Rurality and mental health

here's a lil essay i wrote jus over the past three days about rurality and mental health... hopefully some of u find it interesting... ;p


Rurality and mental health

Over about 10 days, we had the privilege of visiting the small rural community of Berrigan and the surrounding townships, and our eyes were opened to a very different context of medical practice. We observed and participated in the rural lifestyle, and were welcomed warmly and embraced by the local population. Clearly, not only do they recognise and wish to attract more health practitioners to their region, but their friendship and warmth is a genuine one that stems from a supportive community spirit. In this essay, in which I focus on mental health, I shall endeavour to use this context to illustrate some of the important points about mental health practice in rural Australia.

The township of Berrigan has a population of about 1,000. Mostly, the town serves as a farming support town, with the major industries being rice, wheat and maize. Increasingly, the population is aging, and the proportion of retirees finding their homes in Berrigan is becoming greater. There is one general practitioner in the town who works in a clinic attached to the 14-bed hospital. Alongside the GP, there are many allied health professionals, ranging from nursing staff, dentists, a pharmacist, a physiotherapist, and a psychologist, some of whom are based in Berrigan. Overall, with respect to health services, it is considered as part of a sector that encompasses the shires of Berrigan and Jerilderie, which takes in the towns of Finley, Barooga, Tocumwal and Jerilderie, in addition to Berrigan (see Appendix for ARIA and RRMA remoteness scores). Some services, including mental health services, are further shared with the neighbouring sector, based in Deniliquin, which is about 100km from Berrigan.

We encountered a member of the mental health team first at a social night. The psychologist was based in Berrigan, and was on a 12-month contract. Having come from the city, her impressions of the country were initially positive, with her appraisal of the community spirit as friendly and enthusiastic. She enjoyed the job, but had personal ties that meant she returned to Melbourne every weekend. Eventually, those same ties led to her searching for and finding a job in the outer suburbs of Melbourne, for which she was about to leave her employment in Berrigan after only 3 months there.

We met more members of the community mental health team in Deniliquin on a visit there with the drug and alcohol counsellor for the region. The team in Deniliquin consists of two psychologists (one for each sector), two general mental health nurses (three positions: child/adolescent, adult, and one for over 65 years, which is currently vacant), an Aboriginal mental health worker, and a mental health nurse for EDC&C (emergency, crisis). There are also administration positions. Other mental health practitioners work closely with the Deniliquin team across the sectors as well. They liaise closely with other health practitioners, such as drug and alcohol, general practice, and hospital staff. Consultation with psychiatrists is made possible through video teleconferencing (telepsychiatry), and facilities for this have been installed in Deniliquin and several other sites around rural NSW.

How does mental health differ between the rural and the urban settings? This is a complicated question to answer. While there are concerted efforts to improve access to mental health services in rural areas, such as outreach workers, Access Line (a 24-hour free phone number for advice and crisis support), brochures, posters, and close working with other health services, there are still differences highlighted in the statistics comparing rural and urban mental health. Perhaps the starkest statistic is that of suicide rates. Overall, comparing suicide rates between (crudely speaking) rural and urban Australia, there is little statistical difference between suicide rates of females, but male suicide rates are significantly higher in areas termed "rural" as opposed to "urban" (AIHW, Australia's Health 2004). Statistics on overall mental illness prevalence paints a slightly different picture: according to a 2000 ABS survey, it is greatest in large and small rural centres (19.4%), followed by capital cities (17.8%), and lowest among "other rural & remote" areas (15.7%). However, Meadows demonstrated in the same year that the proportion of unmet need for mental health care increased with increasing remoteness.

Why does this pattern/difference exist? It is important to understand that this difference is not simply the result of differences between mental health services available, and accessibility to them. Mental health is the result of so many interacting factors, which are social, economic, cultural, biological, as well as psychological. Diversity in all these factors throughout rural Australia means that a simple cross-assessment of all rural areas together might not yield meaningful results. Instead, an examination of these factors as they apply to areas of rural Australia might help to explain the difference, and indeed, provide more concrete targets at which to aim when developing solutions for rural mental health.

