Living at the intersections: exploring social and structural influences on mental health service use in Oklahoma’s historical Black towns

Abstract

Background

Mental health disparities are heightened in rural communities, where provider shortages, geographic isolation, and systemic inequities limit access to care. For rural Black Americans, these challenges are compounded by structural racism and historical disinvestment, leading to disproportionately high need alongside enduring stigma and mistrust. Oklahoma’s all-Black towns, rooted in resilience yet shaped by inequity, offer a critical context for examining how race and rurality intersect to influence mental health service use.

Methods

Guided by a mental health disparity–adapted version of the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, this applied qualitative study was grounded in pragmatism and informed by interpretive phenomenology to center lived experience. Purposeful sampling, including confirming and disconfirming cases, recruited 15 participants across four generations through community and faith-based networks. A Community Advisory Board (CAB) composed of Black town mayors, a community member, and a mental health expert informed recruitment, interview design, and interpretation. Semi structured interviews were conducted between December 2023 and March 2024 and analyzed in NVivo using Braun and Clarke’s six-phase thematic analysis, integrating inductive and deductive codes mapped to Social Determinants of Health (SDOH) domains. Rigor was supported through reflexive memoing, peer debriefing, member checks, and CAB validation.

Results

Fifteen participants across four generations (Baby Boomers, Generation X, Millennials, Generation Z) described their experiences with mental health programs and services, including available supports and challenges. Findings highlighted reliance on state-funded, tribal, and community health resources constrained by access barriers; the role of community-led and faith-based initiatives in providing culturally familiar support; and the expansion of telehealth and mobile services that increased reach but often lacked relational or cultural resonance. Participants also shared visions for future programming, emphasizing culturally grounded, affordable, and group-based approaches. Results were organized by the five SDOH domains, identifying barriers, facilitators, challenges, and needs across economic stability, education, health care access and quality, neighborhood and built environment, and social and community context.

Conclusion

Findings highlight the complex interplay of cultural, social, and structural factors shaping mental health service use in rural Black Oklahoma communities. Persistent barriers of stigma, mistrust, and logistical strain underscore the need for culturally responsive, community-driven approaches. Strategies such as reframing mental health language, engaging proxy advocates, strengthening faith-based partnerships, and expanding mobile and telehealth services can enhance access and engagement. Grounded in the adapted NIMHD framework, this study emphasizes layered strategies across individual, community, and policy levels. Advancing equity will require addressing systemic bias, sustaining services, and amplifying local strengths through co-developed, trust-based solutions that promote resilience in underserved rural populations.

Supplementary information

The online version contains supplementary material available at 10.1186/s12913-025-13945-6.

Introduction

Mental health is a critical component of overall well-being [1, 2], yet access to and utilization of services remain limited, particularly in rural communities [3, 4]. Residents of these areas face unique barriers, including persistent workforce shortages [5–7] and inequities in reimbursement [8–11]. Many rural counties are designated as mental health shortage areas [5, 12], and projections indicate that demand for behavioral health providers will continue to outpace supply [6, 12–14].

Awareness of these disparities has grown nationally and globally [15]. In the U.S., the Surgeon General has highlighted the worsening youth mental health crisis [16], while the COVID-19 pandemic further exposed inequities experienced by Black Americans in the rural South [17, 18]. Globally, the World Health Organization has emphasized transforming mental health systems as a pathway to advancing health equity [19]. Despite these calls, rural communities continue to experience higher rates of psychological distress, including depression and suicide [4, 20, 21], while having fewer providers and fewer available services than their urban counterparts [5, 22–24]. For instance, more than 65% of nonmetropolitan counties lack a practicing psychiatrist [5] leaving many residents with limited or no access to specialized care. Even when services are available, they are often not culturally responsive [25, 26], which limits their effectiveness [26].

These challenges are especially acute for Black Americans living in rural areas [27]. Structural racism and residential segregation compound the barriers faced by rural residents [28, 29], making an intersectional lens essential for understanding how race and geography intersect to shape lived experience [30, 31]. The burden is evident: up to 30% of rural African Americans report clinically significant depressive symptoms [32]. One in five rural Black women has screened positive for depression [33], and nearly a third report moderate distress [34–36]. Among rural Black men in Georgia aged 15 to 24, one in three recently reported suicidal thoughts [37, 38]. These statistics illustrate that at the intersection of race and rurality, barriers to care do not simply accumulate; they multiply [39], resulting in disproportionately high need, limited access, and enduring stigma and mistrust [39–41].

