Scoping Review: Perceived Needs, Barriers, Facilitators, and Satisfaction With Access and Utilization of Mental Health Services Among Rural Adolescents and Parents in the United States

Abstract

Objective

Adolescents in rural communities in the United States experience significant disparities in mental health service access and utilization. To inform service development and expansion, this scoping review identified the self-reported needs, barriers, and facilitators to accessing and using mental health care services of rural adolescents (ages 12-18) and parents and their satisfaction with services received.

Method

Following a preregistered protocol, 14 databases and repositories were searched from database inception to the present. Records underwent dual screening and extraction, with disagreements resolved by consensus. Studies on US-based rural adolescents and/or parents that identified perceived needs, barriers, facilitators, and service satisfaction were included.

Results

Of 6,437 citations, 70 studies met the inclusion criteria. Service needs/preferences were reported for location and provider type (n = 22), specific treatment targets and delivery models (n = 19), service quality (n = 16), and supports for accessing care (n = 10). Barriers to service access/utilization were identified for service accessibility (n = 27), stigma/negative beliefs (n = 26), service quality (n = 12), and social barriers (n = 6). Youth and parents reported interest in settings, providers, and types of supports that are outside of traditional mental health service settings. They expressed interest in greater use of telehealth and availability of preventive interventions. Youth reported a need for services for depression and anxiety, parents requested parenting support, and both indicated a need for more services for substance use disorders. Families of minoritized backgrounds identified needs for culturally relevant services, multilingual providers, and providers with shared identities.

Conclusion

This review curates a list of US-based rural adolescents’ and parents’ self-reported needs, barriers, and facilitators for access to inform service quality improvement and future research.

Study registration information

Perceived needs, barriers, and facilitators to accessing mental health care among rural adolescents and their caregivers: A scoping review; https://osf.io/3unfv

Plain language summary

To guide mental health services for youth in under-resourced rural areas, this scoping review examined the needs of adolescents and parents, as well as barriers to accessing care. There was an expressed preference for supports outside traditional clinical settings, including telehealth, preventive programs, services for depression and anxiety, parenting support, and more services for substance use disorders. Families from minoritized backgrounds emphasized the need for culturally competent, multilingual, and identity-matched providers.

More than 4 million adolescents in the United States live in rural areas, and they experience significant mental health disparities.¹ Rural adolescents have higher rates of depression, anxiety, suicide, substance use disorder, and behavior problems than adolescents living in urban communities.2, 3, 4, 5 They are also significantly less likely to receive needed mental health care.⁶ More than two-thirds of Health Professional Shortage Areas, federally designated as lacking adequate mental health professionals, are in rural areas.⁷ Rural youth and families also underuse mental health services that are available to them,⁸ owing in part to higher poverty rates, varied insurance coverage, stigma, and concerns about privacy.^1,9 To address the complexity of rural mental health disparities for youth, a comprehensive approach that is attentive to the range of influential factors is needed. Community engagement is critical to this effort, ensuring the perspectives of rural youth and families are represented in the identification of mental health care challenges and solutions alike.¹⁰

This scoping review synthesizes the research on perceived needs, barriers, and facilitators to accessing and using mental health care services reported by rural adolescents and parents and their satisfaction with care received. The goal is to learn what types of services families want and need in regard to intervention targets, setting, modality, and type of provider, as well as their perceptions of key barriers to accessing care and potential facilitators. We focus on adolescents because their stage of development represents a period of both increased risk and opportunity for mental health. As adolescents move toward greater autonomy and independence, they are exposed to a wider array of stressors.¹¹ This increase in stressful events, in combination with greater emotional lability and neural systems involving emotion regulation and decision making that are not fully matured, place adolescents at increased risk for psychopathology.12, 13, 14 However, because adolescents’ brains are still developing, they may also be particularly receptive to the positive influences of mental health supports and services.¹⁵ Adolescents also begin to have more input in making decisions about their own mental health care, and there are some services and supports that they can access on their own without parent consent. Thus, it is important to understand their perspectives and service preferences in addition to the perspectives and preferences of their parents. This review also aims to identify any differences in the attitudes of adolescents and parents.

Method

Our scoping review was conducted in accordance with JBI Scoping Review Methodology Group guidance and is reported per the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews (PRISMA-ScR).^16,17 Our a priori protocol can be accessed at https://osf.io/3unfv/?view_only=00b36463bb654662817de6295121e412.

