Addressing Mental Health Disparities in Rural Areas

Michelle Tsfasman explores the extensive impact mental health issues and lack of mental health services can have on rural populations.

Michelle Tsfasman

Although the number of people struggling with their mental health is similar in rural and urban populations, the amount who seek assistance before they require advanced psychological treatment is much lower in rural areas than in urban ones.

For the purposes of this paper, “rural” is defined by the Health Resources and Services Administration as areas that have less people and therefore rank higher on the scale of Health Professional Shortage Areas (HPSAs). (Health Resources & Services Administration [HRSA], 2017, as cited in Myers, 2018). Based on this definition, the author speculates that residents of rural areas, especially those of an ethnic minority, are less likely to seek mental health services or more prone to experience substandard treatment (Myers, 2018) because they reside in psychiatrist “dead zones” (HRSA, 2017, as cited in Myers, 2018). Myers (2018) reported that African American and non-Hispanic people in these areas are more likely to be negatively affected by the poor healthcare services provided (Erwin, 2017, as cited in Myers, 2018). This has been found to be related to “affordability, accessibility, accommodation, availability, and acceptability” (Myers, 2018, p. 2).

Specific characteristics related to the health disparities faced by the people of rural communities, in contrast to those in urban areas, include poverty, which limits accessibility because of an inability to travel freely, and social pressures that prevent people from seeking help in the first place. These limitations imposed upon the residents of rural communities culminate in staggering health disparities shown through lower life expectancy, higher mortality rates, higher rates of chronic diseases, and preventable hospitalizations (Myers, 2018). In response to these disparities, using advanced communication technology such as telehealth has been promoted as a viable option for rural communities to access health services. The purpose of this paper is to evaluate how telehealth has been used to address these disparities faced by people in underserved communities, and whether it is a viable option for nurses when compensating for patient needs.

Because of these disparities in healthcare access and the poverty that plagues a majority of communities, individuals in rural areas require vast mental health services that are not received. For nurses, this means that a large part of the country requires their help, whether it is through counseling, daily care, or at-home management (Myers, 2018). The reality, however, is that rural areas’ healthcare professional shortage (HRSA, 2017, as cited in Myers, 2018) is due to the fact that many nurses and other non-physician healthcare professionals are not considered primary or mental healthcare providers, and sole licensure as an Advanced Practice Registered Nurse makes them unable to practice in underserved areas unless they receive a Master’s degree in the field they choose (Myers, 2018). Because of these limitations, Myers (2018) points to the younger nursing generation that can use social media platforms to educate, communicate, and lobby for changes (Myers, 2018). She expressly mentions the National Public Radio (NPR) podcast, HealthConnections, which won a Golden Press Award in 2018 for Documentary Public Affairs Programming (Myers. 2018). Widely accessible, informative, and affordable outreach such as podcasts and Facebook posts are very effective in a world so deeply reliant on the internet. While these advocacy tactics may be a solution for the long term, the short-term solution is the focus of Myers’ attention in this article: telehealth. Telehealth is a relatively new tool in the healthcare space, designed to bring nurses and physicians to the patient rather than the patient coming into the hospital seeking specialized care. As Myers (2018) points out, telehealth can be instrumental in bringing more mental health specialists to the people that need them because it is a field that does not require physical patient assessment (Mehrotra et al., 2017 as cited in Myers, 2018). Nurses and physicians practicing via telehealth can aid patients by providing “online assessment questionnaires, cognitive-behavioral therapy via videoconferencing technology, group chats, medication and other self-care reminders via text messages, educational videos, and interactive video consultations” (SAMSHA, 2016 as cited in Myers, 2018).

One of the principal advantages of telehealth is the expansion of healthcare to underserved communities, such as those in rural areas. These benefits apply to both the overall management of chronic diseases, including mental health disorders, and to the delivery of quality care. The use of a virtual service that provides mental health resources, such as telemental health (Hilty et al., 2013, p. 44, as cited in Myers, 2018), is essential in a hospital setting, given that the hospital does not have a licensed professional who can provide mental health resources to those patients that need rapid intervention. It also has utility in its availability to a wider range of people: as long as the patient has a computer, internet access, and the means by which to pay and/or have coverage for the service, they can receive specialized psychiatric help through telemental health. However, the expansion of telehealth services would require many policy reforms in sectors such as education, licensure, and insurance coverage, and internal changes within the medical community, such as cultural sensitivity training and interprofessional collaboration. This has posed barriers to implementing telehealth services for many who need it.

The education and training of primary and mental healthcare providers are at the top of Myers’ (2018) list of suggestions to overcome the barriers to telehealth. This process would require that more nursing students be recruited from rural areas and subsequently complete their clinicals there, and ensure that the education those students receive is of the same quality as those in more densely populated parts of the country. Another important suggestion Myers (2018) lists is the expansion of licensure allowance. According to The Chicago School of Professional Psychology (2020), there are only two types of nursing licenses available as of 2020: single-state licensure and interstate licensure. Interstate licensure allows the nurse that has procured it to practice in any of the 39 states that have received approval for Nursing Licensure Compact status (NCSBN 2023). Single-state licensure, on the other hand, limits the holder to practice only in one state, being the one where they took their licensure exam. Myers (2018) highlights the significance of allowing nurses and physicians to practice to the top of their license, without the barrier of having to be licensed in other states, by implementing telehealth-specific licenses, temporary licenses, etc. (NCSL, 2015; Wilson, Bangs, & Hatting, 2015 as cited in Myers, 2018). Additionally, she cited that expanding HIPAA to more clearly define confidentiality through telehealth and enacting more policies like the Bipartisan Budget Act of 2018, which allowed for the coverage of some telehealth services such as critical mental health resources, under Medicare are important steps to ensure the success of telehealth country-wide (Myers, 2018).

Overall, I think Myers’ (2018) suggestions to create a more equitable and educated healthcare workforce by expanding the limits of nursing certification are very manageable to implement. However, I feel they only work on the surface level. Even if there is a wider licensure program for professionals in this field, there will be no use for these nurses and physicians if these patients do not know about, cannot access, or cannot use this technology. To combat these obstacles, I believe that besides government funding for Medicare coverage of telehealth services, there should be government-funded programs set up to both teach people how to use telehealth and provide them with a means by which to use it. I think this is a good addition to the list of accessibility issues that need to be solved in order to make telehealth more universal because it would not only create a wider healthcare entry point, but it would also create more jobs, including those outside of healthcare.

In conclusion, there is still a very long way to go before the American Healthcare System does its job to work for everyone that needs it. However, making health services more accessible, at least physically, to people that would otherwise not seek it out themselves is a good first step. It is very important for people who care about the livelihoods of individuals living in communities that are not regularly exposed to the benefits of routine mental health care, especially those who are deemed trustworthy by the public, such as nurses and other healthcare professionals, to advocate on the ground in an effort to take these issues to the federal and state level and get them resolved.

References

1. Myers, C. R. (2018). Using Telehealth to Remediate Rural Mental Health and Healthcare Disparities. Issues in Mental Health Nursing, 40(3), 233–239. https://doi.org/10.1080/01612840.2018.1499157

2. School, T. C. (2020, October 12). All you need to know about nursing licensure. Insight Digital Magazine. The Chicago School of Professional Psychology. https://www.thechicagoschool.edu/insight/health-care/all-you-need-to-know-about-nursing-licensure/

3. NLC. (2023). Nurse Licensure Compact (NLC) NCSBN (National Council of State Boards of Nursing. https://www.ncsbn.org/compacts/nurse-licensure-compact.page