title: Overcoming Barriers to Sustained Engagement in Mental Health Care: Perspectives of Rural Veterans and Providers.
abstract: To better understand the attitudes, beliefs, and values that influence use of mental health care among rural veterans.
  
  
  
  In-depth, semistructured interviews were conducted with 25 rural veterans and 11 rural mental health care providers in 4 states. Experienced qualitative interviewers asked participants about the attitudinal factors they thought most influenced rural veterans' decisions to seek and sustain mental health care. Verbatim transcriptions were analyzed using content analysis and constant comparison.
  
  
  
  Rural veterans and their mental health care providers reported the same major attitudinal barriers to veterans' mental health treatment-seeking. Pre-eminent among those barriers was the importance rural veterans place on independence and self-reliance. The centrality of self-reliance was attributed variously to rural, military, religious, and/or gender-based belief systems. Stoicism, the stigma associated with mental illness and health care, and a lack of trust in the VA as a caring organization were also frequently mentioned. Perceived need for care and the support of other veterans were critical to overcoming attitudinal barriers to initial treatment-seeking, whereas critical facilitators of ongoing service use included "warm handoffs" from medical to mental health care providers, perceived respect and caring from providers, as well as provider accessibility and continuity.
  
  
  
  Attitudes and values, like self-reliance, commonly associated with rural culture may play an important role in underutilization of needed mental health services. System support for peer and provider behaviors that generate trust and demonstrate caring may help overcome attitudinal barriers to treatment-seeking and sustained engagement in mental health care among rural veterans.
authors.affiliation: Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas. FischerEllenP@uams.edu.|Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas. FischerEllenP@uams.edu.
authors.forename: Ellen P
authors.initials: EP
authors.lastname: Fischer
authors.affiliation: College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
authors.forename: Jean C
authors.initials: JC
authors.lastname: McSweeney
authors.affiliation: College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
authors.forename: Patricia
authors.initials: P
authors.lastname: Wright
authors.affiliation: Department of Social Medicine & Population Health, University of California, Riverside School of Medicine, Riverside, California.
authors.forename: Ann
authors.initials: A
authors.lastname: Cheney
authors.affiliation: Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas.|Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.|Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
authors.forename: Geoffrey M
authors.initials: GM
authors.lastname: Curran
authors.affiliation: Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas.
authors.forename: Kathy
authors.initials: K
authors.lastname: Henderson
authors.affiliation: Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.|Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington.
authors.forename: John C
authors.initials: JC
authors.lastname: Fortney
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology*; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D036301:Qualitative Research; D012424:Rural Population; D035502:Trust / Q000523:psychology; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration; D014728:Veterans / Q000523:psychology*
keywords: mental health care; peer support; self-reliance; trust; veterans