Background: Although the sociological and clinical literature has expanded understandings of structural racism, health outcomes, and access to healthcare in critical ways, the dynamics of structural racism at the mesolevel – specifically counties – are less well understood. This study investigates the relationship between racial-gender equity and access to mental healthcare.

Methods: The analysis combines data sources from the 2021 Area Health Resources Files, the 2021 County Health Rankings, and the Kaiser Family Foundation to form a sample of 2,853 United States counties. Using binary logistic regression, the study examines whether there is an association between a county’s index of racial-gender equity and location in a mental health professional shortage area. The index aggregates population-level measures of unemployment, educational attainment, severe housing cost burden, overall income inequality, and median household income for the total population. It also assesses gaps in these measures between the overall population and groups classified by race and ethnicity and, where possible, sex.

Results: Counties with lower racial-gender equity were more likely to have a mental health professional shortage than those with higher equity. However, the county’s socio-political landscape, including its state governor’s political orientation and home internet access, mediated the association between racial-gender equity and the availability of mental healthcare. Location in a Democrat-governed state was the key upstream factor that explained this relationship. Conversely, home internet access was the primary downstream factor that explained away the association. Counties in Democrat-governed states with equal or higher levels of internet access compared to the national average had lower odds of being in a mental health professional shortage area than those in Republican-governed states with low internet access.

Conclusions: This study suggests that mesolevel political dynamics mirror structural patterns at the macrolevel that systematically sustain inequities in access to healthcare. Further, access to healthcare is a political issue, and this analysis demonstrates that it can be restricted or expanded depending on the spatial distribution of inequality. This research also illustrates how spatial inequality shapes access to healthcare in racialized social systems. In turn, this study helps clarify the social sources of inequalities in healthcare access and delivery.

Background:

The (2022-2023) Community Health Assessment (CHA) conducted among community members in a rural Western Kentucky county identified mental health as one of the top health issues in the county. The purpose of CHA is to identify key health needs and issues through data and develop strategies for action.

Methods:

Secondary data analyses were performed from survey results conducted by the local health department, local public schools, and the County Health Rankings 2022. The quantitative data was analyzed using SPSS software. Qualitative data were analyzed through qualitative methodologies using a two-cycle coding process.

Results:

Mental health was identified on the community survey portion of the CHA as a top health issue in the rural Western Kentucky county, with stress listed by 57.2% (n=281) participants ranked as the number one issue and mental health/suicide/anxiety listed by 33.6% (n=165) participants ranked as the number four issue. Among town hall meetings with vulnerable groups in Marshall County, lack of mental health services was identified as a barrier. Additionally, per the County Health Rankings 2022, the data showed that there is a major deficit in mental health providers in Marshall County with 3120 patients per mental health provider.

The local health department Access to Care Survey conducted February 2023 among community members and health providers also revealed that one of the top barriers to access was lack of providers, including specialists (8.6%, n=24). This barrier was reiterated by the health providers' responses. Health providers indicated that mental health conditions were the number one challenge when referring patients to specialists and that a psychiatrist, especially a pediatric psychiatrist, was a needed specialist in the Western Kentucky region. Health providers also mentioned the need for specialists to accept Medicaid as that is a barrier to healthcare access.

Conclusions:

Access to mental healthcare is an area of great need in this rural Western Kentucky county. Researcher recommendations include having the regional hospital systems work together to recruit a psychiatrist and work with healthcare providers, especially specialists, to accept Medicaid. It is recommended to cross-train other professionals to address mental health needs in this region.

Background. Rural residents face significant barriers in accessing mental health services. As the need for these services increases and greater emphasis is put on telemedicine, examining geographic availability of mental health facilities and facilitators of telemedicine utilization is critical. To address this need, this study examines geographic variation in driving time to mental health facilities, digital access within households, and household crowdedness.

Methods. A cross-sectional geographic analysis at the ZIP Code Tabulation Area (ZCTA) level was conducted using American Community Survey (ACS) 5-year estimates and SAMHSA Behavioral Health Treatment Locator data. Driving time was calculated from ZCTA centroid to outpatient mental health care, inpatient psychiatric services, and any mental health services. Digital tool ownership, household broadband access, and household crowdedness were used to indicate facilitators of digital access. Rurality was defined using Rural-Urban Commuting Area code, with ZCTAs classified as urban (n=17,523), large rural (n=4,737) and small/isolated rural (n=9,775).

Results. Only 1,653 (9.4%) of urban ZCTAs were located > 30 minutes from the nearest mental health facility, which changed to 829 (17.5%) for large rural ZCTAs and 3,984 (40.8%) for small rural ZCTAs. Driving time to outpatient facilities were higher in rural areas, with 8,545 (86.5%) of small rural ZCTAs and 3,535 (74.6%) of large rural ZCTAs being >30 miles from outpatient care, versus 7,655 (43.7%) of urban ZCTAs. Within those >30 minute communities, 522,154 (16.5%) households in rural ZCTAs, versus 237,800 (11.9%) households in urban ZCTAs, had no digital devices. After adjusting for ZCTA population characteristics, driving times to any mental health facility were greater for small/isolated rural areas (8.6 minutes; 95% confidence interval CI, 8.2-9.1, P<.001) than for urban areas.

Conclusions. Rural communities are farther from mental health facilities and have lower digital access than urban communities. These findings indicate rural communities face significant barriers to access, despite the increase in telehealth availability for mental health services. These barriers may mitigate the effect of help-seeking in rural communities.

Background: Rural Americans have mental illness rates similar to their most urban counterparts, yet they face unmatched challenges accessing health care, and unique challenges accessing the mode of care that soared early in the COVID-19 pandemic: telehealth. The purpose of this study was to identify characteristics associated with telehealth use and examine urban-rural disparities in access to telehealth for those with mental health disorders (MHD) during the COVID-19 pandemic.

Method: The study used National Health Interview Survey 2021 Adult data. Participants were American adults age 18+ (N=28,921). Telehealth utilization in the past twelve months was the outcome variable. The key independent variable was presence of MHD (anxiety and/or depression). The study used logistic regressions to test association between MHD and rural-urban residence with the likelihood of using telehealth. Interaction terms were used to examine the variation of the associations between MHD and rurality and MHD and age. Survey weights were applied. Marginal effects were reported.

Results: Mean telehealth use for those with MHD ranged from 64% in the most urban classification, to 44% in the most rural (p<0.001); for those without MHD, mean telehealth use dropped from 35% to 24% (p<0.001). The marginal effect of MHD on telehealth use was 18% (95% CI [.17 - .2], p=<.001) after controlling for individuals’ demographic characteristics, socioeconomic status, health insurance, and health needs. The probability of telehealth use among the most rural residents was 11% less than among the most urban (p<.001). The interaction term between MHD and nonmetropolitan was 5% less (p=0.02). The interaction term between MHD and age group was also significantly negative.

Conclusions: Our study showed older adults with MHD used telehealth less than younger adults with MHD and that although MHD was associated with reduced urban-rural disparity in telehealth use, rural residents consistently used telehealth less than urban. These findings, and the context of the pandemic, illustrate the importance of investing in infrastructure, resources, and engagement to improve access to care in rural communities, especially among older patients with MHD and those who are Black. Further research is needed to understand telemedicine barriers for older adults with MHD.