This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.
An econometric model estimated the disutility of traveling long distances for depression treatment, and simulations calculated the utility loss associated with selective contracting in rural and urban areas. A representative sample of depression patients (n = 106) and all practicing providers (n = 3,710) in Arkansas were identified and the distances between them were calculated. Using discrete choice analysis, patient preferences for provider type and travel distance were estimated. Simulations calculated the utility loss associated with alternative scenarios of selective contracting. Provider type and distance were significant predictors of provider choice. To equate the utility loss associated with selective contracting in rural and urban areas, a slightly higher proportion of rural physicians and a substantially higher proportion of rural mental health specialists must be contracted. To avoid further reductions in geographic access, managed care organizations should contract with a higher proportion of rural providers than urban providers.
The Department of Veterans Affairs (VA) established community-based outpatient clinics to improve veterans' access to primary care. This article compares VA use and expenditures among primary care users at 76 VA-staffed community clinics ( n = 17,060) and 32 non-VA contract community clinics receiving capitation ( n = 6,842) using VA administrative databases. It estimates utilization using negative binomial models and expenditures using generalized linear one-part or two-part models. Contract community clinic patients are less likely to use all types of outpatient services than VA-staffed community clinic patients but had similar quality of care. For patients seeking care, contract community clinic patients had similar specialty care expenditures but lower primary care, outpatient, and overall expenditures. Results suggest that capitated contract clinics did not shift costs to specialty care and appeared to be an economically efficient mechanism for improving veterans' access to primary care while meeting VA quality of care standards.
We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1,392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.
PURPOSE: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran–civilian differences. Therefore, we examined veteran–civilian differences in several dimensions of social support and whether differences varied by sex. METHODS: We performed a cross-sectional analysis of the 2012–2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran–civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health. RESULTS: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = −0.13, 95% confidence interval [CI] −0.23, −0.03). Among women but not men, veterans had smaller social network size (diff = −2.27, 95% CI −3.81, −0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = −0.13, 95% CI −0.23, −0.03); while among women, the difference was similar but did not reach statistical significance (diff = −0.13, 95% CI −0.23, 0.09). There was limited evidence of functional social support differences. CONCLUSION: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.
ABSTRACT
ObjectivesIdentify geographic variations in health and healthcare among US Veterans living in rural areas and understand the relationships between social determinants of health and these variations.
ApproachData from 11 data sources will be leveraged to create the US Veterans Rural Health Atlas and chart book (VeRHA) patterned after the Dartmouth Atlas, The VeHRA will provide an interactive map and chart book can be used to efficiently examine a wide range of factors related to health and healthcare of rural Veterans. The analyses will assess the relationships between socioeconomic, cultural and environmental factors and geographical variation in access, utilization, quality, satisfaction and outcomes. Semi-structured qualitative interviews will be used to elicit the perspective of Veterans not using VA care and to identify non-governmental organizations who provide care and support to US Veterans. The project will also identify community, state, and federal entities with which ORH could form strategic partnerships to improve health and healthcare for Rural Veterans.
Initially, three maps will be created for Veterans who are not enrolled in care, those enrolled but not using care and those enrolled and using care. Areas where many Veterans live and use VA healthcare will be identified as "hot spots" while areas where Veterans live but do not use care will be identified as "cold spots". Metrics for determining "hot and cold spots" will include measures of temporal and geographic access as well as measures of quality of care. We will first calculate raw rates for outcomes across geographic areas (census tract, county, and market/regions) Exploratory Spatial Data Analysis (ESDA) will be conducted by mapping the geographic distribution of key measures and then calculate the values of the local and global Moran's I measures of spatial autocorrelation.
The relationship between social determinants of health and geographical variation in access, needs, utilization, quality, satisfaction, and outcomes for rural Veterans will be assessed, focused primarily on the "cold spots" – areas of greatest need.
ResultsThe project is a work in progress with initial maps created showing the density of Veterans across the United States. More extensive results will be available for presentation.