Research Questions

This review aimed to identify the following:

• 1.Rural adolescents’ and parents’ preferences and perceived needs regarding intervention targets, setting, modality, and provider type
• 2.Practical and attitudinal barriers to the initiation and engagement with services
• 3.Facilitators of mental health service use
• 4.Satisfaction with services received
• 5.Similarities and differences in adolescent and parent attitudes toward accessing mental health services

Identifying Relevant Studies

All searches were designed and executed by research librarians with input from content and methods experts on the team. The strategies¹⁶ used combinations of controlled vocabulary and natural language representing the concepts of patient needs, mental and behavioral health, and adolescents. The following databases were searched: Medline (Ovid), APA PsycInfo (Ovid), CINAHL Plus with Full Text, Scopus, Web of Science Core Collection, Ethnic NewsWatch, Bibliography of Indigenous Peoples of North America, Education Source, ERIC (EBSCOhost), and Social Services Abstracts. An initial search strategy was created for Medline and then adapted across the other databases, making use of unique controlled vocabularies and search functionalities. Searches were executed in March 2022 and rerun in December 2023. Owing to a lack of access to translation services, English language filters were applied where available. Full details of the search strategies can be found in the online supplemental materials.

To locate gray literature, we also searched the following websites and online repositories: Rural Health Research Gateway (https://www.ruralhealthresearch.org/), Rural Health Information Hub (https://www.ruralhealthinfo.org/), Native Health Database (https://nativehealthdatabase.net/), and PsyArXiv (https://osf.io/preprints/psyarxiv). The reference lists of included articles were also reviewed. The complete search strategy is provided in Figure S1, available online.

Study Selection

Studies were included if the sample included adolescents (age 12-18) or parents/caregivers of adolescents; the sample included individuals living in rural areas in the United States (study defined sample as rural or study location indicated a rural setting based on Office of Management and Budget definitions of rural¹⁸); and the study measures included preferences, perceived needs, barriers, and/or facilitators to accessing mental health care or service satisfaction. Any type of mental health–focused service or support identified by adolescents or their parents/caregivers was eligible for inclusion. Studies that examined children and adolescents together (ie, ages 0-18) or adolescents and adults together (ie, ages >12) were included if results for our age range of interest were presented in the article. Studies that reported results of adolescents combined with other age groups were summarized separately from the adolescent-only studies and were compared with the results of the studies that included only adolescents. Peer-reviewed journal articles, dissertations, and reports from government entities or foundations were included in this review. Studies were excluded if youth were outside the age range of 12 to 18; youth or parents/caregivers of youth did not live in rural areas in the United States; the study was not published in English; or the study did not present original data (eg, editorials, opinion pieces, literature reviews).

Study records were uploaded into Covidence¹⁹ and automatically deduplicated. The first round of screening reviewed titles and abstracts. The screening process included 12 reviewers, with each reference scored by 2 reviewers who were blinded to the other’s decision. Reviewers met to reach consensus, and the first author (M.G.-S.) made the final decision if no consensus could be achieved. A second round of screening reviewed the full text of the studies. Disagreements were resolved by the first author (M.G.-S.).

Charting the Data

All data were independently extracted by pairs of reviewers. Extracted data included study identification number, title, authors, year of publication, type of document (peer-reviewed journal article, dissertation, government/foundation report), study design (surveys, focus groups/interviews, clinical trial, program evaluation), type of participant (youth, parent, both), study eligibility criteria, study definition of rural, mental health concern/diagnosis, sample size, participant demographics (average age/age range, sex/gender, race/ethnicity, average income), preference or perceived needs for services, perceived barriers to accessing care, perceived facilitators to accessing care, and satisfaction with services received. Discrepancies between reviewers were identified and resolved by the first author (M.G.-S.).

Collating, Summarizing, and Reporting Results

Results were organized into tables. Reviewers collated common research themes and findings across studies. Themes and interpretations were discussed for consensus among all coauthors.