At the social level, perhaps one of the most interesting phenomena separating rural from urban living comes into play. In rural areas, where “everyone knows everyone”, people's networks consist primarily of strong ties, and lack weak ties relative to urban-dwellers. The effect of this on mental health is that such social networks tend to act as reverberators of information, and people are probably less willing and able to disclose concerns they may have. Also, the predominance of strong ties means more dependent relationships exist in the community, such that if one person suddenly falls out of their role(s), the community's networks will undergo an upheaval. These things are reflected in the stoicism and self-reliance stereotypically associated with rural-dwellers, and this attitude breeds a reluctance to acknowledge mental health problems and access mental health care. The stigma associated with mental illness further contributes to this reluctance, and compounds the effect that would occur if a diagnosis of mental illness were revealed in the community.

Another relevant social phenomenon involves the multiplicity of roles held by individuals in rural communities, where one’s activities in one role rapidly becomes widely known, and affects the other roles held by that person. For example, if a community leader involved in several different community clubs, on the school board, and mother of two school-age children, decides to send one of her children to a school in another town, then she would be seen as letting down the community and her role and relationships as a community leader would become strained. Similarly, if an individual were to undergo difficult circumstances, he or she might be afraid to seek help for mental health for fear that his or her roles would become disrupted because of the stigma associated with mental illness.

Among the economic factors influencing mental health in rural areas is the changing landscape of industry that drives the rural economy. Traditionally, rural areas have been portrayed as homogenous primary-industry-driven communities where a large proportion of the population dwelt on and made their living from farms, whether livestock, crops or orchards. However, the past few decades have seen a shift from this pattern. Berrigan is a prime example of this phenomenon. It is a town built on irrigated land, and crops of rice, wheat and maize cover the horizon from end to end. This much has changed little, but the way in which farming is practised has changed much. The land is now owned by far fewer people running far larger-scale operations, and their tractors are growing larger and larger in the quest for greater efficiency, as they struggle on the background of the recent drought conditions to break even. Small-scale farmers are a dying breed, most having had to sell out because they were running unsustainable businesses and drowning under the competition, and those who own small plots of land now run intensive operations such as pig igloos or fish farms in order to survive.

This changing economic landscape means that farming is less prominent as an industry in rural towns. One would also suggest that this trend in farming is not isolated, and is mirrored everywhere, including the decline of some rural towns. As society trends towards specialisation and competitiveness, a town must either follow or somehow be extremely innovative to baulk the trend and survive. In many rural areas, farming is being replaced by growth industries of tourism and aged care. Increasingly, country towns are seen as attractive for lifestyle reasons (and Berrigan’s congenial and welcoming community illustrates this well with their laid-back, relaxed pace and simple enjoyment of peace, quiet and friendly company). Those who are settling in the Berrigan area are mostly retirees, while the younger generation (who find themselves often without viable businesses to take over) are migrating to urban areas to seek opportunities for their career. A different pattern is observed in some other country towns such as Tocumwal, whose river location and airfield make it a wonderful magnet for tourists and the younger generation.

This has profound effects on mental health in rural areas. On one hand, the peace and quiet relative to the city would seem to ease stress on the population. But on the other hand, the changing economic climate and the competitive nature of industry is bringing the city’s stresses out into the country.

Rural Australia is also culturally diverse and dynamic. There are growing groups of people with different ethnic backgrounds entering rural towns, although there tend to be concentrations of certain groups in specific areas. For example, there are large Italian communities dwelling in the vicinity of the Murray River in towns such as Cobram, which is just across the border from Barooga, which is in Berrigan Shire. While the Aboriginal population is more highly represented in rural Australia overall compared to metropolitan Australia, the area around Berrigan has very few Aboriginal dwellers. Nevertheless, while ethnicity may contribute to some of the culture of an area, rural areas also differ culturally from urban areas in other ways. Some of this has been illustrated by the community-centric social structure of rural towns. There tends to be a greater sense of trust and loyalty amongst rural communities, because of the social proximity of people to each other, and the spirit by which neighbours look out for one another. Also, the lack of anonymity would tend to reinforce the sense of belonging that one feels in the town. These factors are reflected in the culture of community events, and people enthusiastically support community-run festivals, fund-raisers and other goings-on. Examples during our time at Berrigan were the overwhelming support shown for the Berrigan swimming pool at the swimming carnival fund-raiser, the strong membership of the local Lions club, and the crowd at the Finley tractor pull.

