Addressing social determinants of mental health in medically underserved populations
About 14 million Americans live in medically underserved and rural areas. People who live in these areas are predominately minority groups.
Considering mental health is shaped by the different environments in which people live, including social, economic, and physical, people in underserved and rural areas are affected by social determinants that influence mental health negatively.
In this article, we explore the most common social determinants in medically underserved and rural areas and discuss potential solutions to alleviate mental health issues among these populations.
How to tackle 8 common social determinants of health inequalities
Various studies have discovered that social determinants influence the mental health of populations. Social determinants are evident across social inequalities, and medically underserved and rural populations are at the bottom of the disparities ladder. One or more social determinants can lead to poor life choices that result in mental health issues.
Below, we discuss 8 common social determinants of mental health in medically underserved and rural populations and how key players such as payers, providers, policymakers, and digital mental health vendors can create synergies to reach these vulnerable populations.
1. Poverty and income inequality
A systematic review analyzed the relationship between common mental disorders and poverty in low- and middle-income countries. The review discovered that 79% of 115 studies showed positive associations between various poverty measures and common mental disorders.
Payers can partner with Medicaid, the largest payer of mental health services, to incorporate reimbursement for digital mental health services and telehealth in low-income areas. Individuals in underserved populations should not need to pay out-of-pocket costs for mental health care.
2. Unemployment and job insecurity
A meta-analysis led by Frances McKee-Ryan, Ph.D., demonstrated that unemployment harms mental health. Researchers at the EMGO+ Institute for Health and Care Research in Amsterdam, Netherlands, also showed that financial strain is associated with having a depressive and/or anxiety disorder. People in medically underserved populations typically experience unemployment and job insecurity.
A study published in the Psychological Medicine journal showed that ‘job club’ interventions and cognitive behavior therapy (CBT) may prevent depression in certain people. Key players like payers, providers, and policymakers can integrate such programs into models of healthcare and through digital mental health vendors.
3. Lack of healthcare access and quality
The 2011 National Disparities Report showed that disparities in access to healthcare are common, especially in racial-ethnic minority groups. According to the report, American Indians or Alaska natives, Hispanics, Blacks, and Asians had worse access to care than whites for 62%, 63%, 32%, and 17% of access measures, accordingly.
Another study showed that racial-ethnic minority groups are 20%–50% less likely to initiate the use of mental health services, and 40%–80% are more likely to drop out of treatment prematurely.
Digital mental health vendors can partner with collaborative care models to improve access to mental health care, especially in medically underserved or rural populations where people lack transportation or resources to adhere to physical in-clinic appointments.
4. Shortage of providers
Only 10,000-20,000 psychiatrists exist in the United States, and only 25% of primary care practices have onsite mental health specialists of any sort. In addition, many providers who offer behavioral health services only offer out-of-network rates, which are significantly higher (500%-540%) than for primary care providers, according to a 2017 report by the Mental Health Treatment and Research Institute LLC.
Payers are becoming more aware of how costs contribute to mental health disorders. Two ways to alleviate costs include partnering with organizations to integrate medical and behavioral healthcare, i.e. the collaborative care model, and increasing reimbursement to providers based on value-based care.
5. No insurance coverage or Medicaid populations
Lack of insurance coverage limits access to care as many Americans cannot afford to self-pay. Individuals with incomes below poverty were four times as likely to lack coverage as those with incomes at 400% of the federal poverty level or above (17.3% vs. 4.3%).
Currently, Medicaid is the largest payer for mental health services in underserved populations. Private insurance companies should consider expanding their programs to cover more mental health services for these populations. In addition, providers should partner with digital mental health vendors to provide early identification services and scalable and accessible behavioral care for underserved populations.
6. Lack of access to technology resources and the internet.
The current COVID-19 pandemic has highlighted disparities in health care concerning access to technology. For example, a study conducted in primary care clinics showed that although telehealth video consults increased by 80% in late March and early April of 2020, only a small percentage of consults were by minorities. A lack of Internet availability partly contributed to the lack of technology access.
Policymakers should establish programs that improve connectivity in underserved and rural areas. Case studies: According to the National Conference of State Legislatures, the Federal Communications Commission’s Rural Health Program offers funding for rural health providers to improve and expand their online connectivity. Also, the Georgia General Assembly approved a tax bill that raises money to fund high-speed internet service in rural areas of the state.
7. Lack of education
Lack of education can result in low health literacy, which is a barrier to getting effective health care. Individuals who are uneducated or receive minimal education typically have low health literacy. Literacy surveys show that adults without a high school diploma or GED, with health-related restrictions, with limited access to resources, who are members of minority population groups, and who are immigrants have lower health literacy skills than others.
Digital mental health vendors can provide robust screening programs to identify individuals with low health literacy. Providers can then partner with digital mental health vendors to offer materials that are suitable for each patient.
8. Housing instability
A study on children showed that growing up with food insecurity and housing instability increases the risks for anxiety or depressive symptoms during adolescence. This reveals that mental health issues do not always begin in adulthood. Instead, social determinants during early childhood are generally predictors of the future. According to the CDC, the context of where a person lives matters.
Policymakers can work toward creating economically integrated neighborhoods. According to the National Alliance on Mental Illness (NAMI), one way to do this is to relocate residents to less impoverished neighborhoods, thus improving access to mental health care. Another way to improve housing stability is to increase access to affordable housing.
Summary
To tackle social determinants in underserved and rural communities, synergies should be developed between key players such as payers, providers, policymakers, and digital mental health vendors to reach these vulnerable populations.
The social determinants of the health framework affect populations outside the four walls of the hospital. Therefore, key players must collaborate to offer better resources that enhance the quality of life for underserved and rural populations.
Examples of better resources include:
- Offering higher reimbursements for value-based care
- Incorporating CBT services for the unemployed
- Integrating mental health care using the collaborative care model
- Expanding insurance programs to cover more mental health services
- Offering funding for rural health providers to improve and expand their online connectivity
- Providing robust screening programs to identify individuals with low health literacy
- Creating economically integrated neighborhoods
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