Improving Access to Mental Health Resources in Rural and Remote Regions

Challenges Accessing Mental Health Services in Rural and Remote Communities: A Review of the Literature 

By Melissa Masse, Hilary Nelson & David Nicholas 
Faculty of Social Work, The University of Calgary 
January 21, 2023 

Executive Summary

Compared to urban centres, rural and remote communities in Canada are disproportionately affected by barriers to accessing mental health services. Insufficient mental health service access in rural and remote communities is identified as a pressing issue. Several factors are identified as barriers, including less available trained professionals in communities, implications of funding models, and the diverse needs of a non-homogenous population, particularly when considering the additional impact of neuro-developmental disabilities. Addressing Social Determinant of Health barriers may be particularly challenging and nuanced in rural and remote communities due to the limited resources, and the interplay of relevant factors related to population size, disability and rurality. 

The literature offers various considerations for mental health care provision to address challenges in rural, remote and Northern communities, including the need to address and incorporate traditional and culturally safe services for Indigenous communities. Identified care approaches include: (1) the ‘fly-in and fly-out’ model, (2) telehealth and virtual models of care, (3) collaborative models of mental health, (4) community-based approaches to mental health, and (5) the Extension for Community Health Care Outcomes (ECHO) model. Variable benefits and limitations of these approaches are considered. 
There is a limited but emerging body of literature addressing intersecting factors of neuro-developmental disability, mental health, services, and rurality/remoteness. Community-focused research and innovation in practice and service delivery approach are warranted in advancing mental health service delivery in rural and remote communities. 

Introduction 

Rural and remote communities in Canada are disproportionately impacted by barriers to accessing mental health services in comparison to urban communities (Beks et al., 2018; Canadian Institute for Health Information, 2019; Mental Health Commission of Canada, 2021). In 2002, the Canadian Community Mental Health Survey indicated higher rates of reported depression and use of mental health services in urban populations. However, in rural and remote populations, individuals were significantly less likely to self-report mental health concerns (Romans et al., 2011). Compared to urban populations, poorer mental health outcomes, poorer physical health, decreased use of mental health services, and increased incidents of suicide have been documented in rural and remote communities (Romans et al., 2011; Caxaj, 2016). Given limitations and gaps in current research, this review focuses broadly on mental health in rural and remote communities in Canada. Existing literature can provide a foundation for further examination of the mental health needs of, and resources for, rural dwellers with co-existing developmental disability.  

Strengths and Challenges in Rural Mental Health Support 

There often is a sense of community and social connection in rural and remote populations (Romans et al., 2011), potentially a protective factor supporting mental health. However, rural and remote communities in Canada also face barriers to accessing healthcare (e.g., lack of sufficient local services, the need for significant travel which may be complicated by limited access points and weather restrictions that create time and heavy cost burdens for individuals and families) (Kreitzer et al., 2016). These challenges in accessing appropriate healthcare have further deleterious implications on mental health due to a noted association between poor physical health and the occurrence of depression (Romans et al., 2011). 

While the availability of local healthcare and service provision is not specific to mental health, awareness of the need for more local and high-quality service provision has placed greater focus recently on recruitment and retention of professionals and means to increase the accessibility of mental health services in rural and remote communities (Roberts, 2022; Macleod et al., 2022). Common challenges identified by professionals working in specialized mental health services in rural or remote communities include high demands due to travel to reach populations, community stigma about mental health, disproportionately high rates of exposure to violence in the workplace with no or minimal access to hospital security or violence protocols, limited resources for professional development (Macleod et al., 2022), vicarious trauma, and burnout (Roberts, 2022). Kreitzer and colleagues (2016) noted that when service users have co-occurring developmental disabilities with mental health concerns, they face additional barriers including a lack of staff training and expertise, difficulties coordinating and navigating services, and low staff retention that harms relationships between services providers and users.  

While healthcare funding and service models vary across Canada, they have important implications for mental health care access in rural and remote communities. Healthcare funding models may not effectively account for the additional costs of providing services across large geographic areas, inequitable access to services, and health disparities found in rural and remote locations (Canadian Mental Health Association, Ontario, 2009). While literature universally indicates there is a need for increased mental health funding (Mental Health Commission of Canada, 2017) and integrated approaches (Sutherland & Hellsten, 2017), limited research exists that evaluates the implications of federal, provincial, and territorial funding and service models for mental health in rural and remote communities.   

