Although substantial rates of mental health and substance use problems have been documented among rural homeless persons, efficacy of treatment interventions for these problems in diverse rural populations has not been demonstrated. Many structural, sociocultural, and personal barriers reduce access to rural services generally and to health services in particular (Strong et al., 2005). Although some of these barriers exist in urban settings as well, their impact may be disproportionately greater in resource-poor rural areas, and their impact on homeless and other indigent rural populations is likely to be more severe. Primary structural barriers in rural areas include geographic dispersion and low population densities that increase the cost of services per capita compared to urban areas. Other structural barriers include scarce services, especially for mental health and behavioral health care; inappropriate service models (e.g., urban-based models not adapted to the needs of people living in particular rural areas); lack of outreach to engage rural homeless persons in services; inaccessible health and other services (especially in small rural communities and frontier areas since service programs tend to concentrate in larger rural communities); fragmented systems of health care; lack of cultural competence on the part of program staff; lack of accessible transportation, with greatest impact on families with children and on disabled or older persons; insufficient numbers of health care professionals, particularly specialists; and lack of acceptance by program staff (Patton, 1988; Post, 2002; Strong et al., 2005).
In rural areas, primary care physicians are the main health care providers for persons with diverse health and behavioral health care problems, including comorbid medical, mental health, and substance use problems. These physicians may lack adequate training or experience to treat complex health problems in such a diverse patient population; further, healthcare settings may be understaffed. In many rural settings, recruitment of physicians may be limited to persons providing time-limited services as conditions of training programs, which may present cultural barriers and lack of continuity due to turnover of professional staff.
Sociocultural factors can reduce or delay help-seeking by rural families and individuals, especially for sensitive health and behavioral problems. Many rural communities are characterized by close social ties, reluctance to seek outside assistance, a desire for privacy (especially regarding sensitive problems such as domestic violence or alcohol, drug, or mental health problems), and a tradition of voluntary social support from the community (rather than from fee-based formal agencies) (Strong et al., 2005). Such structural, sociocultural, and personal barriers may result in less use of needed care due to delayed help-seeking. Such delays can lead to more severe symptoms and chronic health problems before the homeless person finally receives care (Post, 2002), which may then entail more intrusive or expensive treatment.
Major personal barriers to care have been reported by health care providers and others, including lack of financial resources and medical insurance; medical disabilities or behavioral health problems that reduce functional status or ability to navigate the available health care system; shame, hostility, or lack of trust, especially for mental health services; a tradition of dependence on self or family and friends; and cultural differences from service providers that may further limit the amount and quality of care available for medical and behavioral health problems (Patton, 1988; Post, 2002; Strong et al., 2005). For example, NSHAPC findings showed that homeless clients in rural areas nationally were less likely to have health insurance (including Medicaid) compared to clients in more urban areas. Furthermore, they were twice as likely as urban homeless clients to have missed getting medical care that they needed in the previous year (Burt et al., 1999). Many in the rural sample reported poor health and having histories of inpatient psychiatric treatment as well as residential treatment for substance use (Vernez et al., 1988). Despite higher apparent need for treatment, however, the rate of any mental health treatment was much lower in the rural county than in the more urban counties, including lifetime psychiatric hospitalization (in Yolo County, 14 percent among people with serious mental illnesses and 0 percent among others). Furthermore, none of the rural county homeless population with SMI had been hospitalized in the previous 12 months and few had received outpatient treatment (6 percent of SMI) or psychiatric medications (9 percent of SMI) in the previous 6 months (Vernez et al., 1988). In contrast, in the Ohio study, there were only minimal differences by county type in health status and utilization of emergency treatment and other health services, and of mental health problems (Roth et al., 1985; Roth & Bean, 1986). However, the urban adults were more likely to have been discharged with no arrangements for follow-up care (37 percent) compared to the non-urban group (24 percent) (Roth et al., 1985).