Project Summary: Existing research shows that rural VA patients report poorer mental health status and reduced access to mental health care compared to VA patients in urban or suburban areas. Obviously, logistical factors, including longer waiting periods, reduced health professionals, and poorer public transportation, limit access to and use of services in rural settings. However, efforts by the VA to overcome logistical barriers by expanding services to rural areas have not led to the expected increase in service utilization. Therefore, identifying logistical barriers answers questions about whether or not a veteran can access MHC, but offers little insight into whether or not a veteran will access MHC. Stigma refers to internalized cultural beliefs about the attributes of those with mental illness that can lead to prejudice and discrimination. In addition to internalized stigma, perceived stigma from external sources influences help-seeking behavior. Research on non-veteran populations indicates that individuals in rural settings are more likely than those in urban settings to cite fear of social stigma and discrimination by the community as barriers to obtaining mental health care. This research is designed to help increase access to and decrease disparities in mental health care for veterans living in rural areas by better understanding the needs and attitudes of rural vs. urban veterans. It addresses several areas designated as high priority by HSR&D, including post-deployment health, access/rural health, equity and health disparities, and mental health. The main aims of the study are to: 1. Determine if veterans in rural communities perceive more community stigma than those located in urban areas (when controlling for other individual and institutional factors differ between rural and urban veterans), and 2. Determine the relationship between individual, institutional, and community stigma-related factors in predicting health care utilization among rural and urban veterans. This is a planned pilot population-based mail survey study that will compare random samples of 100 rural vs. 100 urban veterans in the state of Hawaii, known to have barriers to care in rural regions. The study will identify veterans using both VA geo-coding based designations and ZIP code level rural urban commuting area designations. Methodology includes use of a widely used multi-stage best-practice mailing procedure with monetary incentive to enhance response rates and reduce response bias. Measures will include basic demographic questions and validated measures of individual and community stigma, post traumatic stress disorder (PTSD), physical and mental health quality of life, and an expanded version of a validated measure of health care utilization. Analyses of covariance will be used to evaluate individual and community stigma, controlling for individual and institutional variables associated with beliefs about care. Hierarchical regression analysis will be used to identify factors associated with healthcare utilization (e.g., urban vs. rural status, age, PTSD severity scores, individual and community stigma) in rural OEF/OIF veterans. Relevance: Over 40% of the current veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are from rural areas, and research shows that rural veterans report poorer mental health status and reduced access to care compared to VA patients in urban or suburban areas. This study will provide important information about the logistical, individual, and community barriers to care that prevent rural veterans from receiving needed mental health care. Once we identify these factors, we will better understand the relative importance of each in effecting OEF/OIF veterans'care choices. This study and its planned follow-up research are designed to inform interventions to decrease rural health disparities among rural veterans.