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Research Highlight

Historically, rural residents have used fewer mental health services than urban residents despite equal or greater need. This difference has been documented nationally across the general population and, more specifically, within the Veteran population. VA is aggressively addressing structural barriers to rural Veterans' access to mental health care by opening community-based outpatient clinics (CBOCs), reaching out through mobile clinics and telemedicine, and contracting with community providers, most recently through the Veterans Choice Act. Reducing structural barriers (e.g., distance/time, lack of transportation) is an essential step in reducing rural/urban disparities in Veterans' use of VA mental health care; however, this step alone is unlikely to be sufficient. After need and structural barriers are taken into account, differences in personal characteristics, especially attitudinal characteristics, may still lead to different patterns of help-seeking and service use. Several studies have suggested that attitudes, beliefs, and behavioral norms may have a stronger influence on mental health service use than do structural barriers. However, little empirical evidence has been available on attitudes that influence initiation and sustained use in the rural Veteran population to inform VA program planning.

In this article, we briefly summarize findings from the initial, qualitative component of a sequential mixed-methods study designed to better understand the ways in which attitudinal characteristics influence treatment-seeking and sustained mental health service use among rural Veterans.1 We conducted in-depth, semi-structured interviews with 25 rural Veterans and 11 VA and non-VA rural mental health care providers in four states (Arkansas, Colorado, Maine and Wisconsin). Participants were asked about the attitudinal factors they thought most influenced rural Veterans' decisions to seek and sustain mental health care.

Veterans identified three attitudes that posed significant barriers both to initial help-seeking and to sustained engagement in mental health care: 1) emphasis on self-reliance (not needing help or support from other people); 2) emphasis on stoicism (endurance of pain or hardship without complaint and resisting treatment-seeking until it becomes unavoidable); and 3) stigma (negative attitudes toward mental health treatmentseeking). Veterans were most adamant about an emphasis on self-reliance creating a barrier to service use. They ascribed its origin to military norms, rural norms, and/ or male gender-role expectations. In each of these "cultures," seeking mental health care has historically been seen as a sign of weakness. A fourth, prevalent impediment was raised with regard to initial treatment seeking only—lack of trust in the VA health care system. Prior to enrolling in VA health care, Veterans said they had often avoided VA because they thought it would be nonresponsive, ineffective, and uncaring.

Despite these concerns, over 80 percent of study Veterans had overcome their attitudinal barriers to seeking treatment and were currently using VA mental health care. The two factors they most frequently described as driving initial treatment-seeking were: 1) perceived need for care; and 2) encouragement and support from family and friends, most notably, from other Veterans. Once receiving care, the two factors that seemed to drive ongoing involvement were: 1) the perception that treatment was effective and, most critically, 2) a growing trust in their providers. In describing the latter, Veterans talked about providers showing that they respected and cared about the Veterans as individuals. Importantly, those providers made themselves accessible by giving Veterans their direct telephone numbers and being willing to talk with Veterans outside of regularly scheduled appointments and after clinic hours. Both the barriers and facilitators raised by study participants were consistent across participant-types (Veterans, VA providers, and non-VA providers) and geographic areas.

While many of the issues raised in the study are familiar, findings are especially timely as VA has prioritized increasing access and restoring trust in the system. Participants' comments offer guidance in addressing calls for interventions to improve treatment initiation and retention in VA mental health care. Veterans' and providers' perspectives on the importance of the Veteran to- Veteran bond in initiating care provide support for continuation and expansion of VA's highly regarded peer support programs. These programs' emphasis on communication and caring provides support for the integrated primary care and mental health service initiative that facilitates warm handoffs from medical to mental health care. Our findings are consistent with the literature on cultural/attitudinal deterrents to service use.

Attitudes, such as self-reliance, commonly associated with rural culture may play an important role in underutilization of needed mental health services. System support for peer and provider behaviors that generate trust and demonstrate caring may help overcome attitudinal barriers to treatment- seeking and sustained engagement in mental health care among rural Veterans.

  1. Fischer EP, et al. "Overcoming Barriers to Sustained Engagement in Mental Health Care: Perspectives of Rural Veterans and Providers," The Journal of Rural Health 2016; 32:429-38.

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