Barriers to Rural Mental Health Care: A Mixed Methods Investigation of Mental Health Outcomes, Services, and Help-Seeking

University of Minnesota Ph.D. dissertation.May 2019. Major: Family Social Science. Advisor: Tai Mendenhall. 1 computer file (PDF); ix, 115 pages.Existing rural mental research points to several concerns regarding symptoms and outcomes (e.g., mental health status, mental health symptoms, suicide rates). Research also identifies several barriers that inhibit rural residents from accessing quality mental health services (e.g., factors influencing the availability of services, accessibility of services, and acceptability of services). Investigations that compare rural mental health outcomes and help-seeking to urban counterparts are limited; what does exist points to mixed findings about differences between groups. The research presented here aims to elucidate the limited understanding of barriers to mental health care in rural communities via a two-study, mixed-methods investigation. Study 1 is an analysis of an existing dataset collected in eight counties in Northern Minnesota and Wisconsin in 2015. The survey includes questions about behaviors, outcomes, and social determinants of health and mental health and includes (N = 6,976) responses. Chi-square and logistic regression analyses were used to assess the impact of geographic location (measured by RUCA codes) on mental health symptoms, help-seeking behaviors, and specific barriers to seeking help. Demographic covariates – including age, education level, gender, and income – were also considered. Results reveal some variation between the chi-square and logistic regression analyses, and hypotheses for the disparities are discussed. Findings from the logistic regression analyses revealed no significant differences across rural and urban groups for indication of mental health symptoms, though age and gender did account for some variance. The rural group was more likely to indicate delayed or forgone help-seeking behaviors, and the urban group was more likely to indicate attitudinal barriers to seeking mental health care. Study 2 is a qualitative study that followed a Hermeneutic phenomenological design. The goal of this study was to increase understanding of barriers to rural mental health care via rich descriptions of lived experiences with those barriers. Thirteen (N = 13) family physicians who practice in the same geographic area as the dataset in Study 1 were recruited using convenience and snowball sampling techniques. Family physicians were chosen for these key informant interviews because existing research suggests that primary care often serves as the front line of mental health care in rural communities. Their ability to speak to their own experiences, and to the experiences of their patients, also facilitated the gathering of a range of perspectives and rich descriptions. Findings were organized into seven overarching themes; key ideas therein pointed to both the presence of structural and attitudinal barriers to mental health care, and to ideas physicians have for overcoming them. Implications from the two studies point to the need for continued investigation into the presence of barriers to mental health care for rural communities, and ideas for maximizing existing resources. Differences between structural and attitudinal barriers are discussed alongside findings from these two studies, and future research should continue to investigate the differences between these categories of barriers. Increased understanding of what prevents rural communities from accessing needed mental health care will increase the efficiency and efficacy of future interventions aimed at reducing barriers and increasing access to care