Diverse Populations 

In addressing mental health and mental health care, it is important to note that the experience of mental health is not a homogenous phenomenon. Within rural and remote communities, a wide range of identities exist (as elsewhere), including those related to race, culture, age, gender, ability, and sexuality; each of which present unique considerations and may contribute to mental health/well-being challenge and experiences of mental health care.  

Impact of Race and Culture 

Canadian literature addressing the impact of race and culture on mental health in rural and remote communities is limited. While there has been some focus on Indigenous populations, other racial and cultural groups are largely absent in the literature, thus hindering the critical consideration of the impacts of immigration and newcomer status and/or other related social determinant barriers on mental health and mental health care for these populations in rural and remote communities.  

The literature highlights the need to consider how to facilitate timely, effective, and equitable mental health service provision for Indigenous children and youth in line with Jordan’s Principle (Walker et al., 2018), which promises access to needed supports to all First Nations children in Canada. Of note, many First Nations, Métis, and Inuit people live in rural and remote regions in which services likely are not as accessible as in urban communities. The impact of colonialism, intergenerational trauma, and ongoing oppression and discrimination negatively impacts mental health and amplifies the need for culturally safe mental health service provision (Mental Health Commission of Canada, 2021; MacLeod et al., 2022; Assembly of First Nations & Health Canada, 2015).  

Yet generally, Indigenous communities experience insufficient local services. The presence of and frequent exposure to deep-rooted trauma in small communities has been identified as an additional barrier to the provision of adequate local services. While requiring a highly specialized skillset, the often-shorter tenure and turnover of service providers can be a challenge in these communities (Roberts, 2022). Consideration of Indigenous populations within the literature predominantly focuses on models of care to meet specialized mental health needs, which will be addressed in greater detail in this review. 

Impact of Age 

Diversity across the lifespan presents unique considerations regarding mental health and mental health service provision. However, the impact of age relative to mental health in rural and remote communities is under-represented in the literature. While youth and older adults each have unique known mental health vulnerabilities based on their respective life stages, reference to these specific populations is largely missing in the literature on rural and remote mental health.  

An estimated 15% of children and youth live with a diagnosed mental illness in Canada, and in that group, less than 20% are receiving services (Mental Health Commission of Canada, 2022). The limited number of studies that focus on youth in rural and remote communities in Canada tend to have small sample sizes, and specific contextual foci based on community mental health resources and needs (Dabravolskaj et al., 2021; Matthias et al., 2021). Notwithstanding these limitations, there are indicators of barriers and facilitators for youth accessing mental health resources in rural and remote communities. Of concern however, there is little recognition of intersectionalities of neuro-developmental disability, mental health and rurality as a focus of research, with even fewer studies accounting for factors such as development or age. 

Barriers identified include difficulty accessing services within the community, transportation issues, stigma, and a lack of privacy (Mathias et al., 2021). In a sample of high school students, services offered within schools were noted to be preferred over community-based services, as school services increased accessibility and independence from parents (Mathias et al., 2021). Key identified facilitators include family members, flexible service providers, and informal community support (Mathias et al., 2021). Utilizing a comparative framework of youth mental health in a northern community before and during COVID-19, one study indicated the importance and effectiveness of proactive mental health programming in schools, and recommended drawing on rural communities’ strengths to foster and maintain positive mental health despite stressors associated with the pandemic (Dabravolskaj et al., 2021).  

At the other end of the age spectrum, there is limited research available on the mental health of older populations in rural and remote areas. Only one study was found that specifically identifies the impacts of mental health and mental health service provision on older populations (Herron et al., 2022). While specific to the COVID-19 pandemic, the findings indicate the importance of community integration (e.g., community spaces; opportunities for socialization; recreation and exercise; contribution to family, community and organizations) to support older adults in fostering resiliency and mental health (Herron et al., 2022). How this may be uniquely experienced and nurtured in neuro-developmental disability populations warrants further study.

Impact of Gender and Sexuality 

There has been a limited research focus on the differences and disparities in mental health and services relative to sex and gender particularly in rural and remote regions. In Canada, males account for 4 out of 5 deaths by suicide (Creighton et al., 2017; Herron et al., 2020). Additionally, males who live in rural communities are less likely to access mental health supports than are men in urban communities. Research has focused on rural men’s experiences accessing mental health services, perceptions of masculinity, and the role of relationships and rural locales in understanding and addressing disparities (Ahmadu et al., 2021; Creighton et al., 2017; Herron et al., 2020).  

