Studies of rural communities

This will be a long post for those of who deal with rural populations. Full disclosure – I grew up on a farm and live in a quite rural area. We will touch on a range of issues. First, Kirkby & Papps (2024) published “Correlates of Mental Health Help-Seeking Attitudes among Farming and Nonfarming Rural Women” in Journal of Rural Mental Health. Here are the edited abstract and impact statements:

People living in rural Australia have a significantly greater risk of suicide than those living in major cities. Barriers to mental health help-seeking have been proposed as one reason for this finding. Unique sociocultural factors influence rurality and farmer mental health help-seeking attitudes, yet whether these factors also influence mental health help-seeking in farming and nonfarming rural women is underexplored. This study investigated the relationship between mental health help-seeking attitudes and masculine gender role ideology, stoicism, mental health self-stigma, distrust of health care professionals, and mental health literacy in a farming and nonfarming rural women living in Australia. One hundred ninety farming and nonfarming rural women living in Australia participated. Data were collected through an anonymous online survey using validated measures, and exploratory multivariate analyses were applied to assess differences between farming and nonfarming rural women and the relationships among the variables of interest. Compared with nonfarming rural women, farming women scored higher on masculine gender role ideology, stoicism, and self-stigma, and lower on mental health help-seeking attitudes and mental health literacy. For farming rural women, masculinity, stoicism, and self-stigma were significantly associated with attitudes toward mental health help-seeking. For nonfarming rural women, only self-stigma, distrust, and mental health literacy were significantly associated with attitudes toward mental health help-seeking. Future research could investigate factors related to masculine gender role ideology among farming women to help shape approaches to rural interventions that address the specific needs of the two groups of women. 

The present research demonstrated distinct correlates of mental health help-seeking attitudes for farming and nonfarming rural women, with masculinity and stoicism significant correlates only for farming rural women. Differences identified between farming and nonfarming rural women in correlates of mental health help-seeking suggests that different interventions may be required for mental health support in each group of rural women. 

While this study was done in Australia, I think I was most struck by the issues of masculinity and stoicism, traits very common in the rural women I grew up with. This highlights the challenges of working in rural, especially farming communities. Next, we look at aging rural adults. Costa, Halder, McCrae & Curtis (2024) published “City Lights or Countryside Nights? Rurality, anxiety, and sleep in aging adults” in Journal of Rural Mental Health. The edited abstract and impact statements follow:

Anxiety and sleep health associations are well studied, but contributing factors (e.g., level of rurality) to health disparities in this relationship are understudied, particularly in aging populations. The present study examined the moderating impact of rurality on associations between anxiety and aspects of sleep health in aging adults living in the United States. Cognitively healthy adults 50 years and older (N = 251; Mage = 64.7 ± 7.9 years) completed an online survey measuring residence zip code, Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale. Multiple regression and simple slope analyses examined whether rurality (rural vs. nonrural; coded by delineating core-based statistical areas) moderated associations between anxiety and sleep, controlling for age, sex, education, income, depression, medication usage, and nutritional status (Mini-Nutritional Assessment). Rurality moderated the association between anxiety and sleep disturbances (R² change = .01, p = .04). Higher anxiety was associated with more sleep disturbances for rural (B = .05, p< .001), but not for nonrural participants (p >.05). In mid-to-late life, those living in rural areas may be more vulnerable to the impact of higher anxiety on worse sleep compared with those living in nonrural areas. Findings point to the need for a greater understanding of socioeconomic determinants of health and more tailored treatments, with potential emphasis on mitigating barriers impacting rural access to clinical treatments for anxiety and sleep health. Furthermore, it highlights that anxiety may be particularly important to monitor and target in sleep interventions for those living in rural areas. 

Sleep is a big deal especially for aging people. Here we see evidence that anxiety has a greater adverse impact on sleep in rural communities. Next, we see a contrast between rural and urban areas. Zhang et al. (2024) published “Tele-Mental Health Utilization Trends with Rural–Urban Disparities in Mississippi: 2020–2023” in Journal of Rural Mental Health. Here are excerpts:

Echoing findings from many studies, our research confirms the accelerated adoption of Tele-Mental Health (TMH) services during the COVID-19 pandemic, underscoring its adaptability and imperative role in providing accessible mental health care during the PHE (Bellon et al., 2022; Cantor et al., 2023). However, the resurgence of in-person visits from 2021 onward signals the persistent preference for traditional in-person care, raising concerns about the sustainability of TMH postpandemic. This trend was especially pronounced among pediatrics, possibly due to unique barriers, such as parental involvement requirements and hands-on clinical assessment, that could complicate TMH implementation. While the author (Mark E. Ladner) has noted that patients often expressed a preference for TMH due to its inherent convenience, providers may favor in-person care considering the clinical quality. Other studies also showed the barriers of TMH faced by providers, such as technology limitations and reimbursement uncertainty (Balchander et al., 2022). Addressing these barriers is essential for the sustainable integration alongside traditional clinical care models.

