Impact of Attitudes and Rurality on Veterans’ Use of Veterans Health Administration Mental Health Services
Abstract
Objective:
Veterans, especially those residing in rural areas, continue to underutilize mental health care. This longitudinal study assessed attitudes relevant to seeking mental health care services from the Veterans Health Administration (VHA) over 12 months, adjusting for residence.
Methods:
A questionnaire addressing attitudes, sociodemographic factors, residence, place identity, perceived health status and needs, and structural barriers was administered by telephone to 752 veterans with previous VHA service use. Service use data were obtained from a VHA database.
Results:
In adjusted models, four attitudes were significantly associated with underuse of VHA mental health care (no use vs. any use; no use vs. nonsustained use vs. sustained use). Higher levels of mistrust of others (adjusted odds ratio [AOR]=1.06, p=0.046), emotional stoicism (AOR=1.08, p=0.003), belief in the self-resolving nature of mental health problems (AOR=1.91, p=0.015), and belief in the efficacy of religious counseling for such problems (AOR=1.09, p=0.022) were associated with no subsequent service use versus any use. Place identity (suburban), older age, and greater need were associated with greater odds of VHA use. For the comparison of no use versus sustained use, women had lower odds of no use (AOR=0.49, p<0.001); similarly, women had lower odds of nonsustained use versus sustained use (AOR=0.45, p<0.001).
Conclusions:
The association of potentially modifiable attitudes with underuse of VHA mental health services suggests that attitudes offer useful targets for efforts to increase mental health care use. That these attitudes were influential regardless of residence suggests that programs addressing attitudinal barriers can be broadly targeted.
HIGHLIGHTS
•
The Veterans Health Administration (VHA) wants to better understand the relationship of attitudinal barriers to mental health service utilization among its users, especially among VHA users residing in rural regions.
•
Individual beliefs and attitudes predicted 12-month use of VHA mental health care by veterans with a history of VHA service use, even after adjustment for demographic factors, rurality, need, and structural barriers.
•
Veterans who endorsed a belief in the efficacy of religious counseling for mental health problems were more likely than other veterans to use no VHA services—a finding that supports VHA’s efforts to increase collaboration with community-based religious providers.
The Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) provides health care to >9 million veterans, nearly a third of whom (2.8 million) live in rural areas (1). Veterans, including rural-residing veterans, have underused VHA mental health care (2, 3).
In recent decades, the VHA has improved access to mental health care by creating a network of community-based outpatient clinics (CBOCs) (4), investing in telehealth (5–7), deploying mobile clinics (8), and paying for community-based services (9, 10). An emerging literature suggests that these efforts are also reducing the gap in mental health care utilization between rural and urban veterans (11, 12). However, findings have been inconsistent, especially when non–VHA-enrolled veterans are considered (13), and mental health care utilization remains suboptimal. The residual gap suggests that the VHA will also need to target influences other than service accessibility and availability. We undertook this research to explore the utility of VHA’s targeting individual attitudes and beliefs, overall and for veterans living in rural regions.
Both the theoretical (14) and the empirical literatures (15–18) highlight the influence of attitudes and beliefs on mental health care use among veterans, especially among veterans in rural areas. Several studies have suggested that attitudes, beliefs, and behavioral norms influence mental health care utilization more strongly than do structural barriers (19–22). Despite the high diversity within both rural and military populations (23, 24), several attitudes and beliefs relevant to mental health care utilization are frequently reported for each group, including an emphasis on independence, self-reliance, and stoicism and concerns about stigma (15, 25–35). Rural residence has also been associated with a distrust of “outsiders” (25, 26, 36) and, in some cases, trust in the efficacy of religious counseling for mental and emotional problems (36–38). Negative beliefs about mental health care or mental health care providers have also been found to be associated with reduced treatment seeking in both populations (15, 32, 33, 39–41).
The literature on associations between attitudes and beliefs and mental health care utilization among veterans is relatively limited (15), and the subset of studies exploring attitudes, mental health service use, and rurality is even smaller. In addition, much of this research is cross-sectional or retrospective and looks at the association of attitudes with past service use or hypothetical willingness to use services in the future, thus leaving the direction of association unclear (15). This article presents findings from a longitudinal study designed to assess the association of attitudes with subsequent use of VHA mental health care by veterans with a history of VHA use. Participants completed a telephone interview asking about their attitudes toward mental health care and mental health treatment seeking. Analyses combined interview data with administrative data on VHA mental health services use in the 12 months after interview completion.
Methods
Eligibility and Sampling
Potential participants were identified from the VHA national administrative database, the Corporate Data Warehouse (CDW). To be eligible, veterans had to be 18–70 years old; to be living in one of four VHA administrative regions (Veterans Integrated Service Networks [VISNs])—VISN 1 (New England), VISN 16 (south central states), VISN 19 (Rocky Mountain states), and VISN 23 (north central states); and to have had a positive screen for depression or posttraumatic stress disorder recorded in their VHA medical records between October 1, 2009, and September 30, 2012. We excluded veterans with a diagnosis of dementia, schizophrenia, schizoaffective disorder, or psychosis not otherwise specified, because these conditions may affect memory and insight. Sampling was stratified by VISN, distance between a veteran’s residence and the nearest VA medical center (VAMC) (≤15 miles, 16–49 miles, and ≥50 miles), and gender. We oversampled female veterans to ensure that 25% of participants would be women.
Recruitment and Data Collection
Using CDW contact data, we mailed opt-out recruitment packets to potential participants (42). Two weeks later, project personnel called those who had not opted out to discuss the study in detail, assess interest, and confirm eligibility. We obtained verbal informed consent and HIPAA authorization from interested, eligible veterans. After participants consented, trained interviewers administered a structured questionnaire, using computer-assisted interviewing technology. Questionnaires were administered between July 2014 and April 2016. The Central Arkansas Veterans Healthcare System institutional review board approved the study procedures.
