The nationwide mental health crisis highlights the need to examine school-based mental health infrastructure at the local level. Limited information exists regarding available services and support in rural schools and communities. This study explores school-based mental health infrastructure gaps from the perspective of school nurses (N = 28) in rural Northeast Texas, including quality and availability of services, support, and policies across all grade levels. Over 70% of participants reported that school services do not reflect student needs, and the quality and availability of mental health services within and/or local to their campus were average to poor. More research on rural school-based mental health infrastructure is warranted given the significant challenges and poor outcomes in this region.
Pregnancy loss is a widespread experience, with miscarriage affecting 15% of known pregnancies. Lack of structured emotional and social support following pregnancy loss has been associated with increased risk of prolonged grief, depression, and anxiety symptoms, particularly in rural populations with limited access to mental health services. Despite its frequency, many rural communities lack structured emotional and social support for mothers experiencing loss. This project illustrates a feasible approach which can act as a scalable template for other facilities, integrating evidence-based care, patient support, and community engagement. To support (a) evidence-based education, an interdisciplinary presentation was delivered at an all-medical staff meeting including physicians, midwives, and advanced practice providers in the community. A retrospective chart review was conducted, and results were leveraged to identify community-specific needs and opportunities for improved care delivery. Educational content included demographic trends, information on medical management, and available mental health resources. To promote (b) patient-centered care, pregnancy loss care kits were stocked in the clinic, emergency department, and three regional outreach clinics. Forty kits were created for approximately $200, ensuring care for approximately 3 years based upon hospital demographic data. To support (c) community engagement, a memorial walk was conducted by local leaders, of which >140 community members attended. Continued hospital funding for pregnancy loss care kits and voluntary donations at the memorial walk ensure this project is a self-sustaining endeavor. Overall, rural mothers may benefit from creative initiatives for holistic support for pregnancy loss. Mental health resources are often scarce, and community engagement and social support can help bridge the gap to ensure emotional healing. By combining clinical insight with tangible support and public remembrance, this work illustrates a feasible, low-cost approach model that can be adapted across other rural facilities to strengthen continuity of care and reduce isolation following pregnancy loss.
Children of immigrants face unique stressors that may increase vulnerability to mental health concerns, yet research on their needs in rural U.S. contexts remains limited. This study examines the prevalence and correlates of mental health risks among children of immigrants in a rural county in Georgia during a period of heightened immigration uncertainty. Teacher-reported Strengths and Difficulties Questionnaires were collected by Migrant Education Program staff for 188 K-12 students of foreign-born parents. Findings indicate that 40% of children were at risk on the total Strengths and Difficulties Questionnaires, with elevated proportions across all five subdomains. Middle school students had significantly higher odds of overall mental health risk than elementary school students (OR = 4.52, p < .05). Compared to boys, girls were less likely to exhibit conduct problems (OR = 0.22) and hyperactivity (OR = 0.27) but more likely to experience emotional problems (OR = 3.05, p < .01). Housing instability was associated with increased peer problems (OR = 4.12, p < .05), while higher academic performance and English proficiency emerged as protective factors. Findings highlight substantial unmet needs in rural immigrant communities and underscore the importance of strengthening school-based mental health supports.
This study explores rural farmers' preferences for receiving mental health resources. Structured, in-depth interviews were conducted with full-time farmers (n = 31) throughout 19 counties within the state of Georgia. Interviews were recorded and transcribed, and researchers coded interviews separately before thematic analysis was used to identify common themes. Half of the farmers reported access to local mental health treatment, and most said they were comfortable discussing mental health with their primary care provider, who was often cited as being their main touchpoint for mental health services. Three overarching categories emerged regarding preferred methods for delivering mental health resources: community-based partners, clinical settings, and media platforms. Peer support and farming-specific meetings were the most frequently reported community-based resources, followed by private channels, faith-based settings, and financial services. Primary care providers were the most reported clinical avenue, followed by therapists and telehealth. Many farmers also described the importance of print and online media in distributing mental health resources due to its convenience and privacy. Generational and gender differences in attitudes toward delivery methods were also noted. Farmers generally believed younger peers were more open to utilizing mental health services. Female farmers more often identified peer networks, therapists, and telehealth as useful, while male farmers emphasized private channels, one-on-one meetings, and media. The findings of this study emphasize the importance of further research examining gender and generational differences in farmers' attitudes toward mental health resources to develop more effective strategies to support farmer health and well-being.