In addition, while urban and rural populations followed a similar overarching trend, the higher baseline TMH utilization in urban areas led to a more pronounced shift in the absolute number of visits between TMH and in-person care compared to rural counterparts. This disparity underscores the advanced access of urban patients to both forms of mental health care services, in-person and telehealth, while concurrently highlighting the continual disadvantage faced by rural patients in accessing mental health services. 

With the more discernible increases among urban TMH users compared to their rural counterparts, especially among pediatric patients, it is crucial to include the rural population in these business models. Given the burgeoning trend of integrating mental health services into primary care to enhance clinical outcomes, future endeavors should explore opportunities for value-based TMH reimbursement models for private and public payers and for all populations to advance health equity (Bailey et al., 2019).

The observed distinct and multifaceted shifts in TMH utilization trends, primary payment methods, and household income brackets across rural and urban areas and among adult and pediatric groups emphasize the necessity for adaptable, affordable, and inclusive TMH services and policies. Addressing the nuanced healthcare needs and preferences across diverse sociodemographic and geographical contexts is paramount for future studies in promoting equitable mental health care access in the evolving postpandemic landscape.

I liked this study because it illustrates some of the barriers for rural folk using telemental health especially with pediatric patients. I love the emphasis on the “necessity for adaptable, affordable, and inclusive TMH services and policies.”  The next study extends research on COVID-19. Cuthbertson & Rudolphi (2024) published “Depression, Anxiety, and Self-Rated Mental Health in the Agricultural Community during COVID-19” in Journal of Rural Mental Health. The abstract and impact statements follow:

This study characterized the mental health of rural agricultural community members during the early phases of the COVID-19 pandemic in the United States, including associations between mental health and COVID-19 protective practices, perceptions of effectiveness of protective practices, and opinions about COVID-19. Agricultural producers or stakeholders (N = 1,876) completed an online survey between April and July 2020. Data are restricted to rural respondents only (N = 1,566). Descriptive statistics and Mann–Whitney U tests were used to examine differences in depression, anxiety, and self-rated mental health (SRMH) by demographic characteristics, physical health, and COVID-19-related protective practices, perceptions of effectiveness, and opinions. Results showed that 9.2% indicated fair or poor SRMH, 13.2% met the criteria for depression, and 18.7% met the criteria for anxiety. Depression, anxiety, and fair/poor SRMH were all significantly associated with less belief that social distancing, covering one’s cough/sneeze, and wearing face masks were effective against COVID-19. Participants with probable depressive disorder had less agreement that COVID-19 was a serious illness, and participants with probable anxiety disorder or fair/poor SRMH were significantly less likely to agree that they knew what to do if they experienced COVID-19 symptoms. COVID-19 has required mass engagement in public health measures to reduce the spread of the disease. Understanding mental health across essential rural industries, such as agriculture, is critical to tailoring relevant and appropriate resources and responses. 

Agriculture was an essential industry during the COVID-19 pandemic. From a sample of rural agricultural producers and stakeholders, we found that anxiety, depression, and fair/poor self-rated mental health were primarily associated with less perceived effectiveness of COVID-19 protective practices. Rural public health practitioners must consider how mental health plays a role in pandemic precautions and protective behaviors among essential workers. 

What I found most interesting here is that rural agricultural workers with depression, anxiety and fair or poor self-rated mental health were less likely to accept the seriousness of the pandemic. The next study looks specifically at autistic youth. Gallant, Maddox & Weiss (2024) published “The Mental Health Needs of Autistic Youth in Remote Areas of Ontario, Canada: Clinicians’ perspectives” in Journal of Rural Mental Health. Here are the abstract and public health significance statement:

Children and youth in remote regions can struggle to receive appropriate mental health care. Many researchers have also highlighted the challenges encountered by autistic youth and their caregivers when seeking services in rural communities, but little is known specifically regarding autistic clients with co-occurring mental health needs. To better understand potential barriers to care in remote regions, publicly funded mental health providers (N = 611) completed an online survey. We compared providers from remote, accessible, and easily accessible regions of Ontario on their knowledge, confidence, and experiences when treating autistic clients with mental health needs. Overall, providers from remote regions were more likely to report barriers to care, particularly in terms of the availability of services, compared to clinicians from more accessible regions. This study highlights the challenges experienced by caregivers in remote regions and demonstrates that additional mental health resources and services are needed, particularly those that are tailored to autistic youth with co-occurring mental health needs. In turn, these findings have implications for policies and programs aimed at recruiting specialized health providers to these communities.

