Rural Inequities in Care: Reducing Stigma and Providing Access for All

Illustrated by Eugenia Yoh

It has been over 40 years since the Alma-Ata Declaration defined the concept of primary healthcare and brought international awareness to the extreme health inequities that permeate the globe. Unfortunately, the declaration’s ambitious goal of healthcare for all by 2000 was not met as intended [3]. Nonetheless, there still exist promising implementations of primary healthcare services, particularly for mental health, which can serve as a useful model for other nations to follow. Examples discussed include a community health model from Zimbabwe and telehealth.

Dr. Dixon Chibanda, a Zimbabwean physician and director of the African Mental Health Research Initiative, helped to pioneer an approach which both addresses Zimbabwe’s shortage of psychiatrists and its significant number of mental health issues. Chibanda’s program trained lay health workers, primarily local grandmothers, in a treatment approach known as problem-solving therapy (PST). The program is designed to assist those suffering from common, non-life threatening, mental disorders and aims to find solutions to problems that cause distress in a patient’s life [1]. The approach is primarily self-directed, meaning the provider facilitates the interaction and makes suggestions, but the patient ultimately develops the solutions themselves [1].

Chibanda found great success with the initial program, and later conducted a randomized clinical trial which further demonstrated the effectiveness of the lay health workers. The majority of those suffering from the common mental disorders saw significant improvement six months after receiving just a single treatment [2]. While early results suggest the number of sessions attended is directly proportional to a better outcome, the sessions were designed to be conducted one time only due to difficulties of accessing the treatment site [1]. Furthermore, while Zimbabwe is different from the United States, there are key similarities, chief among them being the severe treatment gap in mental healthcare. That is to say, there is limited access to mental health services for many in both nations.

At present, one-fifth of the United States population resides in a rural setting, and one-fifth of those individuals suffer from mental health conditions, which constitutes well over six million people [4]. These individuals are often far removed from treatment providers, which further complicates the delivery of care [4]. Nicole Summers-Gabr, an assistant professor at SIU School of Medicine, estimates that over 50% of counties do not have direct access to a psychiatrist [6]. This treatment gap is only growing larger. Rural hospitals have been permanently closing at higher rates in recent years [6]. Many patients are rightfully hesitant to drive great distances for care, and providers are often unwilling to work in rural areas, as evidenced by the frequent turnover at rural clinics [5]. Mental health services are also costly. Accessing care could potentially be financially burdensome since 14% of rural Americans live below the poverty line and lack health insurance [5]. Additionally, seeking help for mental health is more heavily stigmatized in rural areas compared to urban areas. In smaller communities care tends to be less anonymous, which causes some to feel embarrassed or guilty when they do seek help [5]. 

With mental health disorders and suicides on the rise, particularly during the COVID-19 crisis, it is imperative that this rural disparity is addressed. While the U.S. has traditionally been in favor of implementing mental healthcare alongside primary healthcare, the current data suggests that this is not as effective as it should be [5]. A non-traditional model based on Chibanda’s approach may prove useful if formally adopted in the United States, but it merits further research and community feedback. Implementing such an approach would involve recruiting physicians and psychologists to train trusted community members, likely elderly and/or trusted residents, on the basics of PST. The approach must be localized, and communities must have confidence in the system. Accessing PST must be promoted in the media, and community members should feel proud when taking action and seeking help.

Another method of providing access to mental health services is through telehealth. When telehealth is properly implemented, it gives patients direct access to a clinician who can diagnose and treat virtually, and it has the potential to greatly reduce stigma. Patients would not have to fear being spotted in public, and care can easily be provided in the comfort of one’s home. However, a stable internet connection and access to computers, while often taken for granted in many urban areas, is not always available in rural areas. Various estimates suggest that 20 million to 40 million Americans do not have stable internet [6]. Summers-Gabr also noted that while the CARES Act (a COVID relief act) provided 100 million USD for rural internet access, most estimates suggest it will take over 80 billion USD to ensure all Americans have access [6].

In summary, Chibanda’s model of care could provide one alternative approach to help alleviate the current mental health crisis in the United States. However, more research is required to determine if such a system could feasibly be applied. In addition, more funding needs to be directed towards rural mental healthcare access to bridge the gaps in care. Rural communities need expanded access to internet and telehealth services, and the United States government has a responsibility to listen to its constituents. These rural communities are speaking through their silence regarding mental health issues and will do so until something changes.

Edited by: Nick Rogers
Illustrated by: Eugenia Yoh

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