Identified needs for change at community and societal levels include increased local mental health services, and greater means of encouraging vulnerability and openness amongst rural men (Creighton et al., 2017). While many “rural men want to talk about mental health and align their perceptions of masculinities with healthier [mental health] practices,” most participants in one study avoided talking about mental health due to feelings of shame (Herron et al., 2020, p. 7). Place-based ideals of masculinity played a significant role in men concealing depression, thoughts of suicide, and alternate sexual identities (Creighton et al., 2017). 

The research indicates that natural support networks (e.g., friendships, partners/spouses) and the ability to consistently access support services gradually over time has helped to create spaces where men’s mental health can be discussed (Herron et al., 2020). Additionally, men identified outdoor spaces and nature, outdoor activities and sports, and workplaces as therapeutic spaces where they could find belonging and social connection (Ahmadu et al., 2021).  Men shared that a sense of wellness can often be attributed to places and opportunities to help others and/or have a contributing role. It was noted that the loss of community spaces, rural decline, and lack of anonymity in rural settings impose barriers to environments that promote mental wellness (Ahmadu et al., 2021).   

Aside from the brief mention of the interplay between male gender, mental health and sexuality (Creighton et al., 2017), consideration of diverse sexual and gender identities in rural and remote settings were not found in this literature review, nor were the additional layer of sex/gender and developmental disability as intersecting factors in mental health and rurality. Considering the high rates of mental health struggles in LGBTQ2S+ communities, this lack of research, practice and societal attention represents a noticeable gap in the literature requiring future research.

Additional Considerations

Research demonstrates a correlation between mental health challenges and Social Determinants of Health barriers such as, among other determinants, insufficient housing, food insecurity, and inadequate access to medical services (Mental Health Commission of Canada, 2021). Addressing Social Determinants of Health barriers may be particularly challenging and nuanced in rural and remote communities due to the resource constraints (McCauley et al., 2015; Mental Health Commission of Canada, 2021), and the complexity of the interplay of relevant factors related to population size/rurality and neuro-developmental disability. More research is required to understand the integration of the Social Determinants of Health in population needs and mental health service provision, with focused research and practice attention on neuro-developmental disability in rural and remote communities. It is likely that small populations and limited funding for rural mental health make it more difficult to comprehensively address the nuanced and unique needs of populations requiring specialized services and healthcare provider expertise, such as those with neuro-developmental disabilities. Accordingly, further attention to viable approaches is warranted, including training/capacity building, service provider access and retention, and the use of technology in rural service delivery. 

Rural Models of Care  

The literature in rural mental health services offers various approaches of care to address needs, challenges and opportunities in rural communities. There is also a consideration for how models of care can be accommodate traditional and culturally safe mental health services for Indigenous communities. Below are examples of approaches that emerged in this review. 

Fly-In and Fly-out Models  

Fly-in and Fly-Out (FIFO) models of care have been described from the perspective of service providers to address the impact of consistent exposure to high rates of violence and intergenerational trauma in some small communities. Early research indicates that this approach is implemented as a resource to address high rates of vicarious trauma and burnout experienced by service providers working in remote communities (Roberts, 2022). FIFO models of care address the systemic challenge of recruiting and retaining trained service providers to work in remote communities (Roberts, 2022).  

While the FIFO approach may offer protective factors for service providers, reviewer feedback commented on drawbacks of this model such as the lack of ability to provide support between visits, the lack of ability for professionals to provide ongoing mentorship to front-line staff such as intervention workers, etc. Also, it was noted by a reviewer that this approach is expensive, and many FIFO staff may be from urban areas and may be less able to build trust and common ground with local cultures and/or not understand the local culture. This may lead to solutions/goals that may not be ecologically valid or viewed as culturally safe or “doable.”.  

Telehealth/Virtual Models of Care  

Virtual models of care exist across Canada, but may be widely under-utilized (Caxaj, 2016; Jong et al., 2019; Simms et al., 2011). Telehealth offers mental health care in regions with limited access to professionals and support services. Research demonstrates that telehealth options may effectively facilitate specialized consultation and reliable diagnostic provision, reduce waitlists, reduce travel, increase confidentiality, reduce hospitalization, and reduce stigma related to seeking mental health support (Caxaj, 2016; Jong et al., 2019; Simms et al., 2011; Dyck & Hardy, 2013). In addition, telehealth models can significantly reduce costs related to health provision in remote communities, as it decreases the need for travel and accommodation in other locales (Jong et al., 2019). For professionals, teleconferencing can reduce isolation and facilitate increased educational opportunities (Caxaj, 2016).   