Here we see further evidence of barriers to obtaining care for clients on the autism spectrum. The next study looks at a range of mental health conditions. Edwards, Hung, Levin, Forthun, Sajatovic & McVoy (2023) published “Health Disparities Among Rural Individuals with Mental Health Conditions: A systematic literature review” in Journal of Rural Mental Health. Here’s the edited abstract and impact statement:

There is growing concern about the availability of health care services for rural patients. This systematic literature review evaluates original research on health disparities among rural and urban populations with mental health (MH) conditions in North America. Using the Preferred Reporting Items for Systematic Reveiws and Meta-Analyses guidelines, we used four electronic databases (Pubmed, Cochrane, APA PsycInfo, Web of Science) and hand searches and included original research conducted in the United States or Canada before July 2021 that compared health outcomes of patients with any mental health disorder in rural versus nonrural areas. Both qualitative and quantitative data were extracted including demographics, mental health condition, health disparity measure, rural definition, health outcome measures/main findings, and delivery method. To evaluate study quality, the modified Newcastle–Ottawa Scale was used. Our initial search returned 491 studies, and 17 studies met final inclusion criteria. Mental health disorders included schizophrenia (4 studies), posttraumatic stress disorder (10), mood disorders (9), and anxiety disorders (6). Total sample size was 5,314,818 with the majority being military veterans. Six studies (35.2%) showed no significant rural–urban disparities, while 11 (64.7%) identified at least one. Of those, nine reported worse outcomes for rural patients. The most common disparities were diagnostic differences, increased suicide rates, and access problems. This review found mixed results regarding outcomes in rural patients with mental health disorders. Disparities were found regarding risk of suicide and access to services. There is still a significant need for more research post COVID-19 on the use of telepsychiatry and rural health populations with mental health conditions. 

Here, the issues of suicide and access are emphasized. The final study looks at clinics. Sulzer, Meier, Bopp-Williams, Cook & Prest (2024) “Challenges and Opportunities for Rural Certified Community Behavioral Health Clinics” in Journal of Rural Mental Health.  Here’s the edited abstract and impact statement:

In 2014, the Substance Abuse and Mental Health Services Administration’s implemented a new pilot program to create Certified Community Behavioral Health Clinics (CCBHC) that would better integrate care and improve substance use disorder and behavioral health outcomes. However, no rural communities had been involved in the CCBHC pilot program. Our program was one of the first attempts at implementing the CCBHC model in a rural setting. Evaluation data, including a community needs assessment, an attestation confirming compliance with the CCBHC criteria, and collection of physical, behavioral, and substance use health outcomes at 6-month intervals, guided an ongoing assessment program. This was further aided by a community advisory board which partnered on programming, suggested interventions and guided data collection. Last, patient satisfaction surveys and interviews were conducted by an outside evaluator to identify any limitations or challenges not otherwise identified. Results indicate that delivery of substance use disorder treatment greatly increased. Access to mental health services, including crises services improved, care coordination expanded, formal partnerships increased, and community involvement was enthusiastic and growing. Nonetheless, securing sufficient workforce was difficult, and the stigma surrounding youth mental health treatment seemed to persist across implementation. The policy context of Utah’s Mental Health Authority system created barriers not anticipated by the CCBHC federal model. Effective treatment of youth, workforce recruitment, and policy challenges unique to Utah’s Medicaid model created barriers that will vary in their impact on other rural implementation sites. Certified Community Behavioral Health Clinics (CCBHCs) are a model designed by Substance Abuse and Mental Health Services Administration to incorporate the best practices of care delivery for substance use disorders and related treatments. Therefore, it is essential to develop the model to ensure it is effective in rural settings. This program is outlined here to give other rural care providers key lessons should they wish to implement a CCBHC in their community. 

I finished with this one because it offers an alternative to telehealth in supporting rural communities. Taken together, these studies illustrate the unique challenges of working with rural populations.