Rural communities face persistent mental health disparities, driven by inadequate health care infrastructure, poverty, geographic isolation, and cultural stigma. Telemental health (TMH) presents a promising solution by expanding remote access to psychiatric care. This article reviews evidence on TMH implementation in rural areas and evaluates its potential in reducing rural-urban mental health disparities. Research suggests that TMH can increase service utilization with clinical outcomes comparable to face-to-face care, though several barriers persist. Future research should examine long-term TMH effectiveness in rural settings, as leveraging telehealth may help improve mental health care in underserved, rural communities. Public Health Significance Statement Limited access to mental health care in rural areas contributes to significant health disparities, leading to higher rates of undertreated mental health conditions and negative health outcomes. While telemental health has expanded access, structural and sociocultural barriers continue to hinder its effectiveness in rural populations. Addressing these challenges is critical to ensuring equitable mental health care access and improving outcomes for underserved communities.
As of 2022, one quarter of U.S. adults have a diagnosed mental health disorder, making access to behavioral health (BH) services critically important. While access to telebehavioral health (TBH; defined as a form of synchronous telehealth-the process of providing BH care from a distance, usually using videoconferencing technology) expanded during the COVID-19 pandemic, it remains limited in rural and frontier areas. Little attention has been paid to spatial associations in TBH access within geographically rural U.S. states. This study examines geospatial access to TBH and its association with social vulnerability variables and rurality in New Mexico (NM), exploring health care resource allocation, geography, rurality, and social vulnerability. Two geospatial data sets were developed to model spatial access to BH specialists and average drive time to reliable cell phone coverage. BH provider data came from the National Provider Inventory directory. A four-step model framework, including global and geographically weighted logistic and linear regression, was used to examine associations between social vulnerability variables, rurality and TBH access vulnerability, and their geographic patterns. Most of the tracts were not classified as "vulnerable," but some showed varying vulnerability levels. Several census tract variables correlated positively with increased telecommunications and BH access vulnerability. Rural NM, especially American Indian or Alaska Native areas, had poorer access to BH services and reliable mobile data. This study highlights spatial disparities in TBH access in rural NM. Improving TBH access and telecommunications infrastructure are crucial for addressing service challenges, particularly for rural areas and American Indian or Alaska Native populations. Federal initiatives are essential to prevent worsening inequalities.
Poverty is a known risk factor for poor mental health in rural areas, where limited resources exacerbate challenges like food insecurity, housing instability, discrimination, and inadequate mental health care, though the specific mechanisms remain underexplored. This study aims to examine the mediating role of social determinants of health, including food insecurity, housing instability, mental health care access, stress, social support, and discrimination, in the relationship between poverty and poor mental health in Southern Appalachia. Repeated cross-sectional data from two waves of the Community Health Needs Assessment panel survey in 2021 and 2024 were analyzed. Mediators included food insecurity, housing instability, mental health care access, stress, social support, and discrimination. A counterfactual four-way decomposition mediation model assessed the direct and indirect effects of poverty on mental health for each mediator and relevant covariates. Stress emerged as a key mediator, with a controlled direct effect (CDE) risk ratio (RR) of 1.11, potentially eliminating 48.6% of poverty-mental health disparities. Food insecurity (CDERR = 1.13) could mitigate 37.3% of disparities, while housing insecurity (CDERR = 1.12) could reduce 42.6%. Mental health care access (CDERR = 1.14) could lower disparities by 33.4%. Discrimination (CDERR = 1.13) and a lack of social support (CDERR = 1.15) also significantly mediated the poverty-mental health link, with potential disparity reductions of 27.1% and 32.1%, respectively. Targeting food security, housing stability, and mental health care access through community and health care infrastructure represents a critical pathway for reducing poverty-related mental health disparities in Southern rural Appalachia, offering actionable strategies for policymakers and clinical practice.