Results

Literature Overview

The initial search identified 6,437 references following removal of duplicates (Figure 1). Of the initial 6,437 references, 6,077 were excluded after title and abstract screening, and 290 were excluded based on full-text review. The criteria for inclusion in this review were met by 70 studies (see Table S1, available online, for study summaries).20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89 Of these 70 studies, 56 were peer-reviewed articles, and 14 were gray literature. Selected studies used the following study designs: surveys (19 studies), focus groups/interviews (21 studies), mixed methods (3 studies), clinical trial (open or randomized) (13 studies), program evaluation (13 studies), and case study (1 study). The selected studies were also categorized by age group focus: adolescents (ages 12-18) (26 studies); children and adolescents (21 studies); adolescents and adults (10 studies); children, adolescents, and adults (8 studies); and youth (age not reported) (5 studies). Figure 2 depicts the distribution of age group by study design, participant (youth, parent, or both), and sample size. Within the selected studies, 26 studies focused on minoritized populations. These included American Indian/Alaska Native (14 studies), Black (4 studies), Latino (2 studies), and LGBTQ+ (3 studies) populations (Figure 3).

Figure 1.

Study Selection Flow Chart

Figure 2.

Bubble Plot: Age Group by Study Design and Sample Size and Respondent

Note:For studies with sample size less than 10 participants or greater than 200 participants, the value of the sample size was winsorized at 10 participants and 200 participants, respectively, to scale the size of the bubbles for east of visual interpretation.

Figure 3.

Bubble Plot: Age Group by Study Design and Sample Size and Population

Note:For studies with sample size less than 10 participants, the value of the sample size was winsorized at 10 participants and 200 participants, respectively, to scale the size of the bubbles for ease of visual interpretation. LGBTQ+ = lesbian, gay, bisexual, transgender, queer, and others.

Within the clinical trials, program evaluations, and case reports, a number of mental health services and interventions were examined (some studies included multiple services or interventions). These included cognitive-behavioral therapy (CBT) (6 studies), other skills-focused programs (9 studies), parenting/family-based programs (9 studies), therapy/counseling (modality not defined) (4 studies), interagency care coordination (4 studies), medication (4 studies), psychoeducation (1 study), and animal-assisted therapy (1 study). In these studies, 17 interventions were delivered in person (9 in schools, 2 in primary care clinics, and 6 in other community settings), 8 were delivered via telehealth, and 3 were delivered digitally (website, social media, or text messaging). Six studies described culturally adapted programs. Some interventions targeted mental health concerns broadly (18 interventions), whereas others targeted specific concerns, including depression (3 interventions), anxiety (2 interventions), suicidal thoughts and behaviors (2 interventions), substance use (2 interventions), posttraumatic stress disorder (2 interventions), and autism spectrum disorder (1 intervention).

Figure 4 categorizes the number of studies by age group and outcome. Many studies covered multiple outcomes, whereas some focused on only 1 outcome. Figure 5 categorizes the studies by outcome subdomain, respondent, and population.

Figure 4.

Heat Map: Outcome by Age Group and Respondent

Figure 5.

Heat Map: Study Outcomes by Subdomains and Respondent and Population

Note:(A) Needs/preferences; (B) barriers. LGBTQ+ = lesbian, gay, bisexual, transgender, queer, and others.

Perceived Needs and Preferences

In 38 studies, perceived needs and preferences of adolescents and/or parents were identified pertaining to service location and provider type (22 studies), specific treatment targets and delivery models (19 studies), service quality (16 studies), and supports for accessing care (10 studies). Both youth and parents expressed preferences for many of the same service locations and types of providers, including school-based mental health services,^{20,22,23,37,49,53,77,84} mental health clinics,^22,66,76,86 nonprofessional supports (family member, friend, close adult, mentor, peer, community leader),^{20,24,25,29,41,68,73,79} and teen/community centers and extracurricular activities.^{20,22,23,25,29,48,60,68,83,86} Rural parents uniquely reported a desire for in-home services^38,60 and emergency services.⁶⁰ In 1 study, Alaska Native youth and parents expressed interest in church-based services.²⁰ In another study, American Indian youth expressed a preference for services delivered by a primary care doctor if the youth tended to prefer solving their problems themselves.³⁹

There was also significant overlap between rural youth and parents regarding treatment models and targets of treatment. Both expressed a desire for individual therapy,^31,46,66,68 family therapy,^22,68 support groups,^60,76,80 and preventive services,^{60,61,67,68,86} as well as targeted treatment for substance use.^{22,25,49,83,86} Rural youth specifically reported needs for targeted treatment for depression,^53,70 anxiety/stress,^53,70 suicidal thoughts/behaviors and self-harm,⁷⁰ eating disorders,⁷⁰ and social skills.²⁶ Rural parents expressed a need for a greater number and range of types of services for their youth,⁶⁰ as well as preferences for short-term services⁴⁶ and for treatments focused on parenting,^20,68,79,84 anger management,⁷⁹ self-esteem,²⁶ behavioral control,²⁶ and grief.⁷⁹