Data Sources and Measures
Data on the use of VHA outpatient mental health care in the 12 months after the survey interview were obtained from the CDW. Our primary outcome measure dichotomized mental health care use as any or none. We also divided use into sustained and nonsustained, where sustained use was defined as at least four outpatient mental health visits on separate days to the same VAMC (including its affiliated CBOCs) during the follow-up year. The four-visit criterion was based on the frequency with which appointments were commonly scheduled for stable patients. The questionnaire addressed sociodemographic data, perceived health status and need for mental health care, attitudes relevant to mental health care use, structural barriers, residence, and perceived rurality. We used the Veterans RAND 12-item Health Survey Mental Component Summary score (VR-12 MCS) as an indicator of need for mental health care (43).
The choice of attitudes to assess was based on the literature and findings from qualitative interviews with rural veterans and providers conducted earlier in this study (37). Whenever possible, attitudes were assessed with existing scales or subscales, specifically the Endorsed and Anticipated Stigma Inventory (beliefs about mental health treatment subscale) (44), Network Orientation Scale (independence and mistrust subscales) (45), Pain Attitudes Questionnaire (46), and Perceived Stigma and Barriers to Care for Psychological Problems (PSBCPP) (stigma [self-stigma of mental health treatment seeking] subscale) (47) (Table 1). We based our four-category classification of relative trust in the VHA for mental health care on dichotomized responses to two questions developed for the study: “If you had an emotional or mental health problem that disrupted your daily life, how likely is it that the people who are important to you would encourage you to seek mental health care at the VA” and, separately, “from a non-VHA provider?” To assess perceived structural barriers to mental health care use (e.g., cost and transportation), we used the PSBCPP barriers subscale (47), with the addition of one item developed for the survey (“mental health services are too far away”). The 13 attitude indicators (Table 1) and the barriers index were scored so that higher scores indicated more of the attitude or more barriers.
| No. of | Score | |||
|---|---|---|---|---|
| Attitude | Measure | items | Item scoring | range |
| Included in multivariable models | ||||
| Efficacy of mental health care | EASI subscale | 8 | 1–5, strongly disagree to strongly agree | 8–40 |
| Efficacy of religious counseling | Study specific | 3 | 1–5, strongly disagree to strongly agree | 3–15 |
| Mistrust of others | NOS subscale, modified | 7 | 1–5, strongly disagree to strongly agree | 7–35 |
| Self-resolving nature of emotional problems | Study specific | 1 | 0–4, no one gets better without professional help to everyone does | 0–4 |
| Self-stigma about seeking mental health care | PSBCPP subscale, modified | 6 | 1–5, strongly disagree to strongly agree | 6–30 |
| Stoicism, emotional | Study specific | 6 | 1–5, strongly disagree to strongly agree | 6–30 |
| Stoicism, physical | Pain Attitude Questionnaire | 6 | 1–5, strongly disagree to strongly agree | 6–30 |
| Trust in the VA for mental health care | Study specific | 2 | 4 categories (trust or encourage use of both VA and non-VA providers, trust VA only, trust non-VA only, and trust or encourage use of neither) | |
| Not included in multivariable models because of lack of bivariate significance | ||||
| Independence | NOS subscale, modified | 10 | 1–5, strongly disagree to strongly agree | 10–50 |
| Mistrust of providers | Study specific | 2 | 1–5, strongly disagree to strongly agree | 2–10 |
| Mistrust of VA system | Study specific | 2 | 3 categories | |
| Public stigma about seeking health care | Study specific | 3 | 1–4, not at all to very embarrassed | 3–12 |
| Willingness to rely on others | Study specific | 3 | Two categories |
a
EASI, Endorsed and Anticipated Stigma Inventory; NOS, Network Orientation Scale; PSBCPP, Perceived Stigma and Barriers to Care for Psychological Problems; VA, U.S. Department of Veterans Affairs.
We constructed two indicators of rurality that tapped distinct constructs. The first, geographic distance from the participant’s residence to the nearest VAMC, was calculated as the distance between the centroids of the zip codes in which each was located. The second, place identity, was self-identification as a rural, suburban, or urban person, assessed through the question, “If you were talking about yourself to others, how would you describe yourself?” Data on place identity were collected as part of the telephone survey. Distance from the participant’s current residence to the nearest VAMC was determined with the VA Planning Systems Support Group zip code database.
Statistical Analysis
Logistic regression was used to test the hypothesis that attitude scores would be associated with VHA mental health care use after adjustment for sociodemographic factors, residence, place identity, need, and structural barriers. Binomial logistic regression was used when the outcome was no or any mental health service use; multinomial logistic regression was used when it was no use, nonsustained use, and sustained use. Because we used stratified probability sampling in recruiting survey participants, sampling weights were used in all analyses. We used multiple imputation (SAS PROC MIANALYZE) with 12 rounds of imputation to address missing survey data. Using a model-building structure informed by Hosmer and Lemeshow’s purposeful selection algorithm (48), we entered variables into regression models in three sequential blocks. We first entered predictors of primary interest (attitudes), followed by confounders of primary interest (rurality indicators), followed by other potential confounders (demographic factors, need, and structural barriers). Because distance and place identity tap distinct aspects of rurality (geography vs. culture) and did not categorize participants identically (data available from the first author), we included both indicators in the final model. To avoid problems of multicollinearity due to the recursive relationship between attitudes and service utilization (14), we did not include previous service use in the regression models. All analyses were performed with SAS, version 9.3.
Results
Participants
We mailed opt-out invitation letters to 3,490 veterans, of whom 1,513 (43%) declined participation, 173 (5%) were found ineligible, and 1,043 (30%) could not be contacted. We interviewed 761 (22%) veterans who were eligible and gave verbal informed consent. Data from nine veterans who did not complete the entire interview were excluded from the analyses.