Rural youth in the United States face multiple barriers to mental health services, such as a lack of trained providers and limited or nonexistent services. Telemental health services in prekindergarten through high school (PK-12) settings offer promising bridges to meet the mental health needs and address service delivery disparities for rural, underresourced youth. The present scoping review aimed to consolidate the defining characteristics of empirical literature on telemental health services in rural PK-12 schools since the COVID-19 pandemic. Fourteen electronic databases and Google Scholar were searched for peer-reviewed articles published from 2020 through 2024 using the established inclusion and exclusion criteria. From an initial N = 4,344 records, a total of eight studies were identified. The authors identified two overarching themes: viability and sustain-ability. All eight studies supported the effectiveness or viability of telemental health, but most were grant funded and experienced various challenges and barriers that could impact sustainability. Only half were conducted with youth and families as recipients, whereas the other half focused on evaluating training and service delivery models in school settings with educators and other professionals. Findings illustrated that (a) school-based telemental health services have substantial potential to address mental health service disparities for rural youth, and (b) more research on sustainable funding pathways and policies that support continued implementation in rural schools is needed. Public Health Significance Statement Rural youth face persistent barriers to mental health care and limited-service infrastructure. This scoping review synthesizes emerging evidence showing that school-based telemental health can expand access, strengthen workforce capacity, and address long-standing service disparities. Findings highlight promising viability but underscore that sustainable funding, infrastructure, and policy support are essential to ensure rural schools can maintain and scale equitable mental health services.
While tele-mental health has improved access to standard medication management and psychotherapy for rural veterans, implementation of interventional psychiatry treatments will require in-person care, potentially leading to the exacerbation of rural-urban disparities in access to mental health care. We studied the availability of interventional psychiatry treatments, delivered clinically or in the context of a research trial, to rural and urban veterans. We used the U.S. Department of Veterans Affairs electronic medical record data to measure the use of electroconvulsive therapy, magnetic seizure therapy, repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation, deep brain stimulation, ketamine (infusion or nasal spray), stellate ganglion block, and medication-assisted psychotherapy (AP) protocols, including 3,4-methylenedioxy-methamphetamine-AP and psilocybin-AP, as appropriate, for U.S. Department of Veterans Affairs patients with major depressive disorder and posttraumatic stress disorder from 2017 through 2024. We compared treatment use in rural and micropolitan locations to use in urban locations. Few patients received any interventional psychiatry treatment across strata. The most common modalities were rTMS, electroconvulsive therapy, stellate ganglion block, deep brain stimulation, and ketamine. The numbers receiving magnetic seizure therapy, vagus nerve stimulation, 3,4-methylenedioxy-methamphetamine-AP, and psilocybin-AP were too small to report in the micropolitan or rural cells. Micropolitan and rural patients had lower odds of receiving rTMS, electroconvulsive therapy, stellate ganglion block, deep brain stimulation, and ketamine than urban patients. The largest disparities were for rTMS and ketamine. There appear to be rural-urban disparities in the emerging field of interventional psychiatry, and the disparities are most pronounced for treatments that require repeated in-person visits, such as rTMS and ketamine.
Rural Hispanic veterans experience elevated suicide rates when compared to urban counterparts. Group differences remain poorly understood. This study evaluates a rurality-stratified sample of Hispanic Veterans Affairs patients, leveraging unstructured electronic health record data to refine population-specific suicide risk prediction metrics. The study utilized a rural and urban Hispanic Veterans Affairs patient data set, including all suicide decedents from 2015 to 2018 (cases). Each case was matched with four patients who shared demographics and treatment year and remained alive (controls). After extracting and preprocessing all unstructured electronic health record text data, the corpus was analyzed using the 500+ variable semantic analysis package. Least absolute shrinkage and selection operator and logistic regression were used to develop prediction models, and the area under receiver operating characteristic curve was used to examine the models' predictive accuracy. The final data sets included 39 rural cases and 148 controls, alongside 273 urban cases and 1,090 controls. The predictive models offered considerable accuracy (rural area under receiver operating characteristic curve = 0.86; urban area under receiver operating characteristic curve = 0.67). While rural models emphasized dislocation from community and communal resources, urban models emphasized alienation and identity challenges. This study enhances understanding about rural and urban Hispanic suicide decedents and could inform suicide prediction and preventive services.
The purpose of this article is to examine existential therapy as an appropriate theory for school counselors to address the unique needs of lesbian, gay, bisexual, transgender, queer, intersex, or asexual students in rural communities, particularly in the context of limited support and increased stressors.