ConclusionThis work demonstrates the value of using large data sets to guide development of policies and programs at a national level.
BackgroundSome veterans face multiple barriers to VA mental healthcare service use. However, there is limited understanding of how veterans' experiences and meaning systems shape their perceptions of barriers to VA mental health service use. In 2015, a participatory, mixed-methods project was initiated to elicit veteran-centered barriers to using mental healthcare services among a diverse sample of US rural and urban veterans. We sought to identify veteran-centric barriers to mental healthcare to increase initial engagement and continuation with VA mental healthcare services.MethodsCultural Domain Analysis, incorporated in a mixed methods approach, generated a cognitive map of veterans' barriers to care. The method involved: 1) free lists of barriers categorized through participant pile sorting; 2) multi-dimensional scaling and cluster analysis for item clusters in spatial dimensions; and 3) participant review, explanation, and interpretation for dimensions of the cultural domain. Item relations were synthesized within and across domain dimensions to contextualize mental health help-seeking behavior.ResultsParticipants determined five dimensions of barriers to VA mental healthcare services: concern about what others think; financial, personal, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and privacy, security, and abuse of services.ConclusionsThese findings demonstrate the value of participatory methods in eliciting meaningful cultural insight into barriers of mental health utilization informed by military veteran culture. They also reinforce the importance of collaborations between the VA and Department of Defense to address the role of military institutional norms and stigmatizing attitudes in veterans' mental health-seeking behaviors.
BackgroundSome veterans face multiple barriers to VA mental healthcare service use. However, there is limited understanding of how veterans' experiences and meaning systems shape their perceptions of barriers to VA mental health service use. In 2015, a participatory, mixed-methods project was initiated to elicit veteran-centered barriers to using mental healthcare services among a diverse sample of US rural and urban veterans. We sought to identify veteran-centric barriers to mental healthcare to increase initial engagement and continuation with VA mental healthcare services.MethodsCultural Domain Analysis, incorporated in a mixed methods approach, generated a cognitive map of veterans' barriers to care. The method involved: 1) free lists of barriers categorized through participant pile sorting; 2) multi-dimensional scaling and cluster analysis for item clusters in spatial dimensions; and 3) participant review, explanation, and interpretation for dimensions of the cultural domain. Item relations were synthesized within and across domain dimensions to contextualize mental health help-seeking behavior.ResultsParticipants determined five dimensions of barriers to VA mental healthcare services: concern about what others think; financial, personal, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and privacy, security, and abuse of services.ConclusionsThese findings demonstrate the value of participatory methods in eliciting meaningful cultural insight into barriers of mental health utilization informed by military veteran culture. They also reinforce the importance of collaborations between the VA and Department of Defense to address the role of military institutional norms and stigmatizing attitudes in veterans' mental health-seeking behaviors.
OBJECTIVE: To compare delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder among post-9/11 veterans relative to pre-9/11 veterans and civilians. METHOD: The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III), a nationally representative survey of US non-institutionalized adults was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, and/or alcohol-use disorder. Cox proportional hazard models, controlling for relevant demographics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment). RESULTS: Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (AHRs=0.69 95% CI=0.49-0.96, 0.74 95% CI=0.56-0.98, for PTSD and depression, respectively) and civilians (AHRs=0.60 95% CI=0.47-0.76, 0.67 95% CI=0.53-0.85, for PTSD and depression, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol-use disorder. Pre-9/11 veterans did not differ from civilians in delay of treatment for any of the three disorders. In an exploratory analysis, post-9/11 veterans with past year military health care coverage (e.g., Veterans Health Administration) showed the shortest delay for depression treatment, although past year coverage did not predict treatment delay for PTSD or alcohol-use disorder. CONCLUSIONS: Post-9/11 veterans delay treatment for some common psychiatric conditions less than pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol-use disorder, highlighting the need for further engagement efforts.
