Challenges and Opportunities for Mental Health Services in Rural Areas
Individuals who live in rural areas face unique challenges and opportunities in receiving effective treatment for serious mental illness and mental health conditions. To understand these barriers and opportunities, the National Rural Health Association describes a framework with four components of rural mental health — accessibility, availability, affordability, and acceptability. The “four As” influence multiple aspects of rural mental healthcare and are important to consider when developing rural mental health programs.
This section describes rural barriers to and opportunities for mental health services by the four As. Throughout the toolkit, the framework is used to organize evidence-based models and examples of rural mental health programs.
Access to Care
Access to care, or accessibility, refers to the ease with which one can obtain mental health services within their community. Transportation is a key factor that impacts access to mental healthcare. There are several barriers to transportation in rural areas. Rural community members are more likely than urban residents to rely on personal vehicles for transportation, meaning rural residents without cars are more isolated from treatment. There are fewer mental health providers in rural areas, meaning community members must travel farther to access mental health services, and without access to transportation, care may be inaccessible.
While transportation to care continues to be a barrier in rural areas, several promising approaches could increase access to mental health services. For example, investing in mobile clinics and expanding telehealth services are two opportunities for addressing challenges related to a lack of transportation.
To learn more about opportunities to improve access to rural mental health services, explore Models to Improve Access to Care.
Availability
Availability refers to mental health services being available to residents. Shortages of mental health professionals impact the availability of mental health services in rural areas. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the mental health workforce is one of the fastest growing in the country. However, mental health professional shortages are greatest in rural and low-income areas compared to more urban areas. These provider shortages may lead to long waitlists for rural residents seeking necessary care.
In general, rural areas often lack specialty mental healthcare. Some estimates suggest that nearly 70% of rural counties do not have a psychiatrist. Without appropriate integration of mental health services, primary care providers may not be equipped to provide treatment for all mental health conditions.
Inadequate reimbursement rates for mental health services, especially under Medicaid, create barriers to recruiting and retaining providers in rural areas where Medicaid enrollment rates are higher than urban areas. Non-clinical mental health providers and Mental Health First Aid training offer opportunities for rural communities to address this barrier.
To learn more about opportunities to improve the availability of mental health services, see Models to Increase Availability.
Affordability
Affordability refers to the costs associated with receiving mental healthcare, including increased costs and low reimbursement rates for services in rural areas. In rural areas, one of the main barriers to treatment is the cost of mental healthcare for patients. Some insurance companies do not cover certain mental health services, making these services too expensive for a patient to pay out of pocket. In addition, rural residents are more likely than urban residents to be uninsured.
Opportunities to improve the affordability of mental healthcare services in rural communities include wraparound services, community-based supports, and school-based social and emotional supports.
To learn more about opportunities to improve affordability, see Models to Increase Affordability.
Acceptability
Acceptability relates to the perceptions of the patient and community associated with the need for mental health services. Factors impacting acceptability include stigma, mental health literacy, and culturally responsive care.
Stigma and Mental Health Literacy
Mental health stigma refers to the negative attitudes and prejudices surrounding mental health issues, often resulting in discrimination against individuals experiencing these conditions, which may deter people from seeking needed mental healthcare. In small, rural communities where everyone knows each other, residents may fear judgment from their peers and worry about lack of confidentiality among mental health professionals. Often, rural communities foster a culture of self-reliance, which may make seeking help for a mental health concern feel less acceptable.
Our identities and experiences can influence overall well-being and perceptions of stigma surrounding mental health. For example, experiences of discrimination and oppression based on gender, race, class, and sexuality can affect individuals seeking mental health support, often exacerbating stigma.
Increasing understanding and awareness of mental health through mental health literacy can play a crucial role in reducing stigma and promoting acceptance within communities. Addressing stigma involves considering various factors such as social norms, resources within communities, and cultural beliefs. For implementation considerations related to reducing mental health stigma in rural communities, see Module 4.
Culturally Responsive Care
Rural areas in the United States are racially and ethnically diverse. Race, ethnicity, culture, language — along with multiple other characteristics, like values and beliefs — may affect peoples' conceptions of mental health and preferences for receiving treatment. Patients may find treatment more acceptable if they have access to a mental health provider with a shared lived experience or understanding of their culture.
Therefore, it is particularly important for rural mental health providers to work toward providing culturally responsive care and embracing cultural humility. Training and education programs can increase awareness of and respect for other cultures while giving providers the opportunity to practice skills like communicating in a culturally competent manner and integrating cultural considerations into a patient's treatment plan.
Mental health organizations can support culturally responsive care by:
- Implementing therapeutic models like trauma-focused cognitive behavioral therapy
- Selecting culturally appropriate screening and assessment tools
- Establishing culturally responsive clinic environments, policies, and procedures
- Recruiting and retaining a diverse workforce
To learn more about opportunities to improve acceptability of mental health services, see Models to Enhance Acceptability.
Resources to Learn More
Confronting Mental Health Challenges in Rural America
Document
Offers insight into the lifestyle challenges rural populations experience when seeking mental healthcare,
including the associated stigma of mental illness.
Author(s): Winton, J.
Organization(s): National Alliance on Mental Illness
Date: 11/2022
Culturally-Responsive Care
and Clinical Adaptation
Video/Multimedia
Identifies cultural factors that may contribute to resistance to mental health clinical services, and
discusses culturally based protective factors and culturally responsive clinical adaptations.
Date: 12/2023
Medicaid Reimbursement for Psychiatric
Services: Comparisons Across States and with Medicare
Document
Provides an understanding of Medicaid reimbursement rates for psychiatric services. Compares Medicaid
rates across states and with Medicare rates.
Author(s): Zhu, J.M., Renfro, S., Watson, K., Deshmukh, A., & McConnell, K.J.
Citation: Health Affairs, 42(4), 556–565
Date: 4/2023
Mental
Health in Rural New York: Findings and Implications of a Listening Tour with Residents and
Professionals
Document
Describes findings from a listening tour of community members in rural New York about availability,
access, and utilization of mental health services and supports.
Author(s): Harris, B., Gallant, K. & Mariani, A.
Date: 1/2023