May/June 2014 Issue
Reaching Rural Veterans
Approximately 36% of America’s 22 million veterans of military service live in rural areas, and 6% of those rural veterans are women, according to Byron Bair, MD, FACP, MBA, director of the Veterans Rural Health Resource Center, Western Region, for the VA’s Office of Rural Health. Compared with their suburban and urban counterparts, rural veterans have a higher prevalence of both physical and mental comorbidities as well as reduced access to care, said Bair, speaking as an expert on rural health and the health of veterans in rural America during a January 2014 webcast sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Bair suggested that rural vets generally are older, sicker, poorer, and more likely to lack options for primary, specialty, and mental health care, and must travel longer distances to receive care.
Additionally, there is a health professional shortage area in one-third of all rural U.S. counties, and rural areas contain 85% of mental health and 75% of primary care health professional shortage areas, according to Hilda Heady, MSW, ACSW, senior vice president and chair of the Rural Health Research and Policy Group for Atlas Research, also speaking during the SAMHSA webcast.
A more practical problem also contributes to reduced access to care for rural veterans: distance. The average distance to a medical facility for a rural vet is 63 miles. Compounded by the lack of public transportation systems in most rural areas, this becomes a major barrier to accessing care. In fact, distance from treatment facilities is the strongest predictor of poor retention in treatment for mental illness and substance use disorders.
The Rural Context
Rural people often view their culture and communities as different and special, with a higher quality of life that comes from knowing what is important in life and accepting a “natural order of the world,” Heady said. Rural people tend to describe themselves as down to earth and are more likely to be employed in high-risk extractive industries (e.g., timbering, drilling, mining, food production) that reinforce the values of self-sufficiency and hard work, Heady said, and they are inclined to view the world with a dose of realism, tending toward pragmatic solutions to problems.
Health care providers should take these aspects of rural culture into account when intervening with rural veterans, Heady said. “When the cultural expectation is self-reliance, it can be difficult to ask for help. When fairness and equal access are valued, being singled out for special attention is difficult,” she said. Combat veterans often are most reluctant to talk about the conflict between their spiritual beliefs not to kill and their experience of killing in battle and thus their worthiness of God’s love, she added.
These cultural norms may provide cultural context for the research Heady cited, which indicates that rural veterans are most likely to confide in another veteran, a family member, or a clergy member before seeking out a mental health or substance use professional.
Treatment of Substance Use Disorders
According to the SAMHSA, one in five veterans of the wars in Iraq and Afghanistan has major depression or PTSD. Results from the Post-Deployment Health Assessment, which is administered when soldiers return from deployment and again three to six months later, show that combat-related PTSD and other co-occurring disorders are likely to develop over time, thus screening of veterans should be repeated to identify early and emergent stages of behavioral and substance use disorders.
A November 2012 report from the Center for Behavioral Health Statistics and Quality found that alcohol is the primary substance of abuse for one-half of veterans aged 21 to 39 who chose to seek treatment in non-VA facilities. Veterans were more likely than nonveterans to report alcohol as the primary problem (50.7% vs. 34.4%), while nonveterans were more likely than veterans to report heroin (16.8% vs. 9%) or marijuana (17.6% vs. 12.2%). Abuse of other opiates was nearly equivalent (12.2% for veterans vs. 12% for nonveterans).
Given that alcohol is the substance most likely to be abused, the VA and the Department of Defense released revised clinical practice guidelines in 2009 that recommend screening all patients for unhealthy alcohol use. The goal of the brief screening is to identify patients drinking above recommended limits as well as patients who are drinking despite contraindications (eg, pregnancy, liver disease, other medical conditions exacerbated by alcohol consumption) to determine the appropriate level of intervention.
These clinical practice guidelines recommend one of two validated brief screening instruments: the Alcohol Use Disorders Identification Test Consumption Questions and the Single-Item Alcohol Screening Questionnaire (SASQ). The SASQ recommended drinking limits are no more than 14 drinks per week and no more than four drinks on any occasion for men, and no more than seven drinks per week and no more than three drinks on any occasion for women. A positive screening indicates the need for further assessment, ideally a comprehensive biopsychosocial assessment.
Bridging the Gaps
The Rural Veterans Outreach Program seeks to improve rural veterans’ access to benefits through community partnerships. With the recognition that the VA cannot have a physical presence in all rural communities, the goal extends beyond outreach to building lasting relationships between community agencies and the VA. The Rural Veteran Outreach Toolkit (www.ruralhealth.va.gov/resource-centers/western/outreach-toolkit.asp) provides resources for identifying and sustaining partnerships.
In recognition that many veterans and family members will make their first contact with the clergy, the Rural Clergy Training Program, offered through the National VA Chaplain Service, provides an educational program addressing issues such as readjustment challenges, spiritual and psychological effects of war trauma, VA benefits and services, and the role of the community in reducing stigma.
“Trust is the key for rural engagement,” Bair said, describing the underpinnings of the work of the Office of Rural Health, from the macrolevel work of integrating systems and building partnerships between communities and the VA to the clinical relationships between veterans and care providers.
— Liza Greville, LCSW, is in full-time clinical practice in rural Pennsylvania.