Regarding perceived needs and preferences related to access to care, both youth and parents expressed interest in using technology such as telehealth, audio recordings, and websites.^31,36,49,61 Rural parents reported needs for outreach to identify and share service opportunities with youth^64,84 as well as care coordination.^64,85 Rural youth expressed a need for services to be available during after-school hours.²⁵

Regarding quality of care, both youth and parents expressed the need for respectful providers who foster trusting relationships.^{25,66,80,81,87} In 1 study, youth expressed a need for services that support privacy and autonomy.⁶⁷ Youth and parents from minoritized backgrounds expressed needs for culturally relevant and responsive services, providers with shared identities, and multilingual providers and materials.^{27,32,62,68,70,79} Black and American Indian parents also preferred services to be provided in a comfortable and welcoming setting.^35,64

Perceived Barriers

Barriers to use of mental health services by rural youth (37 studies) included service accessibility (27 studies), stigma/negative beliefs (26 studies), poor service quality (12 studies), and social barriers (6 studies). Access barriers reported by both youth and parents included distance to services,^{20,22,28,60,61,68,85} limited or lack of availability of services,^{20,25,50,60,67,69,80} lack of health insurance or shortage of providers who accept specific insurance types,^22,27,41 cost of care,^{22,27,28,41,47,64,67,68,73,76,78,80} long waiting lists for services,^27,68,85 and lack of coordination between service providers.^27,80,85 Parents and youth also reported limited knowledge about mental health and availability of services^{27,38,41,50,51,67,68,84} as well as being too busy.^28,30, 31, 32^,47,50,58,85 Access barriers unique to rural parents included lack of transportation^{20,22,47,68,73} and scheduling difficulties/canceled appointments.⁶⁸

Stigma in utilizing mental health services was a frequently reported barrier to accessing and using services for both youth and parents.^{20,25,27,28,41,46,50,51,}60, 61, 62^{,64,67,68,72,73,78} Additional negative attitudes reported by both youth and parents included concerns about confidentiality and privacy,^{25,28,38,39,41,49,50,61,68,69,76} discomfort or embarrassment sharing personal information,^{38,41,51,59,78,82} mistrust of providers,^{39,54,64,68,69,78} and the belief that mental health services would not help them or would make things worse.^{38,39,41,64,76} Youth in some studies specifically denied the need for treatment because they believed they could fix their own problems, they believed the problems would go away on their own, or they denied a problem existed.^{38,41,50,51,54,69}

Parents and youth also described quality of care as a barrier to utilizing services, including treatment not meeting the needs of youth^20,30,80,85 and feeling unheard or not respected by providers.^67,78 Parents and youth of minoritized populations reported a lack of culturally relevant and responsive services, providers with shared identities, and multilingual providers.^27,35,68,70 Parents reported some difficulties with technology-based services.^28,31,32,55 In 1 study of a culturally adapted telehealth-assisted CBT bibliotherapy vs self-directed CBT bibliotherapy for Latino youth and parents, parents reported treatment intensity as a quality of care barrier.³² Regarding social barriers to accessing care, rural youth and parents both reported parents who were unsupportive of services as a barrier.^{25,27,41,54,84} In 1 study, parents also noted barriers related to their own mental health and legal issues.⁴⁷

Perceived Facilitators

Seven studies highlighted facilitators to utilization of mental health services by rural youth. Facilitators unique to youth included affordable services,⁷⁰ having a combination of telehealth and in-person meetings,²⁸ internal motivation,²⁵ a belief that mental health services and providers would be helpful, and positive social support.^25,39 Parents specifically highlighted more logistical facilitators, including scheduling flexibility,³¹ transportation,⁷³ and financial assistance.⁷³ They also noted prior history of treatment.⁷²