The 2024 New Brunswick Eating Disorder Summit brought together 150 experts, people with lived experiences, Indigenous health leaders, policymakers, and stakeholders from diverse health fields across New Brunswick, Canada, to share knowledge and identify priorities in improving access to evidence-based eating disorder services. With over half of New Brunswickers living in rural communities, the lack of publicly funded, specialized eating disorder services in the province leads to extensive human suffering, as well as social and financial costs. This article shares the results of the Summit, as well as highlights community mobilization efforts to improve access to inclusive specialized services. Common challenges identified throughout the Summit included the following: knowledge and training gaps, lack of interdisciplinary support, and no publicly funded treatment pathways. This community engagement effort highlighted three provincial priorities: specialized outpatient treatment options, education and training for care providers, and specialized residential/inpatient treatment options. The Summit has led to clinical networking; development of a social advocacy video, reports, and presentations; province-wide interdisciplinary education; and various ongoing meetings with government and health care decision-makers.
Postgraduate school clinical supervision is a requirement of behavioral health licensure, yet financial, administrative, and logistical barriers limit capacity. This study evaluates the early impact of the Behavioral Health Education Center of Nebraska's American Rescue Plan Act supervision incentive program, which aims to reduce barriers and increase the number of provisionally licensed providers. Researchers used an explanatory sequential mixed methods design to evaluate the program. Nineteen Nebraska organizations received funding between 2023 and 2024 to support supervision of provisionally licensed behavioral health providers. Baseline and follow-up surveys captured organizational characteristics, supervision barriers, and changes in the number of supervisors and supervisees. Paired Wilcoxon signed-rank tests assessed barrier reductions. Semistructured interviews explored program implementation, funding impact, and challenges. The research team analyzed quantitative data using Statistical Package for Social Sciences and qualitative data using NVivo. There was a 110% overall increase in supervisees, with the largest increase in mental health counselors (194%), followed by social workers (72%), and drug and alcohol counselors (50%). There was a statistically significant reduction in barriers related to supervisor funding (p < .01), supervisee funding (p < .05), operating costs (p < .01), and time demands (p < .05). Qualitative data confirmed program and funding value and highlighted the role of technical assistance in successful program implementation. Direct financial incentives can mitigate behavioral health supervision-related barriers. Behavioral Health Education Center of Nebraska's American Rescue Plan Act provides an early, scalable model for state-level licensure support programs and demonstrates the importance of combining funding with technical support to achieve success. These findings can inform workforce development strategies.
Working in rural settings presents unique challenges, and the do no harm, examine ethical codes, examine motives, seek consultation, consent (DEESC) model for ethical decision-making addresses a critical need for mental health providers in rural places. Recognizing the unique cultural, geographic, and socioecological dynamics of rural communities, the DEESC model is a place-based ethical decision-making framework designed for rural mental health providers, integrating nonmaleficence, cultural humility, and reflective practice through five core steps represented in DEESC-do no harm, explore ethical codes, examine motives, seek consultation, and secure consent-to navigate the unique ethical challenges of rural practice. This model acknowledges the complexities of rural mental health practice, such as dual relationships, boundary extensions, confidentiality challenges, and scope of practice challenges, offering a structured yet iterative process to navigate these issues. Through its place-attentive lens, the DEESC model ensures that rural counselors consider the diverse cultural and socioecological contexts that influence their ethical decision making. This framework serves as an ethics resource for counselors and other mental health professionals when navigating the situations that emerge in rural communities. Public Health Significance Statement Mental health providers working in rural areas often face complex ethical challenges, such as overlapping personal and professional relationships, maintaining confidentiality in small communities, and practicing within their professional limits due to limited resources. This article introduces the do no harm, examine ethical codes, examine motives, seek consultation, consent model, a new decision-making framework specifically designed to help rural mental health professionals navigate these unique challenges. The do no harm, examine ethical codes, examine motives, seek consultation, consent model emphasizes doing no harm, cultural awareness, and careful reflection. It guides providers through five clear steps to support ethical, thoughtful choices in difficult situations. This model is important for counselors, social workers, and other mental health professionals serving rural communities, as it offers practical support tailored to the realities of their work, helping ensure responsible and culturally sensitive care.