It is noted that for telehealth models to be successful, they need to be integrated within existing rural healthcare models and community resources (Caxaj, 2016). Technology and internet connectivity must be addressed in remote communities to avoid health disparities by region. Other identified considerations and challenges relative to telemedicine include a lack of professional training, legal and ethical concerns, variable perceptions of telehealth, risks related to high-risk cases, and considerations related to safety protocols if a crisis or emergency occurs during a call (Caxaj, 2016; Gibson et al., 2011; Simms et al., 2011; Dyck & Hardy, 2013). Reviewer feedback also identified concern about service provider utilization of platforms that comply with privacy legislation. 

The literature notes a lack of comparative studies on telehealth in rural and remote communities relative to other care approaches (e.g., face-to-face services). Additionally, further research is needed to explore rural telemedicine users’ experiences and outcomes (Dyck & Hardy, 2013).   

Telehealth in Indigenous Communities  

Research addressing telehealth care models in Indigenous communities indicates that telepsychiatry could reduce systemic barriers and disparities in access to health care, and integrate specialized mental health services with culturally relevant community supports (Caxaj, 2016; Gibson et al., 2011; Jong et al., 2019; Dyck & Hardy, 2013). Telehealth allows community members to remain in their communities and culture while accessing services. Successful models of Indigenous-led telehealth have incorporated traditional practices and beliefs into videoconferencing, facilitating trust and acceptance of the model (Gibson et al., 2011). A reviewer further noted the importance of considering preference/comfort related to camera use in online engagement. 
 

Collaborative Models of Mental Health   

Collaborative models of mental health practice are an emerging response to the challenges of meeting the mental health needs of rural and remote communities across Canada (Goodwin et al., 2016). The literature identifies multiple models of collaborative approaches to mental health, including incorporating mental health in primary care, interprofessional mental health teams, integrated Indigenous care, and coordinated care between multiple service providers and systems (Brinkman et al., 2009; Caxaj, 2016; Goodwin et al., 2016; Maar et al., 2009; Reaume-Zimmer et al., 2019; Romans et al., 2010).  

Research demonstrates that collaborative approaches to rural mental health care can improve patient outcomes, increase accessibility to services, decrease social stigma, and increase continuity of patient-centred care (Caxaj, 2016; Goodwin et al., 2016; Brinkman et al., 2009). Primary practitioners also may benefit from increased knowledge of mental health. In addition, collaborative approaches to mental health care can enable practitioners to address the correlation between poor physical health and mental illness (Romans et al., 2010; Caxaj, 2016). Finally, collaborative care models have been implemented to provide accessible and effective mental health care for vulnerable groups, including youth (Reaume-Zimmer et al., 2019).  

Approaches to the implementation of collaborative approaches vary widely. A rural context may make co-location, coordinated support, use of a mental health liaison, and communication more feasible. However, limited budgeting, staffing, and access to specialized services may hinder the development and maintenance of the integration of mental health services (Caxaj, 2016; Brinkman et al., 2009). Also identified is a need to reframe traditional care models from psychologist-led interventions to a shared leadership model with the involvement of paraprofessionals (Goodwin et al., 2016). Incorporating collaborative approaches into post-secondary education is offered as one way to encourage systematic changes (Goodwin et al., 2016; Paquet et al., 2022).  While appearing promising in the context of neuro-developmental disability, further research, application and consideration of outcomes in this population are warranted.
 