This community enthusiasm can play a particularly protective role against mental illness. There is a spirit of co-dependency among rural communities such that everyone helps one another. When individuals fall into difficult circumstances, often the community will rally to their support.

Part of the flip side of this community enthusiasm is a cultural resistance against external influences that attempt to exert themselves on the town. Without such resistance, small communities are vulnerable to external pressures, and among the health services, city-based authorities are often looked upon with disdain. It is unfortunate that small towns are at the mercy of decisions made by those who all too often have too little to do with the country to understand their plight. When one understands that differences exist between rural culture and urban culture, and that their needs are different, not only from metropolitan areas, but also from one another, it becomes obvious that the best solutions would originate from rural areas themselves.

While this is particularly evident at the level of health service infrastructure and funding arrangements, a simpler example of this can be seen in the pattern of acceptance of overseas-trained doctors in the rural towns. The general practitioner in Berrigan was trained in Iraq, and initially it took some time for the local population to accept him as their doctor. He faced language issues also, and was found to be “hard to understand”. However, time has once again proved to be a healer, and after being welcomed into the community, he has become, more and more, a member of the community. The town is now pleased with the much-needed services that he provides to the town, and most of the locals visit his surgery.

Cultural safety issues go beyond respecting the patient to respecting health care workers. A case of an elderly farm-dwelling male patient whose frontal lobe dementia has led to some disinhibition illustrates this point. Outreach workers regularly visit his home on the farm in order to investigate his progress, ensure that his living standards are maintained, and assess whether or not he is still capable of managing in his own home. However, his disinhibited behaviour has led to reports of sexual advances towards some of the workers, making them feel uneasy. Because of the isolation of the site, assistance for the threatened worker is not at hand, and the response of the workers to date has been to suggest some medication to alleviate the disinhibition.

Access issues can also highlight the particular need for cultural sensitivity in the rural setting. In a town such as Berrigan, where there is only one general practitioner, difficulties arise when cultural conflict occurs. A female Islamic patient, for example, may feel very uneasy with a male doctor, and may refuse physical examination. She would then have two options, either to continue visiting the same doctor reluctantly (perhaps with a compromise measure in place, such as the presence of a female nurse), or go to a different town in order to find a female doctor to treat her. The previous GP in Berrigan was female, and many of the males in Berrigan found it awkward to approach her as their doctor, and so were faced with a similar dilemma. The result of this is that many who should be receiving health care do not receive it, due to cultural or access issues.

This has strong relevance to mental health. The National Mental Health Survey (1997) investigated the role of general practice in mental health care, and demonstrated the vital role that general practitioners have in mental health. Nationwide, three quarters of those who used a health service for mental illness saw a GP, and half of these had their GP as their sole mental health practitioner. Furthermore, 71% of the community put that, if they sought professional help for depression, they would first approach a GP. The sparse distribution of GPs in rural Australia, and even sparser scattering of other mental health practitioners such as psychologists and psychiatrists, means that the interfaces between patients and mental health care are thinly spread in the country. If choice is limited to only one GP in a town, there are few practical options for the individual (highlighted previously), and often it seems most appropriate to forgo seeking help. In a secondary analysis of the BEACH (bettering the evaluation and care of health) study by Caldwell et al, rates of psychological problems identified by GPs per population were demonstrated to decline with increasing remoteness (as measured by RRMA score). Berrigan and surrounding townships have an RRMA classification of 5, which were shown to have significantly fewer psychological problems identified per population. Interestingly, there was little variation across all RRMA classifications in the rate of identification of psychological problems per number of GP encounters. The suggestion here is that the lower identification rate among rural and remote areas is largely due to a lower rate of utilisation of GP services in these areas, and that there is a higher proportion of unmet need for mental health care in rural Australia compared with metropolitan Australia.

