Correlates of comorbid mental disorders in a regional community-based sample

Objective:  The common coexistence of psychiatric disorders has been identified as a significant factor contributing to the disability associated with mental illness. Identifying indicators to the development of coexisting disorders has potential clinical implications. This study aimed to investigate the correlates and impact of coexisting disorders in a rural setting.
Design:  Cross-sectional analyses of data from a cohort interviewed in two phases.
Setting:  A regional community sample in Northern New South Wales, Australia.
Participants:  A total of 1407 participants were interviewed and 968 were re-interviewed at follow up.
Main outcome measures:  Multinomial logistic regression modelling compared subjects with multiple psychiatric disorders with those with a single disorder for sociodemographic characteristics, measures of personal and social vulnerability, psychological distress, functional disabilities and help-seeking behaviours.
Results:  Participants with coexisting disorders were more likely to be male, report a history of severe childhood assault and had higher levels of neuroticism, psychological distress and help-seeking behaviour.
Conclusions:  The findings suggest the role of early developmental factors on the complexity and severity of adult mental illness in a rural setting and the significant clinical consequences of comorbidity.     

Distress among rural residents: Does employment and occupation make a difference?

Objective:  This study investigates the relationship between levels of mental health and well-being (in terms of self-reported levels of distress) with employment and occupational status of rural residents, to better inform the provision of mental health services to those in greatest need in rural communities.
Method:  A stratified random sample of community residents in rural and remote New South Wales with over-sampling of remote areas as first stage of a cohort study. Psychological distress was measured using Kessler-10, inclusive of additional items addressing functional impairment (days out of role). Occupational data were classified using Australian and New Zealand Standard Classification of Occupations categories.
Results:  A total of 2639 adults participated in this baseline phase. Among them, 57% were in paid employment, 30% had retired from the workforce, 6% were permanently unable to work and 2% were unemployed. The highest levels of distress and functional impairment were reported in those permanently unable to work and the unemployed group with rates of 'caseness' (likely mental health disorder) varying from 57% to 69%, compared with 34% of farmers and farm managers and 29% of health workers ( P <  0.01).
Conclusion:  The rural unemployed suffer considerable psychological distress and 'disability', yet they are not the target of specific mental health promotion and prevention programs, which are often occasioned by rural adversity, such as drought, and delivered through work-based pathways. Policy-makers and health service providers need to consider the needs of the rural unemployed and those permanently unable to work and how they might be addressed.     

Queensland extended care services for people with severe mental illness and the role of occupational therapy

Background:  People with serious mental illness in Queensland who require extended rehabilitation may be treated in extended inpatient mental health services. Two of these extended inpatient services, hospital and community-based 'Extended Treatment and Rehabilitation Units (ETRUs) and Community Care Units (CCUs)', are described, including the aims, objectives, philosophy and service delivery.
Methods:  A quality project involving occupational therapists working in these settings, as well as a consumer and carer, provides different perspectives concerning these relatively new health services in Queensland.
Results:  Two main occupational therapy roles were identified: case management and occupational therapy-specific roles (including assessment and intervention). The consumer and carer perspective is also presented.
Conclusion:  These services provide a positive option for people with high levels of functional disability as a result of mental illness and also for their carers. They provide environments with many exciting opportunities and challenges for occupational therapists working in mental health.     

A survey of recruitment and retention issues for occupational therapists working clinically in mental health

Background:  Mental health services Australia-wide have difficulty recruiting and retaining clinical occupational therapists.
Methods:  A survey of occupational therapists to identify factors that could influence their retention or loss from clinical mental health practice was undertaken.
Results:  Typically, respondents were female, aged 30 years or younger, working full-time at a grade 2 or 3 level, and had worked entirely in mental health. The main positive aspects that respondents identified about their positions were the 'social/emotional environment', 'aspects/nature of their roles', and 'using occupational therapy skills'. The main position constraints were 'insufficient time/workload' and 'insufficient use of occupational therapy skills/generic nature of work'.
Conclusions:  Recruitment and retention strategies are required to retain occupational therapists in clinical mental health positions.     

