Claire Snell-Rood is an Assistant Professor of Public Health at UC Berkeley and a member of the Haas Institute's Diversity and Health Disparities research cluster. Here, she discusses mental health problems facing women in rural areas and effective policy and non-policy interventions that can help address these challenges.
To begin, can you talk a bit about your research on women’s mental health in rural areas like Appalachia? What are some key factors affecting health outcomes in rural areas compared to in urban or suburban areas? How does access to healthcare fit into these outcomes?
I began doing research on rural women’s mental health a few years ago, when I was a postdoc. As a medical anthropologist, I was curious to understand about mental health specifically because it is often questioned as less “real” than other types of illness—from a clinical perspective, it often is seen as less straightforward to address or lower priority; from a cultural perspective, there can be social pressures to ignore or not seek care for distress. Rural areas have higher rates of depression, but central Appalachia is particularly affected. Many rural areas definitely have challenging social and economic circumstances that can increase the risk all manner of illnesses—from depression to heart disease. This is absolutely the case in central Appalachia, where the poverty rate is nearly twice that of the broader US. Yet access to behavioral healthcare is also a key barrier. Most rural areas are plagued by shortages in mental health providers, with the result that the treatment that is received is predominantly pharmacotherapy delivered in primary care settings. Overall, the research shows that rural folks simply receive less mental healthcare.
How can women’s social roles and obligations affect how they treat health challenges and access health care?
Research on women’s health shows that women often delay care for themselves or ignore their own symptoms because of gendered pressures to care for others’ first, and, at times, due to outright silencing of their distress. This can make it challenging for women to identify their own symptoms as worthy of recognition, let alone to sustain treatment if they are in care. However, it’s also important to zoom to the level of the family (whether nuclear or extended), where some vulnerability to poor health may be shared if the family is living in poverty. Families living in poverty face challenging questions about which health conditions are most urgent to address with limited resources—questions that are forced upon them by unequal social conditions.
What are some effective policy interventions that can improve the mental health of these women? What about non-policy interventions, like stigma reduction or community-led efforts? What are barriers to their implementation?
Interventions to improve social-economic conditions—such as cash transfer programs or economic development—have shown some positive impacts on mental health of women and families living in poverty, though there are still a lot of questions about the components of programs that are most effective and how they might work in different settings. Other researchers have argued that decreasing inequality at the society level, rather than addressing poverty status alone, can make a huge difference for mental health because it transforms social rank. Efforts to increase access to clinical care through expanding access to insurance and mental health parity laws (such as through the ACA) have made an enormous difference for enabling folks to engage in mental healthcare they hadn’t previously. In terms of interventions to address stigma, in the past few decades, survivors of mental illness built a recovery movement within mental health that has critically addressed stigma—both the stigma of biomedicine and the stigma of society. Survivors posed critical questions about who gets to define mental health problems and treatment plans and made the case that “peers”—or those who have experienced mental illness themselves—need to play a critical role in the provision of care.
The barriers to implementing policy interventions to reduce poverty and inequality are likely the greatest because they require the powerful to give up their resources. That is politically and socially very challenging, though not impossible. However, challenges to improving treatment are also extensive. Many under-resourced areas (domestically and globally) simply don’t have enough providers to offer care to all who might want it. There are also technical and organizational challenges to integrating care in areas that require sustained investment to address. Further, many efforts to expand access to clinical care don’t address how the experience of mental health varies cross-culturally—as must the treatment. There is certainly a need for communities, advocates, cultural psychiatrists, anthropologists, and providers to work together to define how the problems and their solutions vary. Finally, there is the challenge that, as movements like recovery are institutionalized, the voice of survivors is subsumed within the powerful structures of clinical practice.
Families living in poverty face challenging questions about which health conditions are most urgent to address with limited resources—questions that are forced upon them by unequal social conditions.
How has (or hasn’t) government support for rural healthcare—and mental healthcare in particular—shifted under the current administration? What are some implications of this?