Table 2 presents the unweighted characteristics of the 752 veterans who completed interviews. Most interview participants were men and currently married, self-identified as non-Hispanic White, and had an education beyond high school. The mean age was 52.4 (range 24–70) years, and the mean distance to the nearest VAMC was 43.6 miles (range <1–226 miles). (A table comparing characteristics of veterans who participated, who refused, and who could not be contacted is included in an online supplement to this article.)
| Characteristic | N | % |
|---|---|---|
| Demographic | ||
| Female | 188 | 25 |
| Race-ethnicity | ||
| Hispanic | 46 | 6 |
| Non-Hispanic Black | 86 | 11 |
| Non-Hispanic White | 521 | 69 |
| Other | 99 | 13 |
| Marital status | ||
| Currently married | 386 | 51 |
| Divorced | 220 | 29 |
| Never married | 85 | 11 |
| Other | 61 | 8 |
| Education | ||
| High school or less | 127 | 17 |
| More than high school | 446 | 59 |
| Bachelor’s degree or more | 179 | 24 |
| Age (M±SD years) | 52.4±12.5 | |
| Residence | ||
| Regiona | ||
| VISN 1 | 182 | 24 |
| VISN 16 | 194 | 26 |
| VISN 19 | 192 | 26 |
| VISN 23 | 184 | 24 |
| Distance to VAMC (miles)b | ||
| M±SD | 43.6±43.6 | |
| Medianc | 29.9 |
a
VISN, Veterans Integrated Service Network. VISN 1, New England; VISN 16, south central states; VISN 19, Rocky Mountain states; VISN 23, north central states.
b
VAMC, Department of Veterans Affairs medical center.
c
Interquartile range=10.0–63.5.
Attitude Variables Included in Logistic Regression Models
We regressed each of the service use variables (no use or any use, and no use or nonsustained use or sustained use) separately on each of the attitude variables. Eight attitude variables that were statistically significant at p<0.10 in at least one of the bivariate analyses were included in all multivariable logistic models.
No Use Versus Any Use
When dichotomous use (no use vs. any use [the reference category]) was regressed on the set of the eight attitude variables, four were statistically significant (Table 3). Higher scores on mistrust of others, emotional stoicism, belief in the self-resolving nature of mental health problems, and belief in the efficacy of religious counseling for mental health problems were associated with increased odds of no use of VHA mental health care. These significant associations remained after the models were adjusted for each of the rurality indicators separately (Table 4). In these models, increasing distance was independently associated with increased odds of no service use, whereas suburban place identity was associated with decreased odds of no service use.
| Attitudes only | Fully adjusted modela | |||||||
|---|---|---|---|---|---|---|---|---|
| Variable | OR | 95% CI | Z | p | OR | 95% CI | Z | p |
| Attitude indicator | ||||||||
| Mistrust of othersb | 1.07 | 1.02–1.12 | 2.61 | .009 | 1.06 | 1.00–1.11 | 2.00 | .046 |
| Self-stigmab | .99 | .95–1.03 | −.57 | .566 | .99 | .95–1.04 | −.29 | .774 |
| Stoicism, physicalb | 1.00 | .96–1.04 | −.23 | .815 | .99 | .95–1.04 | −.21 | .835 |
| Stoicism, emotionalb | 1.05 | 1.00–1.10 | 2.11 | .035 | 1.08 | 1.03–1.14 | 2.93 | .003 |
| Trust in the VHA for mental health care (reference: trust in neither) | ||||||||
| VHA only | .71 | .32–1.60 | −.83 | .407 | .62 | .27–1.42 | –1.13 | .258 |
| Both | 1.10 | .51–2.36 | .24 | .814 | 1.11 | .51–2.45 | .27 | .789 |
| Non-VHA only | .97 | .41–2.32 | −.07 | .944 | 1.10 | .45–2.72 | .22 | .829 |
| Belief in self-resolving nature of emotional problemsb | 1.97 | 1.21–3.20 | 2.72 | .007 | 1.91 | 1.13–3.21 | 2.43 | .015 |
| Belief in efficacy of mental health careb | .97 | .94–1.01 | –1.47 | .141 | .98 | .95–1.02 | −.88 | .380 |
| Belief in efficacy of religious counselingb | 1.07 | 1.01–1.14 | 2.23 | .026 | 1.09 | 1.01–1.16 | 2.31 | .022 |
| Rurality indicator | ||||||||
| Distance to VAMC (miles)c | 1.003 | 1.00–1.01 | 1.70 | .089 | ||||
| Place identity (reference: urban) | ||||||||
| Rural | .92 | .61–1.38 | −.42 | .677 | ||||
| Suburban | .61 | .39–.96 | –2.15 | .032 | ||||
| Control variable | ||||||||
| Age in years | 1.03 | 1.01–1.04 | 3.80 | <.001 | ||||
| Female (reference: male) | .74 | .53–1.04 | –1.75 | .079 | ||||
| Race-ethnicity (reference: non-Hispanic White) | ||||||||
| Hispanic | 1.18 | .59–2.35 | .47 | .641 | ||||
| Non-Hispanic Black | .79 | .42–1.48 | −.74 | .462 | ||||
| Other | 1.01 | .62–1.62 | .03 | .978 | ||||
| VISN (reference: VISN 16)d | ||||||||
| 1 | .75 | .43–1.30 | –1.03 | .304 | ||||
| 19 | .64 | .37–1.11 | –1.58 | .114 | ||||
| 23 | .97 | .55–1.70 | −.12 | .908 | ||||
| Need (VR-12 MCS)b , e | 1.05 | 1.02–1.07 | 3.68 | <.001 | ||||
| Barriers index (structural and logistic)b | 1.04 | .81–1.34 | .31 | .760 | ||||
a
Adjusted for rurality (distance and place identity), personal characteristics, need, and structural barriers.
b
Scale or subscale score. Odds ratios indicate the change in the odds of the outcome associated with a one-unit increase in the corresponding scale or subscale score.
c
VAMC, Department of Veterans Affairs medical center.
d
VISN, Veterans Integrated Service Network. VISN 1, New England; VISN 16, south central states; VISN 19, Rocky Mountain states; and VISN 23, north central states.
e
Veterans RAND 12-item Health Survey Mental Component Summary score.