Oklahoma presents a particularly important context for examining these issues [42, 43]. The state is largely rural and marked by wide disparities in access, affordability, and the structural competency of care [44–49]. Provider shortages, geographic isolation, and low mental health literacy combine with systemic barriers such as inadequate transportation infrastructure to further limit access [50, 51]. Many residents turn to churches and other community-based supports as alternatives [52, 53], while government-funded programs are often perceived as misaligned with community needs or untrustworthy due to historical abuses that have fostered deep mistrust [54].

The history of Oklahoma’s all-Black towns adds unique historical and cultural depth to these concerns [55–58]. Established after the Civil War as safe havens where African Americans could own land, build businesses, educate their children, and worship freely [57, 59, 60], these towns once thrived with Black-owned banks, schools, and churches anchoring vibrant communities [61]. Over time, discriminatory policies, economic decline, and systemic disinvestment reduced their numbers [58, 62, 63]. Today, 13 original towns remain, along with several later incorporations [57, 64]. These communities continue to carry the legacy of resilience and self-determination, yet structural inequities still shape how residents engage with health and social systems [39, 45, 65]. Historian William J. McAuley noted that Black Oklahomans in rural areas face not only the common hardships of rural life but also systemic inequities tied to racial disparities [65, 66], an observation that remains true today [39, 67].

These dynamics are further complicated by historical and ongoing disputes over citizenship and belonging among Black and Indigenous peoples. The Freedmen controversies, rooted in the exclusion and contested status of descendants of enslaved Africans within Native Nations, continue to influence trust in tribal and state systems [68]. These unresolved legacies shape perceptions of fairness, cultural inclusion, and institutional credibility within Black communities across Oklahoma and beyond [69, 70].

Despite the urgency, research on rural Black mental health remains sparse and underfunded [47, 71]. Few studies have explored the intersection of race, rurality, and mental health in Oklahoma’s Black towns, leaving critical gaps in understanding how systemic and contextual forces shape service needs and experiences. This study aims to address that gap by exploring the lived experiences of individuals from rural Black towns in Oklahoma who have sought or received mental health care [3, 65, 71]. Using a phenomenologically informed approach, it highlights both shared and unique aspects of these experiences [72, 73], with attention to barriers, facilitators, service needs, and contextual challenges that emerged inductively from participant accounts [27, 74, 75]. The goal is not only to document challenges and supports but also to explore the cultural, social, and structural forces that shape mental health service use [40, 76]. At its core, this study asks: What is it like to be Black, live in a rural area, and try to find mental health support? Here, mental health is understood not only as the absence of illness but as a state of emotional, psychological, and social well-being [1], encompassing how individuals think, feel, manage stress, and connect with others [1, 77]. This framing includes diagnosable conditions as well as everyday experiences of stress, grief, anger, resilience, coping, balance, and connection [78].

Methods

Study design

This applied qualitative study was grounded in pragmatism and informed by interpretive (hermeneutic) phenomenology [72, 73]. This orientation emphasizes meaning-making in lived experience and incorporates researcher interpretation [79–81], making it well-suited for examining how Black adults in rural Oklahoma navigate and make sense of mental health service use [27, 74]. Phenomenological principles shaped the research questions by centering meaning rather than outcomes, guided the development of the semi-structured interview guide to elicit participants’ lived experiences in their own words, and informed the analytic process by moving beyond surface-level accounts to interpret contextual and structural significance. Through iterative cycles of coding, memoing, and interpretation, findings reflected participants’ perspectives within broader cultural and social contexts [75, 82, 83], which is especially important when engaging populations historically underrepresented in research [84].

A mental health disparities adaptation of the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, shown in Table 1, guided the study [15, 85]. This adaptation integrated two complementary models:

• Social Determinants of Health (SDOH), which categorizes the conditions in which people are born, grow, live, work, and age into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context [71, 86].

• Socioecological Model (SEM), which describes how individual and contextual factors operate across the individual, interpersonal, organizational, community, and policy levels [87].

Table 1.

Multi-Level Impact Framework for Rural Mental Health Equity, adapted from the National Institute on Minority Health and Health Disparities Research Framework (Alvidrez and Barksdale, 2022)

Together, the adapted NIMHD framework guided interview development, multilevel analysis, and the organization of results, aligning with principles of community engagement and participatory approaches [15, 88]. Findings are presented by SDOH domains to aid in interpretation [89].

The study incorporated elements of community-based participatory research (CBPR) [90]. A Community Advisory Board (CAB) [88] was established that included 13 mayors from historically Black towns in Oklahoma, one community member, and a mental health expert. The CAB reviewed the interview guide, advised on culturally appropriate recruitment strategies [53, 84], interpreted preliminary findings and contributed to final recommendations [88, 91]. Although this was not a complete CBPR design, the CAB’s involvement helped ensure the study remained culturally grounded and responsive to community priorities [88, 90, 91]. The CAB met in person bimonthly and communicated by phone and email.

Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [92].

Reflexivity

The first author identifies as a Black woman and a citizen of a Native Nation with personal and professional ties to Oklahoma and lived experience related to mental health. This insider-outsider perspective offered cultural insight and introduced potential interpretive bias [80, 83, 93]. Reflexivity was supported through journaling, analytic memoing, and critical engagement with the CAB [79, 94]. The co-authors provided additional perspectives that supported analytical balance [95]. Two co-authors are Oklahoma natives, one Black and another a citizen of a Native Nation, with relevant contextual and methodological expertise [90]. These diverse viewpoints enhanced credibility and confirmability by grounding interpretations in both professional and lived knowledge [95, 96] and by promoting rigor through collaborative review [75, 97].

Participants and sample population

Inclusion criteria required participants to be 18 years or older, living in rural Oklahoma communities, and to have engaged with mental health services in some way (seeking, receiving, attempting, or declining). Adults with no interest in seeking mental health services were also included as disconfirming cases, allowing for insights into contrasting perspectives. Self-identification as Black or African American was not required. Although Oklahoma’s historically Black towns were founded as safe havens for Black Americans, they are legally open to residents of any race [56, 57]. Including all residents aligns with legal and cultural developments in the state [98–101].

Rurality was defined according to the U.S. Census Bureau’s rural–urban classification and used to determine eligibility for towns and participant selection [102, 103]. Purposeful sampling was employed with the goal of achieving maximum variation across age, gender, geographic location, and community context, along with confirming/disconfirming case sampling to test emerging patterns [75, 82]. The recruitment goal was 26 participants, with the intent of enrolling at least two individuals from each town [104]; however, the final sample size was 15. This underrepresentation shaped the range of perspectives available for analysis, particularly regarding potential gender differences in mental health service use. These limitations and their implications are discussed more thoroughly in the limitations section.

Data collection

CAB-informed recruitment strategies included digital and in-person outreach. Flyers were posted in community spaces (barbershops, centers, bulletin boards) and shared on social media and organizational newsletters [52, 53, 105]. Outreach also occurred through predominantly Black faith-based organizations [70, 106].

Ethical approval was obtained from the University of Oklahoma Health Sciences Center Institutional Review Board (IRB# 15850). Data were collected between December 2023 and March 2024 [107]. Participants chose virtual interviews via Zoom [108] or in-person interviews at locations selected for comfort and privacy.

Interviews lasted 45 to 75 minutes [109]. Most participants completed one interview, with occasional follow-ups for clarification. A semi-structured interview guide co-developed with the CAB explored needs, barriers, facilitators, perceptions of culturally appropriate care, and broader interactions with mental health services [27, 84, 88].

All participants received a $25 Amazon gift card as compensation [110, 111].

Data analysis

Recordings were transcribed [112] and de-identified [113]. Analysis followed Braun and Clarke’s six-phase thematic analysis [94, 114]. The first author led the coding process; however, analyses were iteratively reviewed with co-authors and refined through team consensus discussions. Additional trustworthiness procedures included CAB validation of emerging interpretations [88], peer debriefing, maintenance of an audit trail [115], and reflexive practices (journaling and memoing). Member checking was employed with some participants to enhance credibility [97]. A summary of preliminary themes, rather than raw data or coding, was shared with participants who were invited to indicate whether the interpretations reflected their experiences. Their feedback was incorporated to refine themes and ensure that findings remained grounded in participants’ perspectives [97].

Coding combined inductive, data-driven codes with deductive codes drawn from the adapted NIMHD framework and interview guide [15, 116]. Deductive anchors included barriers, facilitators, needs, challenges, and available programs and services, which were represented in the interview guide and informed by the research question. Inductive coding captured unanticipated issues, and together these approaches shaped the final thematic structure. Deductive codes also reflected theoretical constructs from the framework, including the five SDOH domains and the SEM’s multilevel factors. The framework guided the analytic process by providing domains and levels as reference points for coding, theme refinement, and checking emergent categories for coherence and consistency. NVivo 14 (QSR International) [117], a qualitative data analysis software program, was used to manage data, memos, and the audit trail [115, 118]. A codebook within NVivo was organized both inductively and deductively and ensured consistent application across transcripts.

All coded segments within each code were systematically reviewed in NVivo to confirm internal coherence and clearly distinguish themes. This process was documented through coding reports and analytic memos, which served as the structured record of decisions and refinements. Categories were further refined through iterative team discussion and consensus [94, 97, 119]. Final insights were organized by the SDOH domains based on dominant contextual meaning [71, 89], with acknowledgment that some findings spanned multiple domains. This strategy improved interpretability and maintained theoretical alignment [15, 120, 121].

