Barriers to Treatment Engagement for Alcohol Use Disorders in Rural and Community Behavioral Health Settings: A Systematic Review

Alcohol use disorder (AUD) remains a significant public health concern in the United States, with rural populations experiencing lower treatment engagement and poorer outcomes than their urban counterparts. In rural areas, community behavioral health settings often represent the primary point of access to AUD care; however, multiple structural, sociocultural, and system-level barriers continue to limit engagement across the treatment continuum. This systematic review synthesizes peer-reviewed studies published from 2020 onward that examine barriers to AUD treatment engagement in rural and community behavioral health settings. Guided by PRISMA principles, studies were identified through searches of PubMed, Scopus, and Web of Science and were thematically synthesized to capture barriers affecting treatment initiation, retention, and continuity. Findings indicate that barriers consistently cluster into several interconnected domains, including limited-service availability and transportation challenges, workforce and organizational capacity constraints, stigma and sociocultural factors, clinical complexity related to co-occurring conditions, and inequitable access to digital technologies affecting telehealth use. These factors collectively undermine both entry into treatment and sustained engagement. In conclusion, engagement in AUD treatment within rural and community settings is shaped by intersecting, multilevel barriers. Addressing these challenges will require integrated and culturally responsive strategies, informed by implementation science and supported by sustained policy and infrastructure investment.