What stresses remote area nurses? Current knowledge and future action

Objective:  Review and synthesise the literature identifying the stresses experienced by remote area nurses (RANs). Identify interventions implemented to address identified stresses. Explore the use of the job demands–resources (JD-R) model.
Methods:  A comprehensive literature review was conducted using the meta-databases Ovid and Informit.
Setting:  Remote Australian primary health care centres.
Results:  The reported demands experienced by RANs can be grouped into four themes: (i) the remote context; (ii) workload and extended scope of practice; (iii) poor management; and (iv) violence in the workplace and community. In this high-demand, low-resource context, the JD-R model of occupational stress is particularly pertinent to examining occupational stress among RANs. The demands on RANs, such as the isolated geographical context, are immutable. However, there are key areas where resources can be enhanced to better meet the high level of need. These are: (i) adequate and appropriate education, training and orientation; (ii) appropriate funding of remote health services; and (iii) improved management practices and systems.
Conclusion:  There is a lack of empirical evidence relating to stresses experienced by RANs. The literature identifies some of the stresses experienced by RANs as unique to the remote context, while some are related to high demands coupled with a deficit of appropriate resources. Use of models, such as the JD-R model of occupational stress, might assist in identifying key areas where resources can be enhanced to better meet the high level of need and reduce RANs' levels of stress.     

Generational attitudes of rural mental health nurses

Objective:  To determine how attitudes of rural mental health nurses differ across generations.
Design:  Survey.
Setting:  Mental health services in rural New South Wales.
Participants:  Practising mental health nurses.
Main outcome measures:  Survey responses.
Results:  Survey response rate 44%. A total of 89 mental health nurses, clustered in inpatient units and community health centres, responded. Of these nurses, 4 were veterans, 52 baby boomers, 17 Generation X and 5 Generation Y.
Conclusions:  There are significant differences in how mental health nurses from different generations view their work, and in what is expected from managers. Managers need to modify traditional working styles, allowing greater flexibility of employment. They must also accept lower staff retention rates, and facilitate the development of younger staff.     

Health behaviours of young, rural residents: A case study

Objective:  To analyse self-reported health behaviours of young people from a rural community and the factors influencing their behaviours.
Methods:  Interviews were conducted with 19 young people, 11 parents and 10 key informants from a small rural Victorian community, asking about teenage health behaviours and the factors influencing these behaviours.
Results:  Young people ate both healthy and unhealthy foods, most participated in physical activity, few smoked and most drank alcohol. The study found that community level factors, including community norms, peers, access issues and geographic isolation, were particularly powerful in shaping health behaviours, especially alcohol consumption. Smoking was influenced by social participation in the community and national media health campaigns. Diet and exercise behaviour were influenced by access and availability, convenience, family, peers and local and non-local cultural influences.
Conclusion and implications:  The rural context, including less access to and choice of facilities and services, lower incomes, lack of transport and local social patterns (including community norms and acceptance), impact significantly on young people's health behaviours. Although national health promotion campaigns are useful aspects of behaviour modification, much greater focus on the role and importance of the local contexts in shaping health decisions of young rural people is required.     

Asthma management in rural New South Wales: Perceptions of health care professionals and people with asthma

Objective:  To investigate the perceptions and attitudes towards asthma management of general practitioners, pharmacists and people with asthma in a rural area.
Design:  Qualitative semistructured interviews.
Setting:  Small rural centre in New South Wales.
Participants:  General practitioners, pharmacists and people with asthma in a rural area.
Results:  General practitioners perceived that the patient provided a barrier to the implementation of optimal asthma services. They were aware that other health care professionals had a role in asthma management but were not aware of the details, particularly in relation to that of the pharmacist and would like to improve communication methods. Pharmacists also perceived the patient to be a barrier to the delivery of optimal asthma management services and would like to improve communication with the general practitioner. The impact of the rural environment for the health care professionals included workforce shortages, availability of support services and access to continuing education. People with asthma were satisfied with their asthma management and the service provided by the health care professionals and described the involvement of family members and ambulance officers in their overall asthma management. The rural environment was an issue with regards to distance to the hospital during an emergency.
Conclusions:  General practitioners and pharmacists confirmed their existing roles in asthma management while expressing a desire to improve communication between the two professions to help overcome barriers and optimise the asthma service delivered to the patient. The patient described minimal barriers to optimising asthma management, which might suggest that they might not have great expectations of asthma care.     

Promoting mental health care in a rural paediatric unit through participatory action research

Objective:  To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research.
Design:  A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research.
Setting:  A 16-bed paediatric unit of a rural general hospital.
Participants:  A purposive convenience sample of all paediatric nursing staff ( n =  20; of 24 nurses).
Outcome measures:  In the first phase of this study, focus groups were conducted to explore the experiences of nurses.
Results:  Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment.
Conclusions:  There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority.     

