Understanding the “4 A’s” of rural mental health

Mental health services should be accessible, affordable, available, and stigma-free for all. Rural communities often face challenges with the provision of mental health services to those in need. Current literature finds four components that impact these challenges, and they are referred to as the “4 A’s”.  It is important for providers, clients, and support systems to understand each “A” for effective progress to be made in overcoming the obstacles faced by those with mental health care needs in rural communities.

The first of the four “A’s” is accessibility and focuses on the knowledge of how, when, and where to obtain services. Having access to mental health treatment is essential and there are many barriers that impact accessibility including transportation (long travel distances, lack of public transportation and cost), a lack of understanding of care options (mental health services availability/location), reduced/no provider choice (if there is a provider, it may be the only one leaving no choice), and a lack of culturally appropriate services (cultural barriers to access for individuals living in rural communities, such as values that are unknown or misunderstood). 

The second “A” is affordability, the costs associated with receiving care. The affordability of mental health treatment is a significant barrier and can impact the first “A”, accessibility as well. Affordability issues include financial and insurance status barriers that are problematic resulting from lack of money or insurance coverage as a result of poverty and unemployment or underemployment (if there is coverage such as Medicaid, providers may not accept it). Further, increased costs and low reimbursement rates for services are often issues in rural health settings (clinics may not want to provide mental health services when the cost of doing business is so high and reimbursement rates are low), and transportation costs (gas, insurance, maintenance, bus fare, etc.) can be prohibitive for both client and provider.

Availability is the third “A”.  Although research suggests the prevalence of mental health issues are similar in rural and urban settings, rural areas have limited availability of services. Several issues are in play with availability including practitioner shortages (higher levels of unmet need for mental health professionals exist in more rural counties) and lower income levels. Rural areas may appear less attractive to providers due to a lack of support from other professionals and lack of access to appropriate services. These practitioner shortages lead to three critical issues: lack of specialty providers (leading to everyone being treated the same and individual needs going unaddressed), lack of comprehensive services (specific interventions such as medication, therapy, support groups, and psychosocial education), and lack of access to pharmacies (for individuals to get the prescribed medications and ongoing refills needed for treatment).

The fourth and final “A” is acceptability which incorporates the constant issues related to the negative perceptions tied to the need for mental health services. Mental health issues are surrounded by stigma and that stigma is often felt more acutely in small, rural towns due to lack of anonymity…everyone knows everyone. This quote highlights this struggle, “…we as a society have a hard time asking for help, so it’s hard enough to ask for help without feeling that everybody’s going to know it. Your neighbors don’t have a clue in a city if you’re going to get some help. But everybody in a small town will know if your pickup truck is parked outside of the mental health provider’s office.” Lack of practitioner competence and understanding the culture of rural communities (the tight knit, supportive communities that exist) can be a problem. If a practitioner comes in and takes over, residents will run them right out of town if they lack competence for the rural culture. Lastly, the use of informal support networks for rural residents includes neighbors, family, and churches. These are all essential and valuable yet may keep someone from utilizing more formal services that can assist them in a professional manner. 

All of these A’s....Accessibility, Affordability, Availability, and Acceptability must be considered together when understanding challenges faced by rural communities related to mental health and as policy is crafted to overcome these challenges. Studies show the 4 “A’s” “lead rural residents with mental health needs to: enter care later in the course of their disease than do their urban peers; enter care with more serious, persistent and disabling symptoms and require more expensive and intensive treatment response.”

• Cohn, T.J. & Hastings, S.L. (2013). Challenges and Opportunities Associated With Rural Mental Health Practice. Journal of Rural Mental Health, Vol. 37, No 1,  37-49. 
• Lancet Commission Report, October 2018
• National Advisory Committee on Rural Health and Human Services, December 2017.
• National Rural Health Association Policy Brief,  February 2015.
• National Alliance on Mental Illness
• National Association of Rural Mental Health
• WICHE Mental Health Program

Mary E. Garrison
LCSW, ACSW, Professor of Social Work | Millikin University