Certainly this administration has drawn attention to rural health disparities, especially the opioid epidemic. However, the administration’s efforts to dismantle the ACA—first outright and now gradually through dissolving some of its key provisions—will have devastating consequences for rural areas. Already, rural areas have seen their options for insurance on the insurance marketplaces diminish due to threats to subsidies. The administration’s efforts to restrict access to the safety net—such as food stamps, TANF, disability income—will put rural residents who depend on these programs in the wake of poor economic conditions at even greater risk for poor health. The vast majority of state-targeted programs to address the opioid crisis will rely on mechanisms of the ACA, such as Medicaid expansion, to establish and sustain their efforts to expand access to treatment.
You previously did research in India, studying women and women’s mental health in slums there. What were some similarities and differences in mental health outcomes there versus in underserved parts of the US? Any surprising takeaways?
In both areas, though physical survival often receives attention as the highest public health priority, I was surprised by how much mental distress and efforts to engender mental wellness were urgent to women. In the US, many more women engaged with some form of clinical treatment for depression at some point, likely due to increasing attention from direct-to-consumer advertising and growing awareness of depression. Still, there was a lot of ambivalence about what it meant and whether clinical care was appropriate. In India, women described their distress more as “tension,” an idiom that refers to the lack of control over circumstances and worry. Mental healthcare is much more challenging to access in India, so most women struggled to address their tension through spiritual practice, through efforts for economic mobility, or trying to strengthen family security.
How does race factor into mental health outcomes in the regions you study? Are there particular challenges that affect women of color that are not experienced by their white peers? And are these issues compounded through additional factors like treatment, stigma, lack of funding, and so on?
Race is definitely a factor in rural mental health, particularly as many rural communities have experienced demographic shifts to include more poor people of color. In some cases, communities of color have been economically and politically restricted into rural ghettos, causing vast social and mental isolation. This absolutely compounds already existing barriers to treatment. Growing anti-immigrant sentiment in the last few years has also exacerbated mental distress among many rural Latina women, making them fear treatment-seeking even more deeply than before. Further, there is a need to better understand how current efforts to expand access to behavioral health treatment—such as the federally funded state-targeted response to the opioid epidemic—can do so equitably among diverse rural populations.
You are currently working to implement science frameworks to create community-based alternatives to clinical treatment for depressed rural women—can you talk a little about this? What are some “community-based alternatives” and what do they offer that standard clinical treatments do not?
I worked with community-based colleagues in Appalachian Kentucky to identify feasible, culturally acceptable strategies through which we could reach depressed rural women. We found that, even though women might articulate severe distress, some would not identify with a clinical label of depression; others were skeptical of treatment because of the mixed quality they had experienced. For many others, it was simply too difficult to get to and stay in treatment considering their extensive social obligations and all of the other co-morbidities many were managing. Therefore, we identified a recovery-based intervention that did not use any clinical language, employed group support, and could be facilitated by peers. We talked to women with depression and areas providers about how we could adapt the program, using implementation science frameworks, to be delivered through a successful regional community health worker program. Women both referred themselves to this “wellness” program and also received referrals from primary care providers with whom they had established relationships. In this way, we both linked into the existing clinical infrastructure and community capacity, but centered the program around women’s experiences of mental health, which may or may not have aligned with biomedical definitions of depression. From here, my goal is to examine how this adapted intervention can be scaled up to other rural settings that face similar barriers to treatment.
Growing anti-immigrant sentiment in the last few years has also exacerbated mental distress among many rural Latina women, making them fear treatment-seeking even more deeply than before.
How does your research intersect with the Haas Institute’s goal of expanding structural inclusion and reduce othering in various dimensions of society?
I started research in rural areas in 2013. Since then, the political meaning of studying rural mental health has changed dramatically—at times obscuring the diversity inherent to the contemporary rural US and provoking questions from all quadrants of society about belonging. I believe that there is much work to be done to address structural inclusion of rural communities, in all of their shapes and forms, and that doing so in a thoughtful way can move beyond the cultural and political categories through which we currently have to understand rural-urban differences. A critical part of this work will involve acknowledging the vast inequalities in resources between rural and urban areas, and that much of the way that healthcare reform has been conceptualized needs to better account for these inequalities.