The COVID-19 pandemic has created a double whammy for rural men and their loved ones: Their access to medical care is often difficult because of long distances to travel for treatment, and they are less likely to have access to high-speed internet for telehealth visits.
Even before the pandemic, healthcare for rural men had unique challenges. For the approximately 60 million Americans — nearly one in five — who live in rural areas, limited access to healthcare professionals, particularly specialist care, is a critical barrier to achieving favorable health outcomes. Compared to metropolitan regions, rural and frontier regions contain more than twice as many “Health Professional Shortage Areas” designated by the US Department of Health and Human Services. The reduced healthcare access is a major factor in rural patients’ greater disease burdens and poorer outcomes from chronic conditions, including hypertension, diabetes, and arthritis.
Those outcomes make rural men especially vulnerable to COVID-19. And if they do get sick with COVID-19, rural men are more likely to require hospitalization because they were sicker to begin with. Increasingly, they’re competing for beds. Hospitalizations for rural COVID-19 patients have been on the rise, from about 10 percent in the first week of October to about 25 percent in late November and early December, a study showed. This is made even more complex and difficult because in many rural areas, hospitals are sparse and tend to have fewer beds in general and fewer intensive care beds.
The study, conducted by the North Carolina Rural Health Research Program, was based on data from the U.S. Department of Health and Human Services. On December 15, HHS published weekly data on each U.S. hospital tracking key indicators for how the facilities were coping with Covid-19 care.
The study raised a concern that, while rural COVID-19 hospitalizations lagged behind urban ones, the higher urban rates may mean that there is no space for rural patients if they require care that’s beyond the scope of their nearest hospitals to provide.
Another significant concern is that rural men are likely to experience a sizable increase in mental health needs during and after the pandemic, whether they had a prior history or not. That double whammy – difficulty in accessing health care and lack of access to high speed internet – applies to mental issues, too. Chief among these mental issues is depression, as people feel isolated and alone during the pandemic.
Men’s Health Network, a non-profit concerned with men’s health issues, convened a conference in 2019 to discuss an ongoing crisis in men’s mental health. You can read the report that came out of that conference here.
“For men and boys, these problems can be amplified by cultural expectations that men be stoic. Men are told they are not supposed to cry or show their emotions outwardly, that they are supposed to be self-reliant, to not ask for help, and that any illness, mental or physical, is a sign of weakness and a source of personal shame. Men’s health has a great impact on society as a whole that we are only beginning to recognize,” said Jean Bonhomme, M.D., Founder and Chair of the National Black Men’s Health Network, who helped organize the conference. It was staged in conjunction with the Patient-Centered Outcomes Research Institute (PCORI).
“Unnecessary illness and disability among men lead to diminished work productivity, greater work absenteeism, and employers incurring the expenses of training replacement workers. Families may be impacted with increased health care expenses in the face of reduced ability to earn. Jails have taken the place of many US mental hospitals, leading to costly but ineffective interventions,” he said.
Men are less likely to seek treatment for mental health issues, the conference found, but new projects may make it easier for them to do so.
Cognitive Behavioral Therapy (CBT) is an important frequently used treatment for depression. Its goal is to help patients learn how to change their thinking patterns to improve how they feel. CBT may be used in conjunction with prescription medicine, or on its own.
Evidence has mounted that CBT can address other conditions, such as anxiety disorders, post-traumatic stress disorder, eating disorders, obsessive-compulsive disorders, and many others. CBT is a preferred modality of therapy among many practitioners and insurance companies alike as it can be effective in a brief period, generally 5 to 20 sessions, though there is no set time frame. Research suggests that CBT can be delivered effectively online, in addition to face-to-face therapy sessions.
Robert Bossarte, Ph.D., of West Virginia University in Morgantown, W.Va., is directing a project to see how remote CBT can improve mental health in vulnerable populations. The project is funded by PCORI.
In remote CBT, patients have online therapy sessions. This may be more comfortable for men, who are often reluctant to seek face-to-face care.
In the Bossarte study, the research team will compare two types of remote CBT with usual primary care for treating depression. The study takes place in rural West Virginia, where usual primary care for depression often involves antidepressant medicine alone, but has value for rural healthcare providers across the country.
To get around the issue of lack of access to high-speed internet, the Bossarte study will include components that use participants’ cell phones, including text messages, phone calls and access to online therapy sessions.
The project is recruiting more than 3,000 patients who are currently being treated for depression at West Virginia clinics, assigning them at random to one of three groups. The research team will compare outcomes for patients in those treatment groups:
• The first group receives usual care plus guided remote CBT. In guided remote CBT, a trained coach helps patients complete online therapy sessions with oversight from a clinical psychologist. The coaches also work with patients by email, text, and phone to help them. This will include reminders to take medicines as directed, monitoring side effects of medicine, determining if medicine is working as intended, coordinating with the patient’s doctor, and providing referrals to specialists.
• The second group will receive usual care plus unguided remote CBT. These patients have access to the same online therapy sessions as patients in the first group. But patients in this group complete therapy sessions online by themselves, without help from a coach. The online program provides automated reminders and encouragement during and between sessions.
• Patients in the third group will receive usual care for depression from their primary care doctor. Usual care may consist of antidepressant medicine and/or therapy.
The research team will survey patients 10 times over the course of a year. Researchers will ask patients if their depression has gotten better and if they are using drugs or alcohol. The team will also look at medical records to see if patients are receiving antidepressant medicines. About a year after treatment, the team will ask patients if they made shared decisions about depression treatment with their doctor.
The research team will compare outcomes between patients in the three treatment groups. In addition, the team is looking to see if certain types of patients benefit from having guided versus unguided treatment, or usual care alone. Finally, the team is looking at whether different types of antidepressant medicine work better than others, alone or in combination with CBT.
The team will explore whether access to remote cognitive behavioral therapy (CBT) will improve mental health symptoms in vulnerable populations. Outcomes of this project could also lead to future comparative clinical effectiveness research, such as a comparison of modes of providing access to remote CBT and comparisons of different online platforms for remote CBT for various population groups.
To see resources that can help rural residents – whether they’re patients or healthcare providers – improve health in their own communities, visit the appropriate page for your state at the Rural Health Information Hub, funded by the Federal Office of Rural Health Policy.
Robin Mather wrote this piece for the Men’s Health Network (MHN). Mather is a third-generation journalist with more than 40 years’ experience working at major daily newspapers and national magazines. A Michigan native, she now lives in Arizona. MHN is an international non-profit organization whose mission is to reach men, boys, and their families where they live, work, play, and pray with health awareness messages and tools, screening programs, educational materials, advocacy opportunities, and patient navigation. For information on MHN’s programs and activities, visit them at menshealthnetwork.org, on Twitter (@MensHlthNetwork), and on Facebook (facebook.com/menshealthnetwork), or call 202-543-6461.