They That Wait: Proposing A Theoretical Model for Understanding Rural Black Americans Utilization of Mental Health Services

Abstract

Black Americans in rural communities confront substantial obstacles to receiving care and experience substantial disparities in mental health outcomes due to multiple social determinants that combine to create remarkably difficult and persistent mental health challenges (Morales et al., 2020). Despite the demonstrated need for psychological services, Black Americans in rural areas are less likely to utilize mental health services than both their Black counterparts in metropolitan areas and White individuals in rural areas. Thus, the conceptual manuscript of this dissertation sought to discuss the social determinants that influence the use of mental health care services by rural Black Americans, and further whether the continued implementation of teletherapy services can adequately address these barriers to care. The Behavioral Model for Vulnerable Populations was utilized as the theoretical framework to propose a model of the pertinent factors that influence health-seeking behaviors within this population. The proposed theoretical model of mental health utilization became the basis for the empirical study, which examined the influence of predisposing characteristics, enabling resources, and need factors on mental health service utilization among rural Black Americans and evaluated whether telehealth mediated the relationship between enabling resources and service utilization. A cross-sectional survey was completed by 201 adult participants who met the inclusion criteria of residing within a rural county for at least one year and identifying as Black or African American. Structural equation modeling was conducted to evaluate relationships among latent constructs representing predisposing characteristics (discrimination, religiosity, and medical mistrust), enabling resources (health insurance and federal poverty status), and need factors (psychological distress and substance use). The final structural model demonstrated good fit (CFI = .983, RMSEA = .033, SRMR = .056). Need factors emerged as the strongest and only significant direct predictor of mental health service utilization (β = .985, p = .003), while predisposing characteristics demonstrated a significant indirect influence through total effects despite a non-significant direct association. Enabling resources were not significantly associated with utilization. Although enabling resources predicted greater telehealth use and more favorable attitudes toward teletherapy, telehealth did not mediate the relationship between enabling resources and mental health service utilization. These findings suggest that perceived mental health need remains the primary driver of treatment engagement among rural Black Americans, whereas culturally rooted factors, including discrimination, religiosity, and medical mistrust, shape utilization through more complex pathways. Interventions aimed at reducing mental health disparities should extend beyond improving structural access to address culturally grounded barriers and strengthen trust and engagement within rural Black communities.