Satisfaction With Services Received

There were 31 studies that focused on satisfaction or dissatisfaction with services received, including service location or type of service. Parents and youth reported satisfaction with most services, settings, and types of providers.^21,26,31, 32, 33, 34, 35^,37,40,42, 43, 44, 45^,51,52,55, 56, 57, 58, 59^{,62,63,65,71,74,75,77,87,88} However, in 1 study of Black adolescents with depression, there was variability in adolescents’ satisfaction with community-based mental health treatment, including therapy and medication.⁵¹ In another study, parents reported dissatisfaction with medication and self-help programming.³¹ In a third study, parents reported dissatisfaction with community mental health care because of feeling unsupported by providers and feeling that needs were not met.⁶⁷

Discussion

This scoping review identified the perspectives of rural adolescents and parents regarding their needs, barriers, and facilitators to accessing and utilizing mental health care and their satisfaction with services received. Included studies used a range of study designs, including surveys, focus groups and interviews, clinical trials, and program evaluations, providing data with both breadth and depth. Overall, the perspectives of adolescents and parents were similar. Among participants who received services, parents and adolescents generally reported satisfaction with the services they received, suggesting that service delivery initiatives thus far have been effective and attentive to the needs of rural communities. However, families also communicated a resounding need for more mental health services and supports, as well as the need for services that are affordable and are easily accessed. They also indicated that to ensure expanded mental health services are utilized, it will be critical to develop delivery models and engagement strategies that address the low mental health literacy, stigma, and concerns about privacy and confidentiality that are prevalent in some rural communities. Drawing from the perspectives of the rural youth and parents who participated in the reviewed studies, some recommendations are proposed to inform service development and expansion initiatives.

Consider Settings, Providers, and Types of Supports That Are Outside of Traditional Mental Health Service Settings

Rural youth and parents both reported particular interest in school-based services and teen/community centers as places to access care. These types of settings may be more easily accessed and less stigmatizing than mental health clinics, and services are often provided at no cost to the patient.⁹⁰ School-based services increase access to care by providing services in a context in which youth spend most of their time.⁹¹ Further, there are no additional transportation needs.⁹¹ In addition, students often have preexisting relationships with school counselors, regardless of whether they are receiving individual services, making it more comfortable to seek them out when more support may be needed.⁹¹

The preference for services at teen or community centers, in particular, may reflect interest in having more spaces in rural communities where youth can receive services while also engaging in activities in a safe and familiar setting. Greater access to extracurricular activities was viewed as important for promoting mental health and well-being. This was particularly noted for prevention of substance abuse as a way to provide alternative ways to have fun that are healthy. These findings demonstrate the need for rural communities to use existing spaces outside of traditional mental health service settings, as well as invest in additional community spaces as a strategy to increase access to mental health supports for youth. Communities might consider multiuse spaces (eg, creating a teen center in an existing building such as a library or town hall). Funding for construction of additional community spaces and for provision of services will also be needed to meet rural youth where they are.

While not specifically noted by youth and parents in the reviewed studies, primary care clinics and Federally Qualified Health Centers are also promising service settings. Primary care clinics are easily and frequently accessed by families,^92,93 and more than 90% of youth in the United States see a physician at least once a year.⁹⁴ Integrated behavioral health care uses existing infrastructure and existing relationships with trusted providers in a private setting. Evaluating the acceptability of these settings for rural youth and parents will be an important area for future research.

Youth and parents also expressed interest in services provided by nonprofessionals, including mentors, close adults, peers, and community leaders. Youth who avoid formal services because of stigma or cultural incongruence may be more inclined to receive services from a trusted community member.⁹⁵ Because of their unique position within the community, such individuals may also be able to reach youth who are systemically distanced from resources and may be able to do so more quickly than professional providers who can be burdened by bureaucratic hurdles.⁹⁵ Research has also shown that lay community members can be trained to competently deliver evidence-based mental health interventions.⁹⁶ Task shifting the delivery of programs typically led by mental health professionals, particularly for youth with prodromal or mild symptoms, has the potential to increase not only service access and availability, but also service efficiency by freeing up professional providers to work with youth who have more complex needs. Because, by definition, paraprofessionals do not have prior training and expertise in providing care to individuals with mental health concerns, it will be important to implement service structure models in which paraprofessionals work in collaboration or under the supervision of mental health professionals.⁹⁷

Expand Access to Technology-Based Services and Supports

Both rural parents and adolescents expressed interest in greater use of technology such as telehealth, audio recordings, and psychoeducational websites to facilitate mental health literacy and access to care. Youth were uniformly positive about the use of technology-supported services, which may be due to youth being more comfortable using technology and relying on online resources for support. Some parents also viewed telehealth services as being as effective as in-person care. However, some parents described barriers regarding availability and functionality of broadband Internet in their community, as well as beliefs that telehealth is insufficient for communing and developing a relationship with a provider. Having an in-person session before subsequent telehealth sessions was suggested as a way to facilitate comfort and relationship building.