| Rurality indicator | ||||||||
|---|---|---|---|---|---|---|---|---|
| Distance to VAMCb | Place identity | |||||||
| Variable | OR | 95% CI | Z | p | OR | 95% CI | Z | p |
| Attitude indicator | ||||||||
| Mistrust of othersc | 1.07 | 1.02–1.12 | 2.58 | .006 | 1.07 | 1.02–1.23 | 2.66 | .008 |
| Self-stigmac | .99 | .95–1.03 | −.65 | .517 | .99 | .96–1.03 | −.37 | .715 |
| Stoicism, physicalc | 1.00 | .96–1.04 | −.20 | .839 | .99 | .95–1.03 | −.59 | .553 |
| Stoicism, emotionalc | 1.05 | 1.00–1.10 | 2.15 | .031 | 1.05 | 1.00–1.10 | 2.05 | .040 |
| Trust in the VHA for mental health care (reference: trust in neither) | ||||||||
| VHA only | .66 | .29–1.50 | –1.00 | .319 | .81 | .32–1.59 | −.84 | .402 |
| Both | 1.03 | .48–2.25 | .09 | .927 | 1.16 | .54–2.48 | .38 | .704 |
| Non-VHA only | .91 | .38–2.18 | −.22 | .826 | .99 | .41–2.36 | −.03 | .979 |
| Belief in self-resolving nature of emotional problemsc | 1.99 | 1.22–3.25 | 2.76 | .006 | 2.01 | 1.23–3.28 | 2.78 | .005 |
| Belief in efficacy of mental health carec | .98 | .94–1.01 | –1.37 | .171 | .97 | .94–1.01 | –1.50 | .134 |
| Belief in efficacy of religious counselingc | 1.08 | 1.02–1.15 | 2.45 | .014 | 1.08 | 1.02–1.15 | 2.43 | .015 |
| Rurality indicator | ||||||||
| Distance to VAMC (miles)b | 1.004 | 1.00–1.01 | 2.09 | .037 | ||||
| Place identity (reference: urban) | ||||||||
| Rural | 1.10 | .76–1.60 | .51 | .613 | ||||
| Suburban | .57 | .37–.87 | –2.60 | .009 | ||||
a
Two separate models; one adjusting for distance and one for place identity (reference: urban). Outcome reference group: any use (0); outcome comparison group, no use (1).
b
VAMC, Department of Veterans Affairs medical center.
c
Scale or subscale score (see Table 1). Odds ratios indicate the change in the odds of the outcome associated with a one-unit increase in the corresponding scale or subscale score.
In the fully adjusted model (Table 3), which included the attitude variables, distance, place identity, age, gender, race-ethnicity, VISN, need, and structural barriers, the four attitude variables remained statistically significant. Not only did adjustment not change which attitudes were significant, it had little impact on the magnitude of effects. Suburban place identity also remained significant; veterans who self-identified as suburban had lower odds of no service use than veterans who self-identified as rural or urban. Among control variables, only age and need were significantly associated with service utilization; the odds of no service use increased as age increased and as VR-12 MCS scores increased (higher MCS scores indicate lower need).
Although gender did not reach statistical significance in the fully adjusted model (p=0.079), because of the priority given to women’s health by VHA, we stratified findings by gender to explore potential differences. The magnitude of the effect of mistrust of others was similar for men and women. However, the magnitude of the effect of emotional stoicism was greater for male veterans, and the magnitude of the effects for belief in the self-resolving nature of emotional problems and in the efficacy of religious counseling was greater among female veterans. Suburban place identity was also more strongly associated with service use among female veterans than among male veterans (see online supplement ).
No Use, Nonsustained Use, and Sustained Use
The 752 participants were fairly evenly distributed among service use categories: sustained use (N=293, 39%), nonsustained use (N=232, 31%), and no use (N=227, 30%). Table 5 summarizes the results of regressing the trichotomous service use variable on the full model. Not surprisingly, the pattern for no use versus sustained use was nearly identical, in terms of the magnitude of odds ratios (but not in terms of statistical significance), to the pattern for no use versus any use. Two attitudes were significantly associated with the odds of nonsustained versus sustained use: the odds of nonsustained use decreased as self-stigma scores increased but increased with increasing belief in the self-resolving nature of emotional problems. Women had significantly lower odds of being nonusers and nonsustained users versus sustained users.
| No use vs. nonsustained use | Nonsustained use vs. sustained use | No use vs. sustained use | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variable | OR | 95% CI | Z | p | OR | 95% CI | Z | p | OR | 95% CI | Z | p |
| Attitude indicator | ||||||||||||
| Mistrust of othersa | 1.05 | .98–1.11 | 1.41 | .159 | 1.02 | .95–1.09 | .54 | .588 | 1.07 | 1.00–1.14 | 1.94 | .052 |
| Self-stigmaa | 1.03 | .98–1.08 | 1.10 | .273 | .94 | .89–.99 | –2.35 | .019 | .97 | .92–1.01 | –1.41 | .158 |
| Stoicism, physicala | 1.02 | .97–1.07 | .75 | .454 | .95 | .91–1.00 | –1.78 | .074 | .97 | .92–1.02 | –1.08 | .281 |
| Stoicism, emotionala | 1.08 | 1.01–1.14 | 2.39 | .017 | 1.08 | 1.02–1.15 | .14 | .892 | 1.08 | 1.02–1.15 | 2.49 | .013 |
| Trust in the VHA for mental health care (reference: trust in neither) | ||||||||||||
| VHA only | .64 | .25–1.66 | −.91 | .362 | .59 | .22–1.62 | –1.02 | .308 | .92 | .33–2.55 | −.16 | .876 |
| Both | 1.38 | .56–3.40 | .70 | .485 | .65 | .24–1.73 | −.87 | .384 | .89 | .34–2.32 | −.24 | .812 |
| Non-VHA only | .97 | .35–2.67 | −.07 | .948 | 1.39 | .45–4.32 | .57 | .572 | 1.44 | .45–4.55 | .61 | .540 |
| Belief in self-resolving nature of emotional problemsa | 1.71 | .92–3.18 | 1.68 | .092 | 2.16 | 1.11–4.24 | 2.25 | .024 | 1.27 | .59–2.71 | .61 | .542 |
| Belief in efficacy of mental health carea | .99 | .95–1.04 | −.41 | .679 | .99 | .94–1.04 | −.55 | .579 | .98 | .93–1.02 | −.98 | .326 |