Results

Participant characteristics

Fifteen participants were interviewed, all of whom identified as Black American. Two identified as male and 13 as female. The sample reflected perspectives across four generational groups: Baby Boomers (n = 5), Generation X (n = 5), Millennials (n = 4), and Generation Z (n = 1). To protect confidentiality, all town, organizational, participant names, and program or service titles in the results have been replaced with pseudonyms. In contrast, generational category, gender identity, and program or service type are reported accurately. This approach ensures protection of participants and communities while avoiding any unintended negative portrayals of specific towns or services. Illustrative quotes supporting each theme are included in the text.

Available programs and services

Participants identified a range of programs and services available in or near their rural communities.

Theme 1: government and Native health services were widely used, but participants experienced them as constrained by structural barriers, stigma, and inconsistent inclusion

State-funded and tribal health resources, along with community clinics and hospitals, were among the most frequently mentioned sources of care. Yet participants emphasized that these services were not consistently accessible, citing restrictive eligibility requirements, changes in hospital ownership, and variability in who could receive treatment. Concerns about confidentiality also emerged. As one participant explained, “As for mental health, Rainbow Health is your first stop to go in this area, but some won’t go because they tell your business” (Dorothy, Baby Boomer female). Others described hospitals as limited in availability or exclusionary in practice. As this participant illustrated, “The nearest hospital is 7 miles to Blue Town … but if you’re not part of the tribe, they might not take you” (Amber, Gen X female).

Theme 2: community-led and faith-based initiatives filled gaps and offered culturally familiar support

Faith communities, local initiatives, and informal gatherings were described as filling critical gaps where formal services were absent. Participants emphasized that these supports were accessible, trusted, and aligned with cultural values. Churches served as anchors, offering both spiritual guidance and social connection. As one participant described, “Now we sing and pray, and everybody just checking in and asking how was your week” (Hannah, Gen X female). Another added, “Most of us rely on religion for our strength” (Melanie, Millennial female).

Beyond church services, programs like Willowfield’s senior meal program and Sunnyville’s youth and family events (movie nights, fall festivals, carnivals) provided essential outlets. Youth programs, though limited, were seen as promising. As one participant noted, “They have little programs now. I guess you could call it Girl Scouts or something. But that’s a start. Our babies need help … with self-esteem, prayer, but also tools and resources to thrive” (Ethel, Baby Boomer female).

Informal spaces such as barbershops also served as counseling environments that reduced stigma. As one participant explained, “We get ours in the barber shops … it’s helpful. We can take it back home and apply it” (Frank, Gen X male).

Theme 3: telehealth and mobile services expanded access but could not fully bridge cultural and relational gaps

Mobile and online platforms connected participants to services otherwise unavailable locally and were valued for increasing access. Some noted challenges in use. “I think [mobile units] would be great if you can get the people to go to it …”(Chelsey, Gen X female).

Others praised models like the Joy Town Behavioral Health caravan that brought multiple supports in one place. As one participant illustrates, “Everything we need, they offer on the caravan … They have a doctor on video, a therapist, case managers, stuff to help you quit smoking, housing support … Everything is just right there. They look out for us because they know a lot of us don’t have no way to get there” (Jessica, Millennial female).

Telehealth expanded after COVID and offered new ways to engage, but participants questioned whether it could build trust or meet cultural needs. One participant explained, “Since COVID, they do the whole telehealth thing … I guess they benefit from looking at someone on Zoom and getting their therapy that way. I need somebody in the room with me. I need to feel like they understand me, not just look at me through a screen” (Kymberly, Millennial female).

Community visions for future program design

Participants shared forward-looking ideas for programs they believe could better meet community needs. They envisioned services brought into familiar spaces like community centers, group-based and creative approaches such as music therapy, and environments offering diverse options to accommodate different needs. Suggestions included tailored groups for men and new mothers, affordable services regardless of income, and physical outlets such as gym activities or boxing as therapeutic ways to “get it out.”

Findings by SDOH domains

Findings are presented by the five SDOH domains. Within each domain, findings are described as barriers, facilitators, challenges, or needs.

Economic stability

Economic conditions were a central influence on mental health service use, shaping whether participants could prioritize care at all.

Theme 1 (challenge): survival needs consistently outweighed mental health care

Participants emphasized that when food, housing, and utilities were insecure, mental health fell into the background. As one participant described, “Sometimes people don’t have food to eat … The last thing on their mind is their mental health” (Geraldine, Baby Boomer female). This view was echoed across interviews, with many noting that daily survival took precedence over attending appointments, paying for prescriptions, or carving out time for self-care. Mental health care was often described as something people wanted but could not realistically prioritize while struggling to meet their most basic needs.