Given the shortages in the mental health workforce in rural areas, telehealth offers an opportunity to provide services to rural youth who may not have access to a provider in their communities. Telehealth can potentially help overcome barriers reported in our literature set, such as lack of scheduling flexibility and lack of transportation to far-away services. Telehealth could also help rural youth and parents from minoritized backgrounds meet their need for culturally relevant care that may not be available locally. However, utilizing telehealth to meet the needs of rural youth will necessitate investments in infrastructure (eg, Internet access and equipment) and digital health literacy.⁹⁸ In rural areas in the United States, 28% of residents do not have access to broadband.⁹⁹ In addition, Hispanic and African American youth in rural areas may have up to 2 to 3 times lower digital health literacy compared with White youth,¹⁰⁰ which in turn could unintentionally exacerbate disparities in access to mental health services by relying solely on telehealth.¹⁰¹ Also, continued research and evaluation of mental health services delivered via telehealth will be needed to address concerns about quality of care.

Expand Access to Preventive Interventions

Rural youth and parents expressed a desire for greater availability of preventive interventions. Prevention may be a more acceptable approach in rural communities, where worries about stigma, privacy, and trust are more prevalent, as are additional barriers to service utilization such as high treatment costs. Preventive interventions also have fewer training demands for providers, as providers may not need training in other aspects of clinical care, such as how to assess and respond to active mental health concerns. This makes these interventions particularly well suited for task shifting to paraprofessionals, increasing their cost-effectiveness.⁹⁰ Group-based preventive interventions have the additional advantage of reaching a larger number of youth per provider. Schools and youth organizations, such as Future Farmers of America or 4-H, may be particularly relevant settings for the implementation of preventive interventions.

Ensure Availability of Services for Specific Mental Health Concerns

Both rural parents and youth expressed a need for services and prevention related to substance use disorders, which is consistent with the increasingly higher rates of substance use among rural youth.⁵ Youth reported a need for services for depression and anxiety. Rates of depression and anxiety in youth have also been increasing over the past decade.¹⁰² Because many of the symptoms of depression and anxiety are internal experiences that may not be outwardly observed by other people, youth may report this as a needed treatment target more often than parents. Parents requested more services that provide parenting support. Parenting programs are often provided as part of early childhood mental health services¹⁰³; however, they are not typically offered for parents of adolescents. Our results suggest that increasing access to parent-based interventions would meet a community need in rural areas.

Provide Services That Are Culturally Relevant and Responsive

Families from minoritized backgrounds identified the need for culturally relevant and responsive services, providers with shared identities, and multilingual providers and materials. These families also stressed the importance of welcoming and comfortable settings and providers able to foster trust and communicate respect. Services that are provided in culturally relevant and respectful ways can help contribute to positive outcomes among rural youth. This is particularly important when providing services for rural youth with intersectional identities, who may be at higher risk of experiencing mental health issues.¹⁰⁴ Given the increasing diversity across rural America,¹⁰⁵ it is important for the rural mental health workforce to reflect this diversity. Approximately 25% of the mental health workforce identifies as BIPOC (Black, Indigenous, or a person of color), and little is known about the percentage of the mental health workforce that identifies as LGBTQ+¹⁰⁶; even less is known about how many rural providers identify as BIPOC or LGBTQ+. Policies and programs aimed at increasing diversity across the mental health workforce are needed to meet the needs of minoritized youth in rural communities.

Provide High-Quality Patient-Centered Care

Rural youth and parents expressed barriers, needs, and preferences regarding quality of care. They stressed the importance of welcoming and comfortable settings as well as empathic and compassionate providers who can foster trust and communicate respect. Quality improvement is an important initiative for mental health providers and settings in all communities, but may be of particular importance in communities where there can be mistrust and hesitation to initiate care.

