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Healthy Children and Families: Reducing Behavioral Health Disparities in Rural and Frontier Areas

Rural Children Don’t Receive the Mental Health Care They Need
Urban Children Also Have Significant Unmet Mental Health Needs
Public Coverage Increases Rural Children’s Access to Services
David Lambert, PhD
Erika C. Ziller, MS
Jennifer D. Lenardson, MHS

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Overview
Twenty percent of all children have a mental illness; most do not receive care for their illness. It is widely assumed that rural children are more likely than urban children to have unmet mental health needs. However, few national studies have examined rural urban differences in children’s mental health service use, and which factors may mediate or reduce differences. This information is important for policymakers as they decide which approaches and strategies to use to better meet the mental health needs of rural children. Of particular interest may be the role of Medicaid and the State Children’s Health Insurance Program (SCHIP) in reducing rural-urban disparities in service use.

 

Resources:

Lambert, D., Ziller, E., & Lenardson, J. (2009.)
Rural children don’t receive the mental health care they need. Urban children also have significant unmet mental health needs. Public coverage increases rural children’s access to services.
Maine Rural Health Research Center.

The Rural Behavioral Health Symposium

The Rural Behavioral Health Symposium will focus on how to create and sustain services and supports during these challenging economic times so that communities are able to reduce the impact of behavioral health problems and promote a good quality of life for the entire community, including those with behavioral health challenges.

This two-and-a-half day symposium is designed for a variety of individuals and will focus on practical strategies that build upon the innovations and strengths of rural communities and address the behavioral health needs of their children and families.

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Medicaid and SCHIP have been found to significantly enhance access to children’s mental health services1 and rural children are more likely to be enrolled in these programs than urban children.2 This study sought to close this knowledge gap by examining rural and urban differences in the use of children’s mental health services and the role that family income, health insurance, and mental health status play in explaining these differences. Rural or urban is measured in terms of Metropolitan and Non-Metropolitan Statistical Areas, as defined by the federal Office of Management and Budget (OMB).3 The analysis is based on three years of pooled data (1997, 1999, 2002) from the National Survey of America’s Families (NSAF). All information, including mental health problems and care received, is based on parent report. Three research questions, comparing rural and urban areas, were examined: (1) What is the mental health need of children, ages 6 to 17? (2) What percentage of children with an identified mental health need used a mental health service in the past year? (3) What role does family income and type of insurance have on the use of mental health services by children?

Key Findings
Prevalence
The percentage of children with a parent-reported mental health problem is very similar in rural and in urban areas (7.5%), which is consistent with the broader epidemiological literature. Rural children are more likely than urban children to be poor or near-poor and have Medicaid or SCHIP, or to be uninsured. Urban children are more likely to have parents with higher education and to have employer-based health insurance.

Use of Services

Our descriptive analysis reveals that rural children are slightly less likely to have a mental health visit than are urban children (7% of rural children versus 8% of urban). Yet, among children with an identified mental or behavioral health issue, rural-urban rates of mental health visits in the past year are the same (about 36.5%, See Figure 1) as are the number of annual mental health visits (12.4).4 However, after controlling for insurance status and other variables known to affect access to mental health services, rural children are 20 percent less likely to have a mental health visit than urban children.

Role of Family Income and Type of Insurance

Though prevalence of mental health problems is not affected by family income, having Medicaid or SCHIP increases the likelihood that a child will receive services and this is particularly pronounced in rural areas (Figure 2). Private health insurance does not play a significant role in whether a child receives services. This may be, in part, because many children’s mental health services are provided through state and locally financed non-mental health specialty systems, e.g., schools, child welfare agencies. Being uninsured, regardless of residence, cuts the likelihood of receiving mental health care in half.

Discussion
The prevalence of mental health problems did not differ between rural and urban children; however, rural children were less likely to use mental health services. It is likely that long-standing barriers to mental health services contribute to this disparity including stigma, cultural differences, and insufficient mental health infrastructure. Medicaid and SCHIP help all children receive mental health services and are particularly important for rural children. Across all areas of the US, children with private coverage receive fewer mental health services than those with public coverage. Children who are uninsured go without mental health services. Public health insurance programs are important policy vehicles for enhancing and ensuring the access of rural children to mental health care. Besides providing insurance, policymakers should enhance the service delivery infrastructure. Policymakers may do this by building and funding services and care systems at the community level that have been shown to promote access to mental health care. Such approaches include systems of care models, school-based mental health clinics, and integrated primary care and mental health programs.

Endnotes
1Howell, E. (2004, August). Access to children’s mental health services under Medicaid and SCHIP. (Series B, No B-60). Washington, DC: The UrbanInstitute.
2Ziller, E.C., Coburn, A.F., Loux, S.L., Hoffman, C., & McBride, T.D. (2003). Health insurance coverage in rural America. (No. 4093). Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; University of Southern Maine, Edmund S. Muskie School of Public Service, Institute for Health Policy.
3The OMB divides U.S. counties into those containing a Metropolitan Statistical Area (MSAs, or urban counties) and counties that are nonmetropolitan (non-MSAs, or rural counties). We recognize that this definition may mask important intra-rural variation in mental health need and use of services, but were limited by small subsamples of rural children with mental health needs that used services.
4It may be that this variable is not precise since it is based on parent selfreport. The distribution frequency of annual mental health visits shows a number of high “outliers” and variability of

Additional Resources:

Rural Mental Health Links:

RuralPSYCH
This is an American Psychological Association website designed to serve as a resource for providers, purchasers, and consumers of behavioral health care in frontier and rural areas. The goal of RuralPSYCH is to alleviate the two primary problems encountered by psychologists providing mental health and substance abuse (MH/SA) treatment in frontier and rural areas: 1) professional isolation and 2) lack of current treatment information.