The objectives of this study were to (a) examine symptoms of anxiety and depression and severity of psychological distress in agricultural producers by gender and (b) investigate whether there are gender differences in agricultural producers' risk of alcohol use disorder. A total of n = 1,135 agricultural producers in 12 Midwestern states completed a paper survey to identify symptoms of common mental health conditions and risk for alcohol use disorder. Symptoms indicating potential anxiety and depressive disorders were measured using the Generalized Anxiety Disorder-2 and Patient Health Questionnaire-2, respectively. Symptoms of psychological distress were assessed using the Patient Health Questionnaire-4, a cumulative score of the Generalized Anxiety Disorder-2 and Patient Health Questionnaire-2. Alcohol-related risk was assessed using the Alcohol Use Disorders Identification Test (U.S. Version). Women agricultural producers met the criteria for a potential anxiety disorder at a higher prevalence than men (14.6% vs. 8.3%; p = .049). Nearly one in five men agricultural producers (17.6%) were at risk for alcohol use disorder, compared to 7.0% of women (p = .011). A higher proportion of women met the criteria for a potential depressive disorder and more psychological distress, although not statistically significant. Women were more likely to have higher education levels (p < .001), not be married (p < .001), report being a partner owner/operator (p < .001), and have fewer years of farming experience (p < .001). Women agricultural producers disproportionately experienced adverse mental health, particularly symptoms indicating a potential anxiety disorder. Comparatively, men producers engaged in riskier drinking behaviors. Our findings can inform gender-responsive mental health and substance use screening, prevention, and intervention strategies in rural areas to better serve agricultural populations. Future research should examine associations between gender-specific stressors and mental health outcomes to design targeted, evidence-based care.
Suicide is a concern in rural veterans, particularly following acute mental health admission. Rural veterans can experience barriers accessing treatment, including mental health treatment. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 aims to alleviate some challenges through access to Community Care, which has since raised concerns about suicide prevention effort discrepancies and barriers between Veterans Affairs (VA) and non-VA providers. Despite concerns, limited studies exist of suicide prevention strategies in rural veterans receiving acute mental health Community Care. We conducted a pilot study of the suicide prevention program, VA Brief Intervention and Contact (VA BIC) Program, in rural veterans who accessed acute mental health Community Care across Northern New England. VA BIC supports treatment engagement and health-promotion behaviors in veterans after Community Care discharge. We developed a process to recruit eligible veterans into a 3-month study of VA BIC. We assessed the feasibility of VA BIC in Community Care veterans and collected mental health outcome pilot data. Among 44 eligible and reachable patients, 45.5% (N = 20) consented. Retention was high, with 95.0% of patients completing all assessments. Among the 10 VA BIC participants, adherence was high, with 90% completing all eight visits and 100% completing six visits. Suicidal ideation, hopelessness, social connectedness, and suicide-related coping trended toward improvement in the VA BIC group at follow-up. It is feasible to study VA BIC following discharge from acute mental health Community Care, and the intervention may benefit veterans. Future studies should confirm the efficacy of VA BIC in reducing suicide risk in non-VA settings.
Objective:While tele-mental health has improved access to standard medication management and psychotherapy for rural Veterans, implementation of interventional psychiatry treatments will require in-person care, potentially leading to the exacerbation of rural-urban disparities in access to mental health care. We studied the availability of interventional psychiatry treatments, delivered clinically or in the context of a research trial, to rural and urban Veterans. Methods:We used VA electronic medical record data to measure the use of electroconvulsive therapy (ECT), magnetic seizure therapy (MST), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), ketamine (infusion or nasal spray), stellate ganglion block (SGB), and medication-assisted psychotherapy (AP) protocols including 3,4-methylenedioxy-methamphetamine (MDMA)-AP and psilocybin-AP, as appropriate, for VA patients with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) from 2017 through 2024. We compared treatment use in rural and micropolitan locations to use in urban locations. Results:Few patients received any interventional psychiatry treatment across strata. The most common modalities were rTMS, ECT, SGB, DBS, and ketamine. The numbers receiving MST, VNS, MDMA-AP, and psilocybin-AP were too small to report in the micropolitan or rural cells. Micropolitan and rural patients had lower odds of receiving rTMS, ECT, SGB, DBS, and ketamine than urban patients. The largest disparities were for rTMS and ketamine. Conclusions:There appear to be rural-urban disparities in the emerging field of interventional psychiatry, and the disparities are most pronounced for treatments that require repeated in-person visits such as rTMS and ketamine.
