"You have no grit:" A qualitative exploration of barriers to eating disorder care in the rural United States.

This qualitative study explored the barriers to eating disorder (ED) treatment among adults with EDs in a rural state. Study participants were adults with a confirmed ED who lived in a rural region of one rural state in the United States. Braun & Clarke's (2006) thematic analysis 6-step framework was used to analyze the transcribed interviews. Description-focused coding was completed, and data were analyzed for themes. Five adults with lived experience of an ED were involved with the study design, and 14 rural adults with ED participated in the study. Four primary themes were identified: geospatial barriers, cultural values of independence and self-sufficiency, lack of awareness, and weight stigma. In the geospatial barriers theme, participants highlighted issues related to access to resources, transportation, and poverty. In the cultural values of independence and self-sufficiency theme, participants reported community-wide ED stigma, a "bootstrap mentality," and social isolation. In the lack of awareness theme, participants noted inadequate knowledge of EDs, conceptualizing EDs as a weight problem, and inequitable treatment toward ED subtypes in their communities. Finally, for the weight stigma theme, participants discussed cultural values for the thin-ideal and weight-stigmatizing experiences. Results indicate that rural adults with EDs experience barriers both similar to and unique from barriers in urban areas (e.g., geospatial and "bootstrap mentality"), with some barriers being exacerbated through inadequate social support and understanding. Findings suggest a need to test digital interventions to overcome geospatial barriers, and community engagement around reducing weight stigma and ED stigma among rural populations.