| Belief in efficacy of religious counselinga | 1.12 | 1.03–1.21 | 2.88 | .004 | .93 | .85–1.01 | –1.68 | .094 | 1.04 | .96–1.14 | .96 | .336 |
| Rurality indicator | ||||||||||||
| Distance to VAMC (miles)b | 1.00 | 1.00–1.01 | 1.35 | .177 | 1.00 | .99–1.01 | .19 | .852 | 1.00 | .99–1.01 | 1.46 | .143 |
| Place identity (reference: urban) | ||||||||||||
| Rural | .87 | .54–1.41 | −.55 | .582 | 1.10 | .64–1.87 | .33 | .738 | .96 | .58–1.58 | −.17 | .864 |
| Suburban | .66 | .39–1.10 | –1.59 | .111 | .86 | .50–1.49 | −.53 | .596 | .57 | .33–.96 | –2.11 | .035 |
| Control variable | ||||||||||||
| Age in years | 1.04 | 1.02–1.05 | 4.23 | <.001 | .98 | .97–1.00 | –1.88 | .060 | 1.02 | 1.00–1.04 | 2.03 | .043 |
| Female (reference: male) | 1.08 | .73–1.60 | .39 | .700 | .45 | .30–.69 | –3.64 | <.001 | .49 | .33–.74 | –3.43 | <.001 |
| Race-ethnicity (reference: non-Hispanic White) | ||||||||||||
| Hispanic | 1.04 | .48–2.28 | .10 | .919 | 1.32 | .53–3.30 | .60 | .548 | 1.38 | .57–3.32 | .72 | .474 |
| Non-Hispanic Black | .86 | .41–1.79 | −.40 | .686 | .83 | .38–1.81 | −.47 | .636 | .71 | .34–1.51 | −.89 | .375 |
| Other | 1.12 | .63–1.98 | .39 | .697 | .81 | .44–1.49 | −.67 | .505 | .91 | .52–1.60 | −.33 | .745 |
| VISN (reference: VISN 16)c | ||||||||||||
| 1 | .95 | .49–1.81 | −.17 | .868 | .63 | .31–1.31 | –1.23 | .219 | .60 | .31–1.18 | –1.47 | .141 |
| 19 | .64 | .34–1.21 | –1.37 | .169 | 1.01 | .49–2.07 | .03 | .977 | .65 | .33–1.29 | –1.24 | .216 |
| 23 | 1.08 | .56–2.07 | .24 | .813 | .78 | .37–1.63 | −.66 | .506 | .84 | .42–1.69 | −.48 | .629 |
| Need (VR-12 MCS)a , d | 1.04 | 1.01–1.07 | 2.78 | .006 | 1.01 | .98–1.04 | .90 | .367 | 1.05 | 1.02–1.08 | 3.62 | <.001 |
| Barriers index (structural and logistic)a | .91 | .68–1.22 | −.62 | .534 | 1.28 | .93–1.75 | 1.53 | .126 | 1.16 | .86–1.58 | .99 | .322 |
a
Scale or subscale score. Odds ratios indicate the change in the odds of the outcome associated with a 1-unit increase in the corresponding scale or subscale score.
b
VAMC, Department of Veterans Affairs medical center.
c
VISN, Veterans Integrated Service Network. VISN 1, New England; VISN 16, south central states; VISN 19, Rocky Mountain states; VISN 23, north central states.
d
Veterans RAND 12-item Health Survey Mental Component Summary score.
Discussion
In this longitudinal study, we found that a subset of attitudes and beliefs was associated with no use of VHA mental health care over 12 months by veterans who had used VHA for general medical or mental health care in the past. This was the case both when utilization was dichotomized (none or any) and when it was trichotomized (no use, nonsustained use, or sustained use). Associations for those attitudes remained statistically significant after adjustments for rurality, demographic factors, need, and structural barriers. The set of attitudes significantly associated with lack of VHA mental health service use was not unexpected. It does not seem surprising that veterans with high scores on mistrust of others, emotional stoicism, belief in the self-resolving nature of mental problems, or belief in the efficacy of religious counseling in resolving such problems would be disinclined to seek mental health care.
One attitudinal barrier frequently endorsed by veterans and active military personnel (33, 35, 37, 49, 50), concern about public stigma and self-stigma, was not associated with reduced mental health service use in our study. Our single significant finding regarding stigma was that veterans with higher self-stigma scores had reduced odds of nonsustained versus sustained service use. Stigma is addressed in most of the published research on attitudes and mental health care utilization. Although the results of these studies are mixed (16, 51), our findings are consistent with an expanding body of research indicating that stigma either is not associated with actual service use or is associated with increased use (16, 32, 52–56). These counterintuitive findings may arise because the severity of the mental health problem outweighs concerns about stigma (51, 52), a need for services increases concerns about stigma (16), or receipt of services increases awareness of the social impact of help seeking (52, 55). They could also arise from inconsistencies and methodological challenges in the measurement of stigma (52).
This study contributes to the existing literature in several ways. Whereas much of the literature on mental health care utilization and attitudes is retrospective, assessing the relationship of current attitudes to previous service use (12, 16, 32, 33, 35, 40, 41, 51, 57), our study clarified the temporal sequence of attitudes and service use by looking at the influence of current attitudes on service use over the 12 months after an interview. To our knowledge, it is the first study that has looked at the influence of both attitudes and rural residence on future use of VHA mental health care. None of the six longitudinal studies we found that assessed the impact of attitudes and beliefs on mental health care use among U.S. military veterans also assessed the impact of rural residence (53, 56, 58–61).
Our study expanded the set of attitudinal barriers commonly assessed and, to our knowledge, it is the first that has studied attitudes and use of mental health care among veterans and includes a measure of beliefs regarding the efficacy of religious counseling. Inclusion of this variable arose from our initial qualitative work as well as from the literature (36–38, 62, 63). Its association with higher odds of no service use warrants additional investigation, especially for female veterans.