Develop Strategies for Increasing Mental Health Literacy and Addressing Stigma

Both rural youth and parents reported limited knowledge about mental health and availability of services. Some participants reported believing that mental health services would not help or would even make things worse. Stigma was a frequently reported barrier to seeking mental health services. Both youth and parents expressed concerns regarding privacy and confidentiality. In small communities, there may be concern about being seen and recognized entering the office of a mental health provider because of limited anonymity and strong social cohesion in rural areas.⁷² Mental health providers may also be more likely to be a known individual in the person’s life, such as a member of their faith community or a parent of a classmate. Rural youth and parents anticipated discomfort or embarrassment sharing personal information, and some reported mistrusting providers. These concerns demonstrate a need for providers in rural areas to provide more education about the confidentiality of mental health services as a way to ease these concerns. Community attitudes likely play a role in many of the additional attitudinal barriers reported. To effectively address mental health disparities, it will be critical to address the educational and attitudinal barriers that impact underuse of services. Research has shown that motivational messaging can effectively increase intentions to engage in health promotion behaviors when it includes personal testimonials delivered by individuals of a similar background or lived experience.^107,108 However, this type of messaging has not yet been developed or evaluated for engaging rural families to initiate mental health services. In addition to providing education and outreach in the community settings noted above, there is also evidence of the benefit of using faith-based outreach for reducing mental health stigma.^109,110 Additional research is needed to evaluate impact for youth in rural communities.

Address Social Determinants That Affect Service Utilization

Access facilitators included financial assistance, transportation, and scheduling flexibility. Rural residents are less likely to have health insurance,¹¹¹ more likely to be low income,¹¹² less likely to have paid sick leave,¹¹³ and more likely to face unique transportation barriers.¹¹⁴ Altogether, this demonstrates the need for robust policies and systems that address these social determinants to increase utilization of mental health services in rural areas.

There were some limitations to this scoping review. Although studies selected in this review process were classified as rural based on the reporting of the study or if the study took place in an area currently designated as rural by the Office of Management and Budget, this may have excluded literature that included areas that may be considered rural through other definitions or had previously been considered rural at the time of the study, but currently are no longer considered rural owing to updated data. Another limitation to our study is that we applied English language filters to our searches where available. This could have eliminated articles written in English but without language tags in their metadata. In addition, we included studies that included adolescents and combined their results with other age groups (eg, adolescents were combined with younger children). We summarized the results of these studies separately, and including these studies enabled us to draw from a larger number of studies to evaluate parent and youth attitudes. However, it does raise the possibility that the results are not exclusively specific to adolescents. Although this review did include studies that focused on minoritized populations within rural communities, there are still gaps in representation across diverse rural populations.

The results of our scoping review are in accordance with prior research, while going further to add more specific details regarding the needs, barriers, and facilitators that can inform initiatives to improve adolescent mental health service accessibility and utilization in the rural United States. Stigma remains a barrier to accessing mental health care and could be overcome by utilizing community-based care settings (such as schools), strengthening the mental health workforce (increasing the number of culturally relevant or concordant care providers and training paraprofessionals), and using supports outside of traditional mental health services (such as mobile health applications). Concerns regarding quality of mental health services were reported as needs as well as barriers in several studies by both parents and youth, highlighting the importance of instituting quality assurance measures through regulatory or reimbursement policies at the system level and through quality improvement initiatives by rural service providers. Greater use of technology was also viewed as a way of increasing access to care given shortages in the rural mental health workforce, although negative attitudes about the quality of telehealth-delivered care remain, as do constraints on access to broadband Internet and lower digital literacy in minoritized populations. Further research is needed to identify methods of increasing mental health literacy and addressing stigma and other negative attitudes toward mental health services in rural communities, especially for populations minoritized based on race/ethnicity, gender and sexual identity, and other cultural and social determinants of health. Lastly, more research is needed to better understand the impact of intersectionality and develop culturally tailored interventions to improve mental health service equity of minoritized populations within rural communities.

CRediT authorship contribution statement

Meredith Gunlicks-Stoessel: Writing – review & editing, Project administration, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Katie Rydberg: Writing – review & editing, Writing – original draft, Formal analysis. Romil R. Parikh: Writing – review & editing, Visualization, Formal analysis. Dawn E. Hackman: Writing – review & editing, Methodology, Data curation. Scott E. Marsalis: Writing – review & editing, Methodology, Data curation. Carrie Henning-Smith: Writing – review & editing. Mary E. Butler: Writing – review & editing.