Journal of Rural Community Psychology
A peer-reviewed, scholarly journal in electronic form devoted to sociological, psychological and mental health issues in rural and small community settings.

Frontier Mental Health Service Resource Network
The basic mission of the Frontier Mental Health Services Resource Network is the collection, analysis, and synthesis of knowledge regarding needs for and delivery of mental health services in "frontier" rural U.S. counties (nonmetropolitan counties with population densities of less than seven persons per square mile). It also offers technical assistance to rural agencies and advocates on mental health/substance abuse topics as they impact upon or exist within such isolated rural areas.

University of Florida National Rural Behavior Health Center
The National Rural Behavioral Health Center (NRBHC) houses a team of behavioral health scientists, educators, scholars, and practitioners dedicated to improving the health care status of rural Americans.
The Center focuses on three components of rural behavioral health: rural disaster and trauma, violence prevention, and health service delivery.

Rural Health Links:

Learning Disabilities
About Learning Disabilities was formed to offer a unique reference point for comprehensive and practical advice on learning disabilities. It contains over 70 articles written by experts who continually update and add new content.

National Rural Health Association
This website gives information about the association, its publications, advocacy efforts, and events. In addition, the site has information on research, educational opportunities, and links to other rural health sites.

Capital Area Rural Health Roundtable
The Capital Area Rural Health Roundtable is a forum for the exchange of ideas and open discussion on important rural health topics. The Roundtable is committed to enlarging the circle of participation in rural health policy; encouraging collaboration through shared knowledge and mutual understanding; and promoting strength through diversity.

Rural Health Webring
The Rural Health WebRing is comprised of sites dedicated to rural health issues-it includes government, educational and health agency websites from around the world.

Rural Mental Health Research:

Southeastern Rural Mental Health Research Center, University of Virginia
The overall mission of the Southeastern Rural Mental Health Research Center is to improve the quality of mental health care for rural, impoverished individuals in the South.

Center for Rural Mental Health Research, WICHE
Representing a core staff of social scientists in sociology, psychology, social work, geography, economics, biostatistics, public health, family medicine and nursing, the Center for Rural Mental Health Research operates as an autonomously organized center in the Western Interstate Commission for Higher Education (WICHE).

Maine Rural Health Research Center
Established in 1992, the Maine Rural Health Research Center (MRHRC) is one of five national rural health services research centers funded by the Federal Office of Rural Health Policy. The MRHRC is also one of five rural managed care centers funded by the Federal Agency for Health Care Policy and Research (AHCPR).

Rural Links:

Center for Rural Affairs
The website for the Center for Rural Affairs, a non-profit organization devoted to policy research, advocacy, and service to America's family farms and rural communities.

RUPRI
The Rural Policy Research Institute (RUPRI) conducts policy-relevant research and facilitates public dialogue to assist policymakers in understanding the rural impacts of public policies and programs.

Western Interstate Commission on Higher Education Mental Health Program
The mission of the WICHE Mental Health program is twofold: 1) to assist states in improving systems of care for mental health consumers and their families; and 2) to advance the preparation of a qualified mental health workforce in the West. The program collaborates with states to meet the challenges of changing environments through regional research and evaluation, policy analysis, program development, technical assistance, and information sharing.

Other Links and Resources:

Inniss, J., Nesman, T., Mowery, D., Callejas, L., & Hernandez, M. (2009.) Serving Everyone at the Table: Strategies for enhancing the availability of culturally competent mental health service.

Telemental Health Guide
This guide is designed to serve as a resource for developing, implementing, and using mental health services through the use of videoconferencing.

The National Association for Rural Mental Health
The National Association for Rural Mental Health (NARMH) is a professional organization that serves the field of rural mental health. NARMH’s membership includes the entire spectrum of the rural mental health community: consumers, family members, practitioners, administrators, educators, researchers, and policy makers.

The Rural Portal: Healthy Children and Families
This website provides a new and valuable technical assistance resource to rural and frontier communities working to transform systems for children’s behavioral health in rural and frontier areas. An outcome of the National Plan for Rural Behavioral Health, this activity is funded by the SAMHSA/Center for Mental Health Services.

Jensen, L. (2006). New immigrant settlements in rural America: Problems, prospects, and policies. The Carey Institute Reports on Rural America. Vol1, 3.


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Recent Comments

Thanks for your question about telehealth in Rural Communities. Here is a link to a good resource: http://www.tmhguide.org/ (see above) 03/18/10

I work for the Children\'s Safety Network, a national resource center that assists state health departments in preventing injuries and violence to children and adolescents. We\'ve recently started a group to help states address rural injuries -- reviewing data, connecting with key partners and taking action on several issues including MH promotion and suicide prevention. Please consider partnering with state health departments, as many are taking on this issue too. You can contact me at estreit-kaplan@edc.org. 03/31/10

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