Objective:Suicide is a concern in rural veterans, particularly following acute mental health admission. Rural veterans can experience barriers accessing treatment, including mental health treatment. The MISSION Act of 2018 aims to alleviate some challenges through access to Community Care, which has since raised concerns about suicide prevention effort discrepancies and barriers between Veterans Affairs (VA) and non-VA providers. Despite concerns, limited studies exist of suicide prevention strategies in rural Veterans receiving acute mental health Community Care. Methods:We conducted a pilot study of the suicide prevention program, VA Brief Intervention and Contact Program (VA BIC), in rural veterans who accessed acute mental health Community Care across Northern New England. VA BIC supports treatment engagement and health-promotion behaviors in veterans after Community Care discharge. We developed a process to recruit eligible veterans into a three-month study of VA BIC. We assessed the feasibility of VA BIC in Community Care veterans and collected mental health outcome pilot data. Results:Among 44 eligible and reachable patients, 45.5% (N=20) consented. Retention was high with 95.0% of patients completing all assessments. Among the 10 VA BIC participants, adherence was high with 90% completing all eight visits and 100% completing six visits. Suicidal ideation, hopelessness, social connectedness, and suicide-related coping trended towards improvement in the VA BIC group at follow-up. Conclusions:It is feasible to study VA BIC following discharge from acute mental health Community Care, and the intervention may benefit veterans. Future studies should confirm the efficacy of VA BIC in reducing suicide risk in non-VA settings.
Residents of rural areas face significant barriers to substance use disorder (SUD) treatment, including poor access, stigma, lack of confidentiality, and distrust of mental health services, which may inhibit treatment engagement. Mobile health (mHealth) approaches offer personalized, private, and easily accessible SUD treatment for rural residents, but differences in treatment mechanisms and efficacy across rural and urban regions are unknown. The present study investigates rural versus urban differences in the efficacy an mHealth SUD treatment via the theorized treatment mechanisms: protective behavioral strategies, readiness to change, and peer network health. The study leverages the results of a randomized clinical trial of an mHealth SUD treatment called Peer Network Counseling-txt (PNC-txt) conducted among a sample of young adults (age 18-25) with cannabis use disorder (CUD). We hypothesize that the impact of PNC-txt treatment on the treatment mechanisms will be stronger in rural, as compared to urban, regions, consequently leading to significantly greater reductions in cannabis use among rural residents. Results indicate that while PNC-txt reduces past 30-day cannabis use at 6 months via 1-month increases in both protective behavioral strategies and readiness to change, these indirect effects of treatment do not differ significantly between rural and urban residents. Our findings suggest that readiness to change and protective behavioral strategies are effective treatment targets for reducing the frequency of young adult cannabis use and support mHealth as an important SUD treatment approach for addressing treatment barriers in rural regions.
Rural youth face significant mental health challenges, and persistent disparities in access to services exist. Yet, there is limited research on the implementation of evidence-based practices (EBPs) for youth mental health problems in rural community mental health (CMH) centers. This study employed a rapid ethnographic assessment to explore determinants of EBP implementation in a rural CMH agency in the Pacific Northwest. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews with 11 clinic staff and completed site visits to understand the unique contextual factors influencing EBP use. Findings revealed complex challenges in rural mental health service delivery. While respondents generally viewed EBPs positively, they highlighted limitations in traditional EBP models when addressing the multifaceted needs of their high-acuity, socioeconomically disadvantaged client population. Reported barriers included staffing shortages, high clinician burnout, limited local resources, and transportation challenges. Respondents reported offering comprehensive services that extended beyond EBPs to address their clients' challenges. The rural context also significantly impacted EBP implementation, characterized by intergenerational trauma, substance use, and limited community resources. By illuminating the challenges of EBP implementation in rural settings, this research provides critical insights for developing more responsive and comprehensive approaches to supporting EBP implementation and improving rural youth mental health.