Collaborative Models in Indigenous Communities   

Many Indigenous communities have implemented interdisciplinary healthcare teams in response to limited resources and the need to integrate cultural wisdom and community knowledge (Goodwin et al., 2016). Collaborative approaches in rural and remote Indigenous communities have indicated positive outcomes, including increased access to mental health services, continuity of care, culturally safe care, and effective integration of cultural and clinical services (Maar et al., 2009). In one example from Manitoulin Island in Northern Ontario, integrated care is provided through a holistic Indigenous framework that addresses physical, mental, emotional, and spiritual dimensions of health (Maar et al., 2009). The team is comprised of clinical staff and traditional healing services in collaboration with other sectors, including social services.   
The literature identifies emergent ways of strengthening collaborative approaches to mental health, including enhancing cultural competency for professionals and overall community capacity building (Maar et al., 2009). However, due to resource limitations, integrated programs may still have to refer clients outside Indigenous communities where they may not receive holistic care (Maar et al., 2009). Moreover, a lack of integrated training regarding neuro-developmental disability impedes specialized training in neuro-developmental disability and mental health. Further, a reviewer suggested further exploration regarding support for academic training or other means to equip local individuals to become mental health professionals. A question was posed regarding whether training of local individuals may result in greater the likelihood of them returning to or remaining in their communities, with implications for recruitment and retention. 

Community-based approaches to mental health   

The literature highlights the unique nature of rural communities, and the need to develop community-specific approaches that are responsive to local/regional strengths, resources and challenges (Caxaj, 2016; Young et al., 2019). In rural communities, residents, the voluntary sector, community-based organizations, social services, and culture may play a meaningful role in developing multi-faceted approaches to mental health support (Caxaj, 2016; Young et al., 2019). Community-based approaches also consider Indigenous communities and the need to address the colonial legacy, intergenerational trauma, and health disparities within mental health services. Additionally, a community-based approach may more likely enable greater inclusion of Indigenous community members while providing culturally appropriate care (Caxaj, 2016).  

Building from a community-based approach, reviewers noted the importance of collaborative relationships with Indigenous community leaders/organizations and the opportunity to use the strength of existing community ties to support interested community members to seek education and training opportunities to fill the professional mental health roles. One recent Alberta study highlights the positive impact of exposure to communities and rural practice through rural rotations built into profession training as a potential contributor to graduates choosing non-urban practice (Paquet et al., 2022).  

Extension for Community Health Care Outcomes (ECHO) Model 

The Extension for Community Health Care Outcomes (ECHO) is an education-based model aimed at expanding the knowledge and skills of primary healthcare providers through ongoing virtual access to expert interdisciplinary teams (Project ECHO Ontario, 2019; Serhal et al., 2022). The ECHO model was developed to address regional health disparities and improve care for people living in rural and remote regions without the requirement to travel out of their community (Serhal et al., 2022; Lunsky et al., 2022). The model is currently used in four Canadian provinces to support optimal patient care with mental health and addictions, including Ontario, Quebec, Newfoundland, and British Columbia. 

The province of Ontario has the most extensive mental health focused program in Canada utilizing the ECHO model, called Project ECHO Ontario Mental Health. Since launching in 2015 (based on a reported in 2017), the program engaged over 4,100 healthcare providers and 1,600 organizations (Project ECHO Ontario Mental Health, 2017). Studies evaluating the program's effectiveness demonstrate high retention and satisfaction of primary care providers, increased knowledge and skills to support improved mental health care, substantial cost savings, and ongoing program sustainability (Serhal et al., 2022; Sockalingam et al., 2018). While these studies offer insight into the ECHO model's ability to increase patient outcomes and support primary healthcare practitioners in Canada, further research would add insight into its application/integration within rural and remote communities. However, international research indicates that the ECHO model may improve rural patients' mental health outcomes (Komaromy et al., 2019).  

In the context of neuro-developmental disability, the ECHO model offers an approach to reduce barriers to healthcare often experienced in rural and remote communities, including the limited knowledge of healthcare providers and the lack of access to specialist care (Dreiling et al., 2022; Lunsky et al., 2022; Mazurek et al., 2017). For example, in Ontario the ECHO model has been adapted to build the capacity of both the healthcare and social service sectors to support the mental health needs of adults with intellectual and developmental disabilities (ECHO-AIDD) (Lunsky et al., 2022). The pilot evaluation of ECHO-AIDD indicates that it helped practitioners feel supported and influenced positive change in their practice (Lunsky et al., 2022). In addition, organizations in the United States have utilized the ECHO model to facilitate increased access to mental health services for autistic individuals (Dreiling et al., 2022).  

Conclusion  

Existing studies offer guidance and inform future research and strategy development. There is a limited but emerging body of literature addressing intersecting factors of neuro-developmental disability, mental health, services, and rurality/remoteness. Community-focused research and innovation are warranted in advancing approaches and methods for mental health service delivery in rural and remote communities. 

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