Biological factors may also play a part in the rural-urban mental health differential. Overall, the health status of individuals in rural and remote communities is poorer than in urban areas. In particular, the mortality rate in rural Australia is significantly higher than in major cities. This is likely to be due to a number of factors, including a different demographic (with higher proportion of Aboriginal people who have life expectancies about 20 years shorter than non-Aboriginal Australians), poorer access to health care, poorer education status (perhaps associated with less effective health outcome preventative measures), and more hazardous environmental factors (e.g. motor vehicle accidents). Mortality from causes such as coronary heart disease, chronic obstructive pulmonary disease, motor vehicle accidents, and diabetes, feature heavily among the causes of excess deaths in rural Australia. Largely, these causes are modifiable to an extent by appropriate behaviours, such as quitting smoking, practising safe driving, or controlling diet. Perhaps more aggressive promotion of healthy behaviours would help to reduce these excess deaths.

It is also well known that mental illnesses such as depression are often linked to poorer health status. Diseases seen more often in rural areas such as coronary heart disease, chronic obstructive pulmonary disease, and diabetes, are illnesses that by-and-large cause significant stress for individuals, and contribute to the mental health burden.

So what can be done to improve rural mental health? The issues identified above largely fall into the categories of availability, access, and health promotion. Perhaps some of the “problem” lies in the culture of stoicism and self-reliance seen in rural-dwellers, but this is a difficult area to target in itself. However, it is possible that campaigns might be instituted to reduce the stigma associated with mental illness (and one such campaign is proceeding in the Hume area, encompassing Shepparton).

On the front of availability, strategies must be developed to recruit more health practitioners into the country. Communities are welcoming and mostly recognise the need for more services, and increasingly so in mental health as awareness of psychological illness increases. In Berrigan shire, positions are available and are mostly advertised as twelve-month contracts. This method of advertisement acts to lure practitioners by binding them only for a short time, leaving open the option to leave the position after that time, and positions frequently come packaged with a place to live or other incentives that serve to assist assimilation into the community. As one of the nurse administrators said, the plan is to attract them, and once they arrive, to get them so involved with the community that they are unable to leave. Recruitment is, however, limited by funding provided by the government, and lobbying for more funding to attract more health professionals is always an ongoing, difficult and complicated task.

Access is another major issue that should be targeted. The access problem is highlighted by the high suicide rate, which indicates that much mental illness may be going unidentified or unmanaged until it becomes far too severe. For less severe mental illness, access is also an issue, but is available through outreach mental health workers, travelling psychologists, and telepsychiatry. These arrangements are well established in Deniliquin.

Telepsychiatry, in particular, has been a topical issue since its advent many decades ago. It allows consultation via camera and television screen with a psychiatrist at a distant site, which is Sydney for those in Deniliquin. This facilitates access by cutting travel time and cost, and the time saved can often mean one less day absent from work or school, less disruption to family, or simply less to stress about. It also makes possible a quick second opinion to be given by more experienced personnel. Studies on telepsychiatry have demonstrated its reliability for child psychiatric assessments, depression and cognitive status assessments for the elderly. Positive outcomes have also been achieved with interventions administered by telepsychiatry. However, there is a suggestion that telepsychiatry is less reliable than in-person consultation for behaviours requiring visual observation, and it is not the modality of choice for patients with schizophrenia.

Overall, telepsychiatry is seen as an acceptable and cost-effective means of accessing psychiatric expertise from a rural area. Where such vast distances are involved, such as from Berrigan and Deniliquin to Melbourne, patients mostly prefer to use the telepsychiatry facility. Concerns are expressed about confidentiality and the impersonal nature of the teleconference, but the positive outcomes achievable by this modality demonstrates that it is a worthwhile step forward in improving access to mental health services in rural Australia.