Theme 2 (barrier): financial disparities made services technically available but practically inaccessible

Out-of-pocket expenses, insurance gaps, and limited income meant therapy or psychiatric care were often out of reach. One participant explained, “There isn’t any disposable income in most rural Black households. It’s hard enough just meeting the basic needs” (Amber, Gen X female). Others shared that even when a clinic was nearby, they could not afford the session fees, co-pays, or the gas money needed to get there. Participants described the frustration of knowing services existed but feeling unable to use them because their household budgets left no room for anything beyond essentials.

Education access and quality

Participants’ reflections showed how knowledge gaps and cultural dissonance shaped their understanding of mental health.

Theme 1 (barrier): mental health was narrowly understood as a diagnosis, not everyday stressors

Inadequate mental health literacy was a barrier across generations. Many participants equated mental health exclusively with diagnosed conditions, overlooking everyday stressors such as anxiety or grief. As one participant explained, “People don’t realize that anger, sadness, stress, and anxiety are all mental health; they just focus on the diagnosis” (Melanie, Millennial female). Several participants described growing up without conversations about mental health in their homes or schools, which left them with limited ways to recognize or talk about everyday struggles.

Theme 2 (facilitator): generational shifts fostered growing openness to care

At the same time, shifts were occurring. Several participants described growth through new perspectives, where increased exposure to mental health concepts fostered openness to care. As one participant, Chelsey, reflected, “I don’t want to say I didn’t ever believe in it before, but I aint never even really talked about it. Now, I be feeling like I really do need to go talk to somebody. I think I’m much more open to it now” (Chelsey, Gen X female). Others noted that conversations among peers, media exposure, and changing community norms encouraged a different outlook than what they remembered from growing up.

Theme 3 (need): culturally resonant education was viewed as essential

Participants also identified the need for culturally relevant education that resonates with rural Black communities. Suggestions included adapting Mental Health First Aid training and embedding education in trusted spaces like churches and community centers. One participant, Kymberly, elaborated, “There’s a training … first aid for mental health or something like that. We need that but for us, you know what I mean?” (Kymberly, Millennial female).

Health care access and quality

This domain was the most frequently discussed, underscoring the complex interplay between availability, responsiveness, and cultural fit. Participants described deep skepticism toward providers, shaped by negative past experiences, cultural disconnects, and the absence of continuity in care.

Theme 1 (barrier): negative past experiences fueled mistrust of providers

Stories of racism, microaggressions, confidentiality breaches, and dismissive treatment undermined trust and left participants feeling dismissed and devalued. As one participant, Faith, recalled, “At first, we kind of got ‘the look’. I could tell that there were not that many Black people going there … Lots of racism and microaggressions every time … It just made me feel so low. I wasn’t being listened to” (Faith, Gen X female). Another participant added, “White psychologists … they don’t understand us. A lot of times, they just try to talk around us in words or just shove it off” (Bob, Baby Boomer male). Participants described how these experiences discouraged them from returning to care or made them hesitant to trust new providers.

Theme 2 (facilitator): care was often sought only in times of crisis

Bereavement or acute stress pushed participants toward services otherwise avoided. As one participant, Hannah, explained, “The only time I wanted services was when my mother passed away … Sometimes you just can’t figure out how to get through one stage to the next” (Hannah, Gen X female). Others described similar patterns, explaining that services were not something they pursued regularly but were turned to in moments of loss, grief, or overwhelming pressure when they felt they had no other choice.

Theme 3 (facilitator): faith served as a bridge between spirituality and professional care

Participants often described using faith as a first step or as a parallel practice to counseling. Some explained that prayer and church involvement gave them strength, while counseling provided tools to manage daily challenges. Frank, a Gen X male, stated, “We’ve got to hold our people accountable … you can’t just pray it away”. For many, faith communities and professional services were not in conflict but were seen as ways that could work together in supporting well-being.

Theme 4 (challenge): structural and logistical constraints reinforced futility

Participants explained that barriers such as long distances to appointments, unreliable scheduling, court or insurance requirements, and the stigma tied to institutions made the process of getting care overwhelming. Several described feeling tired and discouraged because of these conditions. Dorothy, a Baby Boomer, summarized this experience: “People give up because they feel like it’s too much work.” Others noted that the effort required to secure and maintain services often led people to step away from care altogether.

Theme 5 (need): representation and continuity were critical for building trust

Participants said they wanted services that were stable, not dependent on income level or eligibility, and providers who could relate to their lives. Ethel, a Baby Boomer, emphasized, “We should have more access without having to meet all these benchmarks; without having to have money, belonging to the tribe. It should be for everybody, no matter your race and no matter what side of town you came from”. Others added that having a provider who shared their racial or cultural background was important. Lesha, a Millennial, explained, “I’d want my therapist to be Black … they’ve been in my shoes”. Participants consistently described continuity and representation as necessary to feel comfortable in care.

