1045 — Attitudinal Influences on Treatment-Seeking and Access to Mental Healthcare among Rural Veterans

Fischer EP, Center for Mental Healthcare & Outcomes Research, North Little Rock, AR; McSweeney JC, Univ. of Arkansas for Medical Sciences, College of Nursing, Little Rock, AR; Wright PB, Univ. of Arkansas for Medical Sciences, College of Nursing, Little Rock, AR; Cheney A, Univ. of California-Riverside, Riverside, CA; Curran GM, Center for Mental Healthcare & Outcomes Research, North Little Rock, AR; Henderson K, Center for Mental Healthcare & Outcomes Research, North Little Rock, AR; Fortney JC, COIN-VA Puget Sound Healthcare System, Seattle, WA;

Objectives:
Qualitative interviews were conducted as the first phase of an HSRandD-funded project to better understand the attitudes, beliefs and behavioral norms that may partially drive underuse of mental healthcare among rural Veterans.

Methods:
In-depth, semi-structured interviews were conducted with 20 rural Veterans and 11 rural mental healthcare providers from VISNs 1, 16, 19 and 23. Experienced qualitative interviewers asked participants about the attitudinal factors they thought most influenced rural Veterans' decisions to seek and sustain mental healthcare. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using content analysis and constant comparison.

Results:
Rural Veterans and their mental healthcare providers reported the same major attitudinal barriers to mental health treatment-seeking. First among those barriers was the importance rural Veterans place on independence and self-reliance. Self-reliance was considered a pre-eminent virtue in rural, military, gender and, in the South, religious belief systems. Participants' emphasis on self-reliance as a barrier no doubt reflects, at least in part, the extent to which these belief systems overlap and are mutually reinforcing in a rural Veteran population. 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. Many rural Veterans do, however, use mental healthcare. Critical facilitators of service use include warm handoffs from medical to mental healthcare providers, perceived respect and caring from providers, continuity and accessibility of providers, as well as referrals and support from other Veterans.

Implications:
Qualitative findings indicate that norms and values, like self-reliance, commonly associated with rural culture may play an important role in rural/urban differences in mental health service use. If replicated in the larger, quantitative phase of the project, increased VA support for peer and provider behaviors that facilitate engagement in care, especially among rural Veterans, should increase access and help reduce geographic discrepancies in utilization.

Impacts:
Reducing gaps in knowledge that impede effective tailoring of VA programs to the needs and preferences of the 41% of VHA-enrolled-Veterans living in rural areas will improve the health and well-being of a growing segment of the nation's high priority, underserved Veterans.