The Rural Perspective on Continuity of Care: Pathways to Care for Children with Emotional and Behavioural Disorders

Key Implications for Decision Makers

  • Pathways to children's mental healthcare are non-linear, complex, and dynamic. The concept of a single point of access to children's mental health services needs further investigation.
  • Rural communities differ from urban communities. What works in facilitating access to children's mental health in urban centres may not work in rural communities. There is a need to address alternate or more flexible funding mechanisms and/or service delivery models for rural areas.
  • There are multiple challenges to accessing mental healthcare for children and youth in rural communities. Within each community, these challenges coexist with unique advantages and strengths. There is no one homogenous rural reality; therefore, decision-making for these areas should be tailored to the specific strengths and needs of each community.
  • Family self-help and advocacy groups facilitate access to and utilization of children's mental health services. Financial support is required for these groups to form and flourish.
  • Several mental health service programs were identified as facilitators to successful treatment access. Evidence-based programs that are working well in rural communities need to be promoted and expanded upon.
  • Skilled, local service providers could be trained to act as support to more specialized practitioners. They require financial support, as well as acceptance and recognition by other professionals, both inside and outside the community.
  • Locating mental health professionals in school settings requires further consideration in order to address issues of access. For example, building local capacity in school settings to conduct risk assessments could lead to earlier intervention and prevention.

Executive Summary

Decision makers indicate the need for evidence-based research to advocate for improved or different services and support (CHSRF, 1999). They have identified the lack of an evidence base in the children's mental health system. In rural areas, the situation is even more pronounced (Pitblado & Pong, 2000). Decision makers have had to rely on anecdotal evidence about the pathways and barriers to care and have noted that recent calls to strengthen the evidence base of policy development have become more pronounced in response to pressures for greater transparency and accountability in decision-making.

Currently, there are as many as 10 million Canadians who can be considered rural residents - one-third of all Canadians (Pong, 2000). Children and their families in rural and northern areas may face more obstacles to obtaining health services and supports than those in urban areas (Cutrona, Halvorson & Russell, 1996; Starr, Campbell & Herrick, 2002). The problems of service access often result from geographic, economic, and cultural factors (Kelleher, Taylor & Rickert, 1992; Letvak, 2002).

The objective of this study is to examine access to mental healthcare for children and youth in rural Ontario communities, from the perspectives of service providers and families. Participants were asked to identify the challenges and facilitators to accessing and delivering services to children with emotional and behavioural disorders and their families. Qualitative methods were used to obtain the voice of families and service providers regarding access issues in the children's mental health service system in rural areas.

Four focus groups were held with a broad range of community stakeholders in the children's mental health system to obtain a comprehensive overview of the system and identify issues faced in the delivery of services on a daily basis. Qualitative in-depth interviews were conducted with 30 parents who live in the rural catchment areas of our two study sites (Sudbury and Owen Sound) who had a child, three to 17 years of age, with a formal diagnosis of an emotional or behavioural disorder. In addition, 30 service providers were interviewed in both study sites, including children's mental health professionals, private practitioners, policy makers, and providers of related services such as teachers and police officers.

Pathways to mental healthcare for children in rural communities are complicated, dynamic, and non-linear. Although faced with multiple roadblocks, there are also several factors to help minimize these barriers. The interview data show three overall thematic areas that describe the main barriers and facilitators to care for children and youth with mental health problems in rural Ontario. These are personal, systemic, and environmental factors. More importantly, our analysis reveals that service providers and family members are constantly negotiating ongoing tension, struggle, and contradiction vis-à-vis their attempts to access and provide mental healthcare for children. Most factors identified as barriers are also, under different circumstances, facilitators. Our analysis clustered around the contrasts, contradictions, and paradoxes present throughout the interviews. For example, the small size of communities was often mentioned as a reason for ease of access to care through word of mouth in a close-knit community. This notion of a more supportive rural community has been noted previously (Philo, Parr & Burns, 2003). On the other hand, the small size of the community contributes to the lack of anonymity and stigma associated with mental illness. This "glare of rural familiarity" (Voss, 1996) can contribute to the reluctance of some people to use mental health services. The fear of being seen is frequently an important issue related to the decision to avoid seeking mental health services (Bachrach, 1983).

The assumption of a rural homogeneous reality masks the diversity and uniqueness of rural communities. While emphasizing the common themes prevalent in service providers' and family members' narratives, we have attempted to highlight the unique perspectives and experiences that each participant shared with us. Consequently, recommendations made by the parents and service providers participating in this study were varied, but several common themes emerged: i) accessibility; ii) integration; iii) early intervention; iv) education and promotion; v) school and child care; vi) parental support; and vii) rural approach to service delivery.

This research was based on an approach designed to have decision makers participate in all aspects of the study from implementation to dissemination. Information from this study will be used to inform the strategic planning activities of the agencies and organizations serving these rural communities. Thus, project results have important implications for the organization and delivery of mental health services for children in rural areas. It offers information to support the development and evaluation of policies and procedures to overcome some of the barriers to care for children and youth with emotional and/or behavioural disorders.