digital modalities may help in the development of digital items for future SHEP questionnaires. In addition, our joint publication with investigators on the CREATE CRE#12-300 (perceived access instrument development) project regarding our experiences with opt-out recruitment has contributed to the practical literature in research methodology.
- Miller CJ, Burgess JF, Fischer EP, Hodges DJ, Belanger LK, Lipschitz JM, Easley SR, Koenig CJ, Stanley RL, Pyne JM. Practical application of opt-out recruitment methods in two health services research studies. BMC medical research methodology. 2017 Apr 14; 17(1):57.
- Fischer EP, McSweeney JC, Wright P, Cheney A, Curran GM, Henderson K, Fortney JC. Overcoming Barriers to Sustained Engagement in Mental Health Care: Perspectives of Rural Veterans and Providers. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2016 Sep 1; 32(4):429-438.
- Fischer EP, Mcsweeney J, Wright PB, Cheney AM, Curran GM, Henderson KL, Fortney JC. Attitudinal influences on treatment-seeking and access to mental healthcare among rural Veterans. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.