Neighborhood and built environment

Geography and infrastructure strongly influenced service access. Unlike other domains, participants mainly identified barriers in this area.

Theme 1 (barrier): geographic isolation created significant barriers to care

Participants described how few local providers and long travel distances made it difficult to use services. Some said that even basic appointments required travel to larger towns or cities, creating delays and additional costs. Bob, a Baby Boomer, shared: “We had to travel 35 miles just for treatment.” Others explained that the type of providers they felt most comfortable with were often only available in metropolitan areas such as Tulsa, Oklahoma City, or Fort Smith, Arkansas, adding even more distance to overcome.

Theme 2 (barrier): transportation challenges compounded privacy concerns

Even when transportation could be arranged, participants said it came with challenges. Rides from family or neighbors required extra planning and could expose personal information that people wanted to keep private. Hannah explained: “If you don’t have your own ride, you have to depend on somebody to take you, and then they know all your business. It makes you think twice about going back.” Participants described how this reliance on others not only made it harder to keep appointments but also raised concerns about stigma.

Social and community context

Cultural norms, stigma, and social networks shaped how participants viewed mental health and the process of seeking care.

Theme 1 (barrier): expectations of stoicism and strength discouraged vulnerability

Participants described how community ideals encouraged silence about emotional struggles. Jessica, a Millennial, reflected: “A strong Black woman … They don’t let their emotions show. You got to act like really nothing bothers you … You know, put on a front.” Many explained that these expectations made it difficult to admit when help was needed.

Theme 2 (barrier): privacy concerns heightened stigma in small communities

Participants noted that in small towns, where most people know each other, seeking care carried the risk of being recognized or discussed. Amber, a Gen X supervisor, explained: “I guess I would be hesitant about really reaching out to resources that are through my employment, especially now for privacy since I’m a supervisor.” Several echoed concerns about being seen at specific clinics or having information shared within their community.

Theme 3 (facilitator): social modeling encouraged openness when others sought help

Participants said seeing friends, family, or peers use services made it easier for them to consider doing the same. Melanie, a Millennial, emphasized: “If you plant that seed and they see you healing yourself … that will bring other people closer.” Others gave similar examples of how one person’s actions encouraged conversations and openness within their circles.

Theme 4 (challenge): cultural inertia and unstable environments reinforced barriers

Participants shared that traditions and family rules often discouraged talking about mental health. Brenda, a Baby Boomer, recalled: “We was told, ‘what goes on in this house stays in this house.’” Others described how returning to unstable households or environments made it difficult to follow through with care, even when they wanted to.

Theme 5 (need): participants called for new, culturally resonant approaches

Participants said language and approaches mattered in how services were received. Frank, a Gen X male, explained, “Black folks ain’t trying to hear about no therapy. I suggest not calling it that.” Kymberly, a Millennial, suggested adapted training, and Ethel, a Baby Boomer, said providers should build trust by working through churches and community leaders. These accounts highlighted participants’ desire for approaches that felt familiar and rooted in their communities.

Table 2, shown on the next page, summarizes how participants described programs and services, as well as the barriers, facilitators, challenges, and needs that shaped their experiences. These were organized across the five SDOH domains and connected to ecological levels of the SEM. Together, the findings highlight how influences on mental health service use extended across multiple levels, from individual circumstances to broader community and policy conditions. Positioning the results within this combined framework shows how personal, interpersonal, organizational, community, and policy dynamics came together and overlapped across domains to shape mental health service use in rural Black communities.

Table 2.

Community member findings mapped to the Multi-Level Impact Framework for Rural Mental Health Equity, summarizing barriers, facilitators, challenges, needs, and programs and services across ecological levels and Social Determinants of Health domains

Discussion

This study utilized a phenomenological approach to explore the lived experiences of Black residents in rural Oklahoma navigating mental health care. Participants identified cost, provider shortages, and insurance gaps as major obstacles [4, 122] compounded by mistrust and stigma toward formal services [26, 41]. Their reflections illustrate how structural inequities and cultural histories are not abstract concepts but lived realities that directly influence decisions about care [40, 76]. Survival needs often outweighed mental health, echoing prior research showing that economic precarity pushes treatment to the margins even when services exist [123–125]. These findings align with scholarship on accessibility challenges, cultural mistrust, and the enduring impact of historical injustices [126].