Because we examined individual attitudes rather than a composite of negative beliefs and attitudes, this study also allowed for a more nuanced understanding of the influence of individual attitudes. The association we observed between increased service utilization and self-identification as a suburban person (i.e., place identity) is intriguing. Its significance in models that included distance as well as measures of attitudes, need, and structural barriers and its greater salience for women suggest a need for additional qualitative research to better understand other aspects of rural, urban, and suburban cultures that influence mental health service use (64–66).
Our findings should be considered in the context of study limitations. First, all participants had used VHA general medical or mental health services in the past, and most used at least some VHA mental health care in the 12 months after their telephone interview. Findings may not generalize to veterans using services outside the VHA system. Second, we had no data on participants’ use of mental health services outside the VHA during the follow-up year. Although we expect that the significant attitudes would influence VHA and non-VHA mental health care utilization similarly, additional longitudinal research incorporating both VHA and non-VHA data is warranted to test that hypothesis. Third, although the response rate is respectable for a telephone survey (67, 68), two-thirds of the eligible participants whom we could contact (1,513 of 2,274) declined to take part. We used statistical weighting to ensure that our sample conformed to the study population with respect to VISN, distance to the nearest VAMC, and gender, and we found no significant differences in race-ethnicity between participants and nonparticipants. Although we cannot rule out nonresponse bias arising from differences in other characteristics, including age, we are encouraged by the Pew Research Center’s findings of little nonresponse bias for the types of questions included in our survey (68). Fourth, several of the attitude indicators used have not been validated, although similar items have been used in comparable surveys.
Fifth, we recognize that attitudes are dynamic and that some attitudes about mental health care may both reflect previous treatment experiences and influence future service utilization. Because our analyses focused on the impact of attitudes on subsequent service use rather than on attitude development, to avoid overcontrolling, we did not include presurvey treatment experiences in our analytical models. Sixth, because the study was not adequately powered for the trichotomous outcome analyses or for the gender-stratified dichotomous outcome analyses, nonsignificant findings in these analyses may not be stable. These limitations are offset in part by the study’s strengths, including its longitudinal nature, use of probability sampling, use of objective administrative data for VHA mental health care utilization, and separate consideration of attitudinal and structural barriers.
Conclusions
Our finding that participants’ attitudes and beliefs were independently associated with VHA service use after analyses that controlled for service need and distance indicates that addressing attitudes is another potentially useful target for the VHA in its efforts to increase veterans’ utilization of needed mental health care. Although several attitudes frequently ascribed to many rural cultures were associated with patterns of VHA mental health care utilization, taking attitudes into account did not eliminate the association of utilization with distance and with place identity, a cultural marker of rurality. The finding that attitudes are influential regardless of residence suggests that VHA programs that address attitudinal barriers can be broadly targeted.
Not all attitudes are amenable to intervention by the VHA—e.g., general mistrust of others. However, our findings suggest additional avenues by which the VHA might work to reduce the rural-urban gap in mental health care use. For example, this study’s findings regarding the impact of belief in the efficacy of religious counseling support expansion of ongoing VA efforts to increase veterans’ engagement in mental health care through collaborative relationships between VHA mental health care providers and community-based religious providers (62, 69). Similarly, the role of emotional stoicism and the influence of belief in the self-resolving nature of mental problems as barriers to VHA mental health care utilization suggest that expansion of the suicide prevention educational and behavioral campaign, epitomized by the slogan “It takes the strength and courage of a warrior to ask for help,” could contribute to reductions in the rural-urban utilization gap (70).
Acknowledgments
The authors thank the veterans who participated in the study. They also thank Greer Sullivan, M.D., Kathy Henderson, M.D., Terri Tanielian, M.A., Teresa Timmons, M.D., Michelle D. Sherman, Ph.D., and other members of the Scientific Advisory Committee for their guidance and Mary K. Bartnik, M.A., Susan Moore, M.Ed., Shane Russell, B.A., and Beverly Williams, M.P.H, for logistical support. The views expressed in this report are those of the authors and do not necessarily represent the views of the VA.
Supplementary Material
File (appi.ps.201900275.ds001.pdf)
- View/Download
- 116.33 KB
References
1.
Rural Veterans. Washington, DC, US Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, 2019. http://www.ruralhealth.va.gov. Accessed April 24, 2019
2.
National Academies of Sciences, Engineering, and Medicine : Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC, National Academies Press, 2018
3.
Mott JM, Grubbs KM, Sansgiry S, et al : Psychotherapy utilization among rural and urban veterans from 2007 to 2010. J Rural Health 2015 ; 31 : 235 – 243
4.
Kehle SM, Greer N, Rutks I, et al : Interventions to improve veterans’ access to care: a systematic review of the literature. J Gen Intern Med 2011 ; 26 ( suppl 2 ): 689 – 696
5.
Jacobs JC, Blonigen DM, Kimerling R, et al : Increasing mental health care access, continuity, and efficiency for veterans through telehealth with video tablets. Psychiatr Serv 2019 ; 70 : 976 – 982
6.
Lindsay JA, Day SC, Amspoker AB, et al : Personalized implementation of video telehealth. Psychiatr Clin North Am 2019 ; 42 : 563 – 574
7.
Godleski L, Darkins A, Peters J : Outcomes of 98,609 US Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatr Serv 2012 ; 63 : 383 – 385
8.
Veterans Access, Choice, and Accountability Act of 2014: Section 204: Improvement of Access of Veterans to Mobile Vet Centers and Mobile Medical Centers of the Department of Veterans Affairs. Fact Sheet. Washington, DC, US Department of Veterans Affairs, Office of Public Affairs, 2014. https://www.va.gov/opa/choiceact/documents/Fact-Sheet-Mobile-Vet-Centers.pdf
9.
Sayre GG, Neely EL, Simons CE, et al : Accessing care through the Veterans Choice Program: the veteran experience. J Gen Intern Med 2018 ; 33 : 1714 – 1720
10.
VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018.Washington, DC, US Congress, 2018. https://www.govinfo.gov/app/details/BILLS-115s2372enr. Accessed March 30, 2020
11.
Hudson TJ, Fortney JC, Williams JS, et al : Effect of rural residence on use of VHA mental health care among OEF/OIF veterans. Psychiatr Serv 2014 ; 65 : 1420 – 1425
12.
Whealin JM, Stotzer RL, Pietrzak RH, et al : Deployment-related sequelae and treatment utilization in rural and urban war veterans in Hawaii. Psychol Serv 2014 ; 11 : 114 – 123
13.
Teich J, Ali MM, Lynch S, et al : Utilization of mental health services by veterans living in rural areas. J Rural Health 2017 ; 33 : 297 – 304
14.
Fortney JC, Burgess JF Jr, Bosworth HB, et al : A re-conceptualization of access for 21st century healthcare. J Gen Intern Med 2011 ; 26 ( suppl 2 ): 639 – 647
15.
Vogt D : Mental health-related beliefs as a barrier to service use for military personnel and veterans: a review. Psychiatr Serv 2011 ; 62 : 135 – 142
16.
Vogt D, Fox AB, Di Leone BAL : Mental health beliefs and their relationship with treatment seeking among US OEF/OIF veterans. J Trauma Stress 2014 ; 27 : 307 – 313
17.
Bovin MJ, Miller CJ, Koenig CJ, et al : Veterans’ experiences initiating VA-based mental health care. Psychol Serv 2019 ; 16 : 612 – 620
18.
Johnson EM, Barrie KA, Possemato K, et al : Predictors of mental health care utilization in veterans with post-traumatic stress disorder symptoms and hazardous drinking. Mil Med 2016 ; 181 : 1200 – 1206
19.
Vanheusden K, van der Ende J, Mulder CL, et al : Beliefs about mental health problems and help-seeking behavior in Dutch young adults. Soc Psychiatry Psychiatr Epidemiol 2009 ; 44 : 239 – 246
20.
Bayer JK, Peay MY : Predicting intentions to seek help from professional mental health services. Aust N Z J Psychiatry 1997 ; 31 : 504 – 513
21.
Fox JC, Blank M, Berman J, et al : Mental disorders and help seeking in a rural impoverished population. Int J Psychiatry Med 1999 ; 29 : 181 – 195
22.
Kovess-Masféty V, Saragoussi D, Sevilla-Dedieu C, et al : What makes people decide who to turn to when faced with a mental health problem? Results from a French survey. BMC Public Health 2007 ; 7 : 188 – 196
23.
Hartley D : Rural health disparities, population health, and rural culture. Am J Public Health 2004 ; 94 : 1675 – 1678
24.
Merchant J, Coussens G, Gilbert D (eds): Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary. Washington, DC, National Academies Press, 2006
25.
Perceptions of Rural America. Battle Creek, MI, Kellogg Foundation, 2001
26.
Hamilton LC, Hamilton LR, Duncan CM, et al : Place Matters: Challenges and Opportunities in Four Rural Americas. Durham, University of New Hampshire, Carsey Institute, 2008
27.
Ortega AN, Alegría M : Self-reliance, mental health need, and the use of mental healthcare among island Puerto Ricans. Ment Health Serv Res 2002 ; 4 : 131 – 140
28.
Willging CE, Salvador M, Kano M : Pragmatic help seeking: how sexual and gender minority groups access mental health care in a rural state. Psychiatr Serv 2006 ; 57 : 871 – 874
29.
Wray LO, Pikoff E, King PR, et al : Veterans’ mental health beliefs: facilitators and barriers to primary care-mental health use. Fam Syst Health 2016 ; 34 : 404 – 413
30.
Nash WP, Silva C, Litz B : The historic origins of military and veteran mental health stigma and the stress injury model as a means to reduce it. Psychiatr Ann 2009 ; 39 : 789 – 794
31.
Hoge CW, Castro CA, Messer SC, et al : Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004 ; 351 : 13 – 22
32.
Finley EP, Mader M, Bollinger MJ, et al : Characteristics associated with utilization of VA and non-VA care among Iraq and Afghanistan veterans with post-traumatic stress disorder. Mil Med 2017 ; 182 : e1892 – e1903
33.
Kim PY, Britt TW, Klocko RP, et al : Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Mil Psychol 2011 ; 23 : 65 – 81
34.
Greene-Shortridge TM, Britt TW, Castro CA : The stigma of mental health problems in the military. Mil Med 2007 ; 172 : 157 – 161
35.
Britt TW, Bennett EA, Crabtree M, et al : The theory of planned behavior and reserve component veteran treatment seeking. Mil Psychol 2011 ; 23 : 82 – 96
36.
Reiling DM : Boundary maintenance as a barrier to mental health help-seeking for depression among the Old Order Amish. J Rural Health 2002 ; 18 : 428 – 436
37.
Fischer EP, McSweeney JC, Wright P, et al : Overcoming barriers to sustained engagement in mental health care: perspectives of rural veterans and providers. J Rural Health 2016 ; 32 : 429 – 438
38.
Haynes TF, Cheney AM, Sullivan JG, et al : Addressing mental health needs: perspectives of African Americans living in the rural south. Psychiatr Serv 2017 ; 68 : 573 – 578
39.
Smith LD, McGovern RJ, Peck PL : Factors contributing to the utilization of mental health services in a rural setting. Psychol Rep 2004 ; 95 : 435 – 442
40.
Elbogen EB, Wagner HR, Johnson SC, et al : Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv 2013 ; 64 : 134 – 141
41.
Pietrzak RH, Johnson DC, Goldstein MB, et al : Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr Serv 2009 ; 60 : 1118 – 1122
42.
Miller CJ, Burgess JF Jr, Fischer EP, et al : Practical application of opt-out recruitment methods in two health services research studies. BMC Med Res Methodol 2017 ; 17 : 57
43.
Selim AJ, Rogers W, Fleishman JA, et al : Updated US population standard for the Veterans RAND 12-item Health Survey (VR-12). Qual Life Res 2009 ; 18 : 43 – 52
44.