Outreach workers exist in many of the disciplines associated with mental health. We spent some time with a member of the aged care assessment team (ACAT) on home visits to elderly patients. Their role in mental health is vital, calling on a vulnerable sector of the population, inquiring about problems they may be experiencing, and advising them on the allied health services available. They assess their need for services and are able to make referrals to services such as occupational therapy, mental health services and general practitioners. On this front, outreach workers are performing well at addressing access issues in those who have identified health concerns.

The greatest difficulty is in addressing the problems of those with mental illness that have not been identified. This is where health promotion and awareness must be targeted. Promotion of Access Line is one of the measures taken to address this. Access Line posters and brochures are visible in doctors’ surgeries, in hospitals and in community health centres. They make people aware that there is a free number they can call for assistance with any mental health concerns. However, these posters are hardly visible away from health facilities, where perhaps they are most needed. The other problem with this strategy of promoting awareness of services is that it relies on individuals with mental illnesses or their friends and relatives to identify their problems. As it would be costly, unethical and impractical to probe into the lives of every member of the community in order to catch those with mental illness, promotion of services is probably the most feasible method.

How can this be better achieved? Perhaps other media such as newsprint, television and radio should be more aggressively enlisted, in order to reach a wider audience. Perhaps community-driven events to promote healthy behaviours and strategies to identify mental illness might be effective. In some areas, mental illness is still a taboo topic, and so a campaign to reduce the stigma, such as in the Hume region in Victoria, might be synergistic to other promotion strategies. Mentally ill people will only come forward to seek help if they understand that it is OK to do so. In the end, however, these strategies can only be possible with more resources being made available for mental health promotion in rural areas.


Resources

Australian Institute of Health and Welfare (2004). Australia’s Health 2004. Canberra: AIHW

Caldwell TM, Jorm AF, Knox S, Braddock D, Dear KBG, Britt H (2004). General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia. Aust New Zealand J Psychiatry 38:774-780

Fraser C, Judd F, Jackson H, Murray G, Humphreys J, Hodgins GA (2002). Does One Size Really Fit All? Why the Mental Health of Rural Australians Requires Further Research. Aust J Rural Health 10:288-295

Fuller J, Edwards J, Procter N, Moss J (2002). Mental Health in Rural and Remote Australia. In The New Rural Health (eds Wilkinson D, Blue I), Oxford University Press, South Melbourne, pp 171-86

Glover JJ (2003). Rural Bioethical Issues of the Elderly: How Do They Differ From Urban Ones?. J Rural Health 17(4):332-335

Harrison CM, Britt H (2004). The rates and management of psychological problems in Australian general practice. Aust New Zealand J Psychiatry 38:781-788

Humphreys J, Hegney D, Lipscombe J, Gregory G, Chater B (2002). Whither Rural Health? Reviewing a Decade of Progress in Rural Health. Aust J Rural Health 10:2-14

Hyler SE, Gangure DP (2003). A Review of the Costs of Telepsychiatry. Psychiatric Services 54(7):976-980

Hyler SE, Gangure DP (2003). Legal and Ethical Challenges in Telepsychiatry. J Psychiatric Practice 10(4):272-276

Monnier J, Knapp RG, Frueh BC (2003). Recent Advances in Telepsychiatry: An Updated Review. Psychiatric Services 54(12):1604-1609

Murray G, Judd F, Jackson H, Fraser C, Komiti A, Hodgins G, Pattison P, Humphreys J, Robins G (2004). Rurality and mental health: the role of accessibility. Aust New Zealand J Psychiatry 38:629-634

Special thanks must go to the people of Berrigan, especially our hosts and the hospital staff. Thanks and best wishes also go to the mental health team of Deniliquin for their valuable time, and their enthusiasm that went into showing us what they do and the special challenges they face.


Appendix

ARIA/RRMA Scores for Towns

Berrigan - ARIA 2.72, RRMA5
Finley - ARIA 2.59, RRMA5
Barooga - No ARIA score available, RRMA5
Tocumwal - ARIA 2.47, RRMA5
Jerilderie - ARIA 3.28, RRMA5
Deniliquin - ARIA 2.33, RRMA5

Source: Personal correspondence, Craig Winfield, Department of Health and Ageing