Mental health and well-being within rural communities: The Australian Rural Mental Health Study

Objective:  This paper outlines the methods and baseline data from a multisite cohort study of the determinants and outcomes of mental health and well-being within rural and remote communities.
Methods:  A stratified random sample of adults was drawn in non-metropolitan New South Wales using the Australian Electoral Roll, with the aim of recruiting all adult members of each household. Surveys assessed psychological symptoms, physical health and mental disorders, along with individual-, family/household- and community-level characteristics. A stratified subsample completed a telephone-administered World Mental Health-Composite International Diagnostic Interview (World Mental Health-3.0). Proxy measures of child health and well-being were obtained. Follow up of this sample will be undertaken at one, three and five years.
Results:  A total of 2639 individuals were recruited (1879 households), with 28% from remote/very remote regions. A significant relationship was found between recent distress (Kessler-10 scores), age and remoteness, with a linear reduction of Kessler-10 scores with age and the lowest mean scores in remote regions.
Conclusions:  Existing rurality categories cannot address the diverse socio-cultural, economic and environmental characteristics of non-metropolitan regions. While it has limitations, the dataset will enable a fine-grained examination of geographic, household and community factors and provide a unique longitudinal dataset over a five-year period.     

Mental health impact for adolescents living with prolonged drought

Background:  A 2004 study showed adolescents living in rural Australia were aware of the impact of drought on self, family and community, but did not report levels of emotional distress higher than adolescents of similar age and gender in the Australian community. It was proposed that the rural lifestyle had helped adolescents build resilience for managing this environmental adversity.
Objective:  To re sample adolescents from the same rural area and determine if this resilience remained after ongoing drought three years later.
Design:  A mixed methods approach using focus groups and a self-report questionnaire.
Setting:  Government Central Schools within the Riverina region of New South Wales.
Participants:  Male and female adolescents ( n =  111) aged 11–17 years completed the self-report questionnaires, while some adolescents ( n =  61) within this group also participated in focus groups.
Main outcome measure:  The Strengths and Difficulties Questionnaire and a Drought and Community Survey for Children comprised the self-report survey.
Results:  Adolescents reported significantly higher levels of emotional distress than those in the previous study ( t (191)  =  2.80, P <  0.01) and 12% of adolescents scored in the clinical caseness range. Thematic analysis showed consistency with the previous study as well as new themes of grief, loss and the impacts of global climate change.
Conclusions:  Results indicate a reporting of lesser well-being than was reported by a comparable group of young people four years earlier. A preventative intervention with a focus on family and community is recommended to address the mental health of adolescents enduring a chronic environmental adversity such as drought.     

The Occupational Performance History Interview in community mental health case management: Consumer and occupational therapist perspectives

Background/aim:  This study aimed to explore the use of the Occupational Performance History Interview from the perspectives of mental health consumers and occupational therapist case managers in community mental health settings.
Methods:  This qualitative study, based on naturalistic inquiry, involved 10 participants: four occupational therapists who interviewed six mental health consumers, using the Occupational Performance History Interview. All participants participated in follow-up interviews or in focus groups to gain an understanding of their perspectives of this experience. Transcribed data were analysed using the constant comparative method.
Results:  Consumer participants valued telling their occupational stories. Occupational therapist participants described the interview as supporting them to be more occupationally focused within their case management roles.
Conclusion:  The findings suggest that the Occupational Performance History Interview can potentially enhance client-centred and occupationally focused practice in community mental health case management.     

The effect of first year mental health fieldwork on attitudes of occupational therapy students towards people with mental illness

Background and Aims:  Despite recent initiatives to reduce stigma towards people with mental illness, negative attitudes persist both in the community and among health professionals. Fieldwork experience has been identified as the most powerful way of modifying the attitudes of health professional students. Research to date suggests that later placements tend to have a more positive effect on attitudes than do earlier placements. However, inconsistencies within the literature suggest that it is the nature of the fieldwork experience that is the critical factor. We set out to investigate whether a program of fieldwork that included a tutorial component would bring about positive attitudinal change in first year occupational therapy students.
Methods:  We conducted secondary analysis of data collected from first year students before and after first year fieldwork experience in mental health settings. Student statements were rated to identify positive versus negative attitudes, and attitudinal themes were analysed.
Results:  Quantitative analysis revealed that students made significantly more statements reflecting positive attitudes following fieldwork than they did before. From pre- to post-fieldwork, attitudinal themes changed from: people with mental illness as different, fear of people with mental illness, and a deficit focus of mental illness, to: the 'ordinariness' of people with mental illness, students' understanding of people with mental illness, and an enabling approach to people with mental illness.
Conclusions:  A program of fieldwork that includes a structured tutorial component can bring about positive changes in the attitudes of first year students towards people with mental illness.     