Vogt D, Di Leone BAL, Wang JM, et al : Endorsed and Anticipated Stigma Inventory (EASI): a tool for assessing beliefs about mental illness and mental health treatment among military personnel and veterans. Psychol Serv 2014 ; 11 : 105 – 113
45.
Vaux A : Factor structure of the Network Orientation Scale. Psychol Rep 1985 ; 57 : 1181 – 1182
46.
Yong H-H, Gibson SJ, Horne DJ, et al : Development of a pain attitudes questionnaire to assess stoicism and cautiousness for possible age differences. J Gerontol B Psychol Sci Soc Sci 2001 ; 56 : 279 – 284
47.
Britt TW, Greene-Shortridge TM, Brink S, et al : Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. J Soc Clin Psychol 2008 ; 27 : 317 – 335
48.
Hosmer DW, Lemeshow S, Sturdivant RX : Applied Logistic Regression, 3rd ed. New York, Wiley, 2013
49.
Hoge CW, Grossman SH, Auchterlonie JL, et al : PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatr Serv 2014 ; 65 : 997 – 1004
50.
Sayer NA, Friedemann-Sanchez G, Spoont M, et al : A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry 2009 ; 72 : 238 – 255
51.
Kulesza M, Pedersen E, Corrigan P, et al : Help-seeking stigma and mental health treatment seeking among young adult veterans. Mil Behav Health 2015 ; 3 : 230 – 239
52.
Sharp M-L, Fear NT, Rona RJ, et al : Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiol Rev 2015 ; 37 : 144 – 162
53.
Spoont MR, Nelson DB, Murdoch M, et al : Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatr Serv 2014 ; 65 : 654 – 662
54.
Edlund MJ, Fortney JC, Reaves CM, et al : Beliefs about depression and depression treatment among depressed veterans. Med Care 2008 ; 46 : 581 – 589
55.
Fox AB, Meyer EC, Vogt D : Attitudes about the VA health-care setting, mental illness, and mental health treatment and their relationship with VA mental health service use among female and male OEF/OIF veterans. Psychol Serv 2015 ; 12 : 49 – 58
56.
DeViva JC, Sheerin CM, Southwick SM, et al : Correlates of VA mental health treatment utilization among OEF/OIF/OND veterans: resilience, stigma, social support, personality, and beliefs about treatment. Psychol Trauma 2016 ; 8 : 310 – 318
57.
Kehle SM, Polusny MA, Murdoch M, et al : Early mental health treatment-seeking among US National Guard soldiers deployed to Iraq. J Trauma Stress 2010 ; 23 : 33 – 40
58.
Harpaz-Rotem I, Rosenheck RA, Pietrzak RH, et al : Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans. J Nerv Ment Dis 2014 ; 202 : 97 – 104
59.
Hoerster KD, Malte CA, Imel ZE, et al : Association of perceived barriers with prospective use of VA mental health care among Iraq and Afghanistan veterans. Psychiatr Serv 2012 ; 63 : 380 – 382
60.
Rosen CS, Greenbaum MA, Fitt JE, et al : Stigma, help-seeking attitudes, and use of psychotherapy in veterans with diagnoses of posttraumatic stress disorder. J Nerv Ment Dis 2011 ; 199 : 879 – 885
61.
Stecker T, Fortney J, Hamilton F, et al : Engagement in mental health treatment among veterans returning from Iraq. Patient Prefer Adherence 2010 ; 4 : 45 – 49
62.
Sullivan G, Hunt J, Haynes TF, et al : Building partnerships with rural Arkansas faith communities to promote veterans’ mental health: lessons learned. Prog Community Health Partnersh 2014 ; 8 : 11 – 19
63.
Haynes TF : Religious Beliefs, Attitudes Toward Mental Health Treatment, and Mental Health Utilization Among Southern Rural African Americans. Doctoral dissertation. Ann Arbor, University of Michigan, Department of Psychology, 2010
64.
Pretty GH, Chipuer HM, Bramson P : Sense of place amongst adolescents and adults in two rural Australian towns: the discriminating features of place attachment, sense of community and place dependence in relation to place identity. J Environ Psychol 2003 ; 23 : 273 – 287
65.
Pruitt LR : Place matters: domestic violence and rural differences. Wisc J Law Gend Soc 2008 ; 23 : 346 – 416
66.
Cheesmond NE, Davies K, Inder KJ : Exploring the role of rurality and rural identity in mental health help-seeking behavior: a systematic qualitative review. Rural Mental Health 2019 ; 43 : 45 – 59
67.
The Future of US General Population Telephone Survey Research. Washington, DC, American Association for Public Opinion Research, 2017. https://www.aapor.org/Education-Resources/Reports/The-Future-of-U-S-General-Population-Telephone-Sur. Accessed Nov 27, 2018
68.
What Low Response Rates Mean for Telephone Surveys. Washington, DC, Pew Research Center, 2017. https://www.pewresearch.org/methods/2017/05/15/what-low-response-rates-mean-for-telephone-surveys. Accessed Nov 27, 2018
69.
Pyne JM, Rabalais A, Sullivan S : Mental health clinician and community clergy collaboration to address moral injury in veterans and the role of the Veterans Affairs chaplain. J Health Care Chaplain 2019 ; 25 : 1 – 19
70.
National Strategy for Preventing Veteran Suicide, 2018–2028. Washington, DC, US Department of Veterans Affairs, 2018. https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf
Information & Authors
Information
Published In
History
Received: 30 October 2019
Revision received: 14 July 2020
Revision received: 7 September 2020
Accepted: 10 September 2020
Published online: 11 March 2021
Published in print: May 01, 2021
Keywords
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This work was funded by HSR&D award IIR 11-290 from the Veterans Health Administration, and the VA South Central Mental Illness Research, Education, and Clinical Center. Dr. Curran was supported in part by grants UL1 TR-003107 and U54 TR-001629 through the Translational Research Institute from the National Center for Advancing Translational Sciences of the National Institutes of Health.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).