Mental Health Care Providers' Decisions to Practice in Rural Areas: Contributing Factors

Background and Purpose:

Rural areas in the U.S. have worse health and mental health outcomes compared to urban areas. One reason for these disparities is persistent shortages in the rural health and mental health workforce, including social workers. Past studies demonstrate the strongest predictor of the decision to practice in a rural location is growing up in a rural area. However, this study sought to identify modifiable and policy-relevant factors related to mental health providers’ decision to practice in rural locations in the state of Minnesota. The goal of this research is to provide policy guidance to increase the rural mental health workforce and subsequently promote health equity across geographic context.

Methods:

This cross-sectional study used a combination of administrative data from Minnesota health licensing boards and data from the Minnesota Department of Health’s Healthcare Workforce Survey of active health care providers from February 2022-February 2023. The study population was four groups of Minnesota mental health providers (n=8,908): (1) mental health clinicians licensed to prescribe medications (2) licensed mental health professionals (including clinical social workers) (3) licensed psychologists and (4) licensed alcohol and drug counselors. The key outcome of interest was the decision to practice in a rural area and the independent variables of interest included 16 unique items from the workforce survey spanning five general categories: family considerations, practice considerations, financial and loan forgiveness incentives, education and training experiences, and characteristics of the area itself. We ran one binary logistic regression for each of the four mental health provider categories and controlled for relevant covariates.

Results:

Across mental health care provider types, between 3.6-9.7% professionals practice in rural Minnesota, compared with 25.7% of the state that lives in rural areas. Having grown up in a rural area was associated with rural practice across all four provider types; all other factors varied by provider type. Having autonomy at work was associated with rural practice for prescribers (adjusted odds ratio [AOR]: 2.12, p<0.05) and psychologists (AOR: 1.86, p<0.01) and loan forgiveness was associated with rural practice for mental health professionals (AOR: 1.70, p<0.001) and psychologists (AOR: 1.48, p<0.05). Negative associations with rural practice included family considerations psychologists (AOR: 0.87, p<0.05), internships for prescribers (0.67, p<0.4), and financial incentives for mental health professionals (AOR: 0.73, p<0.001) and LADCs (0.76, p<0.05).

Conclusions and Implications:

Policy interventions to address rural mental health workforce shortages should focus on bolstering the pipeline of rural residents entering practice, but other policy efforts need to be tailored and multi-faceted, depending on provider type. Our findings suggest strengthening loan forgiveness programs for clinical social workers in rural areas could increase the rural clinical social work workforce and, in turn, bolster the rural mental health workforce overall.