Living at the intersections: exploring social and structural influences on mental health service use in Oklahoma’s historical Black towns

Mental health disparities are heightened in rural communities, where provider shortages, geographic isolation, and systemic inequities limit access to care. For rural Black Americans, these challenges are compounded by structural racism and historical disinvestment, leading to disproportionately high need alongside enduring stigma and mistrust. Oklahoma’s all-Black towns, rooted in resilience yet shaped by inequity, offer a critical context for examining how race and rurality intersect to influence mental health service use. Guided by a mental health disparity–adapted version of the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, this applied qualitative study was grounded in pragmatism and informed by interpretive phenomenology to center lived experience. Purposeful sampling, including confirming and disconfirming cases, recruited 15 participants across four generations through community and faith-based networks. A Community Advisory Board (CAB) composed of Black town mayors, a community member, and a mental health expert informed recruitment, interview design, and interpretation. Semi structured interviews were conducted between December 2023 and March 2024 and analyzed in NVivo using Braun and Clarke’s six-phase thematic analysis, integrating inductive and deductive codes mapped to Social Determinants of Health (SDOH) domains. Rigor was supported through reflexive memoing, peer debriefing, member checks, and CAB validation. Fifteen participants across four generations (Baby Boomers, Generation X, Millennials, Generation Z) described their experiences with mental health programs and services, including available supports and challenges. Findings highlighted reliance on state-funded, tribal, and community health resources constrained by access barriers; the role of community-led and faith-based initiatives in providing culturally familiar support; and the expansion of telehealth and mobile services that increased reach but often lacked relational or cultural resonance. Participants also shared visions for future programming, emphasizing culturally grounded, affordable, and group-based approaches. Results were organized by the five SDOH domains, identifying barriers, facilitators, challenges, and needs across economic stability, education, health care access and quality, neighborhood and built environment, and social and community context. Findings highlight the complex interplay of cultural, social, and structural factors shaping mental health service use in rural Black Oklahoma communities. Persistent barriers of stigma, mistrust, and logistical strain underscore the need for culturally responsive, community-driven approaches. Strategies such as reframing mental health language, engaging proxy advocates, strengthening faith-based partnerships, and expanding mobile and telehealth services can enhance access and engagement. Grounded in the adapted NIMHD framework, this study emphasizes layered strategies across individual, community, and policy levels. Advancing equity will require addressing systemic bias, sustaining services, and amplifying local strengths through co-developed, trust-based solutions that promote resilience in underserved rural populations.