Given these complex and deeply felt experiences, phenomenology was essential for centering lived experience and meaning-making. Beyond documenting barriers and facilitators, this approach revealed how mistrust, stigma, and resilience were felt and interpreted in daily life [72, 94]. By foregrounding participants’ subjective accounts, phenomenology offered depth that would not have been possible through survey-based or strictly descriptive methods alone [73, 107]. Reflexive practices, contextual awareness, and attention to participants’ language ensured that the analysis remained grounded in rural Black realities while linking individual experiences to broader structural and cultural forces.

A notable finding was the need for accessible, culturally resonant language about mental health. Participants emphasized that clinical terms such as “therapy” carry stigma, while reframing concepts as wellness, resilience, or strength reduced discomfort and encouraged engagement [127]. This aligns with evidence that non-clinical terminology resonates in communities where mental health often implies judgment or pathology [25, 41, 128]. Generational shifts toward greater openness suggest that tailored education can further accelerate the change in norms [129, 130].

Participants also emphasized the need for educational approaches tailored for rural Black communities. They acknowledged the value of programs such as Mental Health First Aid, while noting that generic models often fail to reflect cultural realities. This reflects research showing that education rooted in trusted community spaces improves literacy and engagement [131].

Although a range of services existed, participants described them as uneven, inaccessible, or mismatched with their needs. Distance, provider shortages, and financial constraints often pushed people toward virtual or mobile care, yet skepticism, trust concerns, and technology barriers limited impact. Telehealth expanded reach but could not replace the value placed on face-to-face, culturally grounded relationships.

Geographic isolation and transportation challenges described in the Results highlight how the built environment functions as both a structural and cultural barrier. These realities underscore why broadband expansion and transportation investments are essential complements to efforts that diversify the workforce and strengthen culturally responsive care [132]. At the systems level, participants also pointed to the need for equity-focused policies. Implicit bias training was identified as critical for creating welcoming environments and reducing discrimination, while expanded telehealth resources and strengthened broadband infrastructure were viewed as essential to addressing geographic isolation [133, 134].

Faith, family, and informal networks emerged as essential sources of support when formal systems felt unwelcoming or inaccessible. These culturally grounded networks offered familiar, stigma-reducing, and trust-building alternatives, consistent with extensive research on the central role of Black religious and kinship networks in emotional well-being [135, 136]. Participants’ descriptions also align with scholarship documenting longstanding mistrust of mental health services among African Americans due to historical mistreatment, perceived discrimination, and ongoing negative encounters. Participants described experiences of racism, microaggressions, and dismissive care that reinforced mistrust in clinical settings and contributed to crisis-driven rather than preventive engagement.

Historical context further shaped attitudes toward care [137]. Participants connected present-day mistrust to both personal experiences of discrimination and collective memories of exclusion. The Freedmen controversy, centered on the contested rights of Black descendants within Native Nations, was described as an example of unresolved historical injustice that continues to influence perceptions of institutional credibility [68, 98]. These histories are not only remembered but actively felt in present-day health decisions and align with evidence that historical trauma and exclusion influence service use patterns [41, 138, 139].

Representation within mental health care was another critical concern. Participants expressed a desire for therapists who shared their cultural background, noting that racial concordance increased trust and comfort. This reflects long-standing calls for a more diverse mental health workforce and aligns with evidence that provider-patient racial concordance improves communication, trust, and perceived quality [140–142].

The findings also highlight the importance of culturally tailored interventions, including faith-based partnerships, community-led education, storytelling, and the use of lived experience. Trusted voices and intergenerational influence emerged as powerful pathways for normalizing care. These reflections echo research demonstrating that education and supports rooted in community structures can shift norms and reduce stigma [131, 143]. Participants’ descriptions of cultural norms related to stoicism, privacy, and the “strong Black woman” ideal illustrate how stigma is reinforced within small communities [144, 145]. At the same time, younger generations’ openness provides opportunities for change.

Calls for reframing language, strengthening faith-based partnerships, and expanding on non-carceral crisis response options echo participants’ recommendations, emphasizing that solutions must resonate culturally and be rooted in trusted community structures [39, 52, 53]. Together, these findings highlight the importance of community-built and community-shaped approaches that address policy barriers while providing culturally relevant supports [137].

Limitations

Several limitations should be considered when interpreting these findings. The purposive sample, though diverse across four generations, had limited geographic and demographic representation. We were unable to achieve equal participation across towns or balanced representation of men and Gen Z participants, despite the original goal of recruiting at least two individuals per town. Recruitment challenges, including time and cost constraints and community hesitancy toward research, also contributed to the smaller final sample of 15 rather than the intended 26. While topics were repeated across participants and points of convergence observed, full data saturation could not be achieved.