Developing a worker role: Stories of four people with mental illness

Background and Aims:  Work plays an important role in adults' well-being, irrespective of health status. Vocational rehabilitation can enable people with mental illness to return to open employment. A narrative approach was used to explore how individuals with a mental illness made sense of their work-related experiences.
Methods and Results:  Four Clubhouse members in open employment for at least 6 months completed in-depth, semistructured interviews, from which narratives were created to reveal events, significant persons and actions that assisted these individuals to resume work. Woven into the participants' stories were four 'impelling forces' contributing to a sense-of-self as a worker. These impelling forces were: support from significant others, the personal meaning of work, experiences within the Clubhouse programme, and the ongoing struggle with illness. Implications for occupational therapy practice are discussed.
Conclusion:  The findings of this study urge occupational therapists and others to provide opportunities to provide on-going support to people with a mental illness who seek paid employment.     

Perceptions of occupational therapists practising in rural Australia: A graduate perspective

Background:  The difficulty in recruiting and retaining health professionals into rural and remote areas of Australia is well recognised. This study explored the perceptions of occupational therapists practising in rural locations regarding the essential skills necessary for rural practice and the ability of undergraduate education to prepare them for rural practice.
Methods:  A qualitative study using a phenomenological approach was conducted using semistructured in-depth interviews. Participants included occupational therapists who were graduates of James Cook University, who were practising in rural areas in Queensland and Victoria, and academic staff.
Results:  This study demonstrates that it is important for universities to develop both a mindset in their graduates for rural practice, as well as developing broader skills in addition to core discipline-specific skills. While subjects developing core occupational therapy skills are at the centre of undergraduate education, the importance of developing a broader understanding of rural health issues and skills in public health, primary health care and health promotion was emphasised.
Conclusion:  The development of specific skills to become competent rural practitioners and to cope with the challenges of rural practice can be strengthened through initiatives at the undergraduate level. Ongoing commitment from all universities across Australia to include rural curriculum content has the potential to improve recruitment and retention of occupational therapists and other health professionals into rural Australia.     

Key considerations in delivering appropriate and accessible health care for rural and remote populations: Discussant overview

Objective:  To provide an overview of papers discussing optimal service delivery models for rural and remote Australia.
Design:  A synthesis of overarching considerations guiding rural and remote health service policies.
Setting:  Small rural and remote communities in Australia.
Participants:  Invited delegates attending the Inaugural Rural and Remote Health Scientific Symposium in Brisbane 2008.
Main outcome measures:  Key issues underpinning health service provision for small rural and remote communities.
Results:  The formulation and implementation of effective health service provision policies must be underpinned by overarching health goals, agreed health service requirements, recognition of how rural and remote health contexts impact upon health service provision and the constraints limiting health service responses.
Conclusion:  Systemic change is required in order to ensure equitable access to health care services in small rural and remote communities.     

Riverina men's study: An exploration of rural men's attitudes to health and body image

Aim:  To determine the attitudes of rural men to matters of health and body image.
Methods:  Focus group discussions were used to examine the attitudes of a sample of Australian rural men to matters of health and body image in the context of their eating and exercise behaviours. Forty-two rural men, aged 25–64 years, took part in four focus groups, one exclusively for farmers, in south-western New South Wales (NSW).
Results:  Results from these focus groups reveal that many of the masculine myths surrounding male behaviour in relation to health and ideas on body image persist among rural men in south-western NSW. Talking about health is not considered a male past-time; visiting health professionals is still seen as a last resort; being a 'big bloke' is perceived to be advantageous and heavy drinking is still considered an Australian male domain, especially among the younger men in the groups.
Conclusion:  The present study provides a deeper understanding of rural men's attitudes to body image issues and lifestyle behaviours, which is critical to helping change health outcomes for this hard-to-reach group.