In addition, recruitment may have favored participants with preexisting interest in mental health, introducing the potential for selection bias. Limited broadband access in rural areas may also have excluded individuals with lower digital literacy or unstable internet connections, reflecting broader inequities in access to telehealth and digital resources [146]. These considerations highlight the need for future studies to adopt expanded, hybrid recruitment strategies that incorporate both online and in-person approaches to more fully capture the diversity of rural Black communities across regions.

The positionality of the first author as a Black woman and member of a Native Nation provided valuable cultural insight but also introduced the possibility of interpretive bias. Reflexive practices, including journaling, memo-writing, and consultation with CAB, were used to mitigate this influence, but future research should incorporate multiple researchers with diverse positionalities and include CAB members more directly in the analytic process [80].

Future research directions should build on these findings by investigating the long-term impacts of community-based mental health workers, proxy advocates, and culturally safe spaces on mental health outcomes in rural Black populations. Studies should also explore intergroup dynamics between rural Black and tribal communities to understand how implicit bias and historical tensions influence mental health access. Finally, longitudinal mixed-method designs with larger and more diverse samples are needed to capture how service delivery, attitudes, and needs change over time and to assess whether strategies that are effective in the short term also produce sustainable improvements [75, 107].

Conclusion

When race, systemic factors, and geography intersect, rural Black communities face disproportionately poor mental health outcomes. This study highlights persistent barriers, including stigma, financial and logistical strain, institutional mistrust, and cultural skepticism [40, 41]. At the same time, the findings underscore the importance of continuity of care, culturally responsive services, and sustained community engagement. Interventions that draw on community knowledge and local strengths while addressing structural inequities can shift conditions from limited access toward greater equity and resilience [147]. By situating the findings within the adapted NIMHD framework, this study further demonstrates how structural, cultural, and interpersonal factors overlap and reinforce one another [40, 85].

The recommendations emerging from this study emphasize layered strategies that address individual, community, and policy levels simultaneously. Implicit bias training can promote mutual respect and cross-cultural communication in shared rural spaces. Proxy advocates, including spiritual leaders, younger relatives, and individuals with lived experience, can bridge gaps by reducing stigma, normalizing care, and facilitating acceptance across generations. Culturally safe spaces hosted by trusted organizations provide opportunities for collective healing, resilience, and visibility. Accessible mental health language that avoids clinical jargon and resonates with community values can further reduce stigma and promote understanding. Policy adjustments that expand telehealth, strengthen partnerships with faith-based organizations, and advocate for culturally responsive training and rural mental health funding are equally critical [147].

Equity in mental health is not only about fixing what is broken but also about amplifying the strengths and wisdom already present. The path forward requires cultural humility to build trust, community engagement to ensure solutions reflect local realities, and systemic change to remove structural barriers. Above all, systems must recognize that trust is not automatically given by offering services but must be continually earned [147]. Taken together, these strategies highlight that mental health equity in rural Black communities is possible, but only through solutions co-developed with communities, grounded in respect, and sustained through collective action.

Electronic supplementary material

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Abbreviations

CAB

Community Advisory Board

CCBHC

Certified Community Behavioral Health Clinic

DHS

Department of Human Services

EAP

Employee Assistance Program

EOD

Employment Opportunities Division

HIPAA

Health Insurance Portability and Accountability Act

IPS

Individual Placement and Support

IRB

Institutional Review Board

NIMHD

National Institute on Minority Health and Health Disparities

OUHSC

University of Oklahoma Health Sciences Center

SDOH

Social Determinants of Health

SMI

Serious Mental Illness

Authors’ contributions

BLH conceptualized the study, conducted all interviews, and led the coding process. Analyses were iteratively reviewed with co-authors and refined through team consensus discussions. The co-authors provided additional perspectives that supported analytical balance and contributed relevant contextual and methodological expertise. Their diverse viewpoints enhanced credibility and confirmability by grounding interpretations in both professional and lived knowledge and by promoting rigor through collaborative review. KMR provided critical guidance on study design, contributed to the development of the interview guide, supported interpretation of findings, and provided substantial revisions to the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no specific funding for this work. Investigator effort and resources were partially supported by American Cancer Society grant CHERC-24-1160021-01-CHERC and the Oklahoma Tobacco Settlement Endowment Trust.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the qualitative data and potential risks to participant confidentiality, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the University of Oklahoma Health Sciences Center (OUHSC) Institutional Review Board (IRB #15850). All participants provided informed consent before participation in the study.

Consent for publication

Not applicable.

Authors’ information

BLH holds a PhD in Health Promotion from the University of Oklahoma and a Master of Public Health in Policy and Management from Boston. University. Her research focuses on health equity, rural mental health, and culturally responsive care, with a particular emphasis on how structural, cultural, and contextual factors influence healthcare access and utilization in historically underserved populations.

Competing interests

The authors declare no competing interests.