Mental health of farmers in Southern Queensland: Issues and support

Objective: To inform the development of an initiative designed to support the mental well‐being of farmers in Queensland. Design: Interactive focus groups. Setting: Rural and remote Queensland. Participants: Health professionals, farmers and representatives of organisations and agencies working with farmers. Main outcome measures: Determination of factors contributing to the declining mental health of rural landholders. Content material for inclusion into mental health first aid programs held for field officers. Results: Key areas identified to contribute to the decline in mental health of farmers were: increasing isolation in its varying forms, the ongoing drought, increased government regulations and widening of the schism between urban and rural Australians. The issues that affect farmers are recognised to have a ‘knock‐on’ effect on the people who interact with them. In particular, rural support organisations are concerned for the well‐being of their staff, prompting some to begin to put protocols in place to address their staff need for mental health support. Additional mental health training of field officers that involves awareness, recognition, communication skills, understanding and empathy was recognised by participants to be beneficial. Conclusion: Training of field officers was considered to be of benefit to the support of farmers. An understanding of the various and diverse issues that rural landholders face should be a fundamental component of that training.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

Physical activity of young people in the Torres Strait and Northern Peninsula Region: an exploratory study

Objective: The present study explored the practices of, and perceived barriers to, physical activity of young people living in remote communities in the Torres Strait and Northern Peninsula Area of Far North Queensland. Design and setting: A cross‐sectional survey exploring physical activity practices of children attending primary and secondary schools in two communities in the Torres Strait, Far North Queensland. Participants: A total of 367 primary and secondary school‐aged children (aged 9–16 years). Main outcome measures: Only 50% of the children reported being active for more than 30 min a day and approximately 25% of both primary and high school children surveyed were ‘pretty much active only at week‐ends’. The major barriers cited to being active were related to the climate, lack of equipment and child‐specific activities and low self‐perception of ability. Conclusions: A large proportion of school students in the Torres Strait and Northern Peninsula Area reported low levels of physical activity. The main barriers cited to being active suggest that structural and family‐based strategies are required to help young people, especially girls, to engage in more physical activity. There is also a need for skills and confidence‐building activities delivered in a non‐competitive environment for those who feel that they lack the necessary skills to participate fully.     

Pre-pregnancy predictors linked to miscarriage among Aboriginal and Torres Strait Islander women in North Queensland

Objective : Identify preventable pre‐pregnancy risk factors that may affect the prevalence of miscarriage among a cohort of Australian Indigenous women. Methods: Data from 1,009 Indigenous women of childbearing age who participated in a 1999–2000 health screening program in far‐north Queensland were linked to Queensland hospitalisation data. Women who attended hospital after their health check (censor date: March 2008) for a pregnancy‐related condition were identified. Characteristics associated with becoming pregnant and subsequent miscarriage were analysed using generalised linear models. Results: After adjusting for age and ethnicity, women who became pregnant were more likely to be smokers and to have low red cell folate at baseline. The risk of miscarriage increased with age. Women who reported risky drinking or had elevated gamma‐glutamyl transferase were also at higher risk. After further adjustment for risky drinking, the presence of chlamydia or gonorrhoea before pregnancy was associated with miscarriage. The presence of both infections at baseline compared with women who had no infection, again after further adjustment for risky drinking, was strongly associated with miscarriage; these women had more than a four‐fold increase in risk (PR: 4.57 [2.21–9.46]). Elevated body mass index, high blood pressure and smoking were not statistically significantly associated with risk of miscarriage. Conclusions and implications: A high prevalence of pre‐pregnancy sexually transmitted infections and high rates of risky drinking are associated with miscarriage among young Indigenous women in rural and remote communities in north Queensland.     

Implementing a chronic disease strategy in two remote Indigenous Australian settings: a multi-method pilot evaluation

Objective: To test an evaluation framework designed to evaluate implementation of the North Queensland Indigenous communities between August and December 2005. Setting: Both communities are located in Cape York, North Queensland. Community A has an estimated population of around 600 people; Community B has an enumerated population of 750, although health centre records indicate a higher number. Participants: Process evaluation involved health centre staff in both communities; clinical audits used random samples from the adult population (each sample n = 30); ethnographic fieldwork was conducted with resident population. Main outcome measures: Health centre scores and qualitative findings using a System Assessment Tool; clinical audits – extent to which scheduled services recorded; selected primary health performance indicators; qualitative ethnographic findings. Results: On almost all indicators, implementation of NQICDS had progressed further in Community A than in Community B; however, some common issues emerged, especially lack of linkages between health centres and other groups, and lack of support for client self‐management. Conclusions: The evaluation framework is an effective and acceptable framework for monitoring implementation of the NQICDS at the primary health centre level.     

Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa

Objective: Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non‐Indigenous health professionals in north‐west Queensland assist to refine the meaning of this term and uncovered other issues disguised as ‘cultural’ difference. Design: Semistructured interviews with community and health professionals. Setting: Mount Isa, Queensland, Australia. Participants: Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009. Results: Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships. Conclusions: For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.     

Overseas‐trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains

Objective: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs’ transition, integration and retention. Method: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co‐workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin. Results: Identity as ‘fluid’ emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process. Conclusion: The reconstruction of OTDs’ identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs’ integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains. Implications: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs’ capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

Women living in a remote Australian mining community: Exploring their psychological well‐being

Objective: To explore the factors believed to influence the psychological well‐being of women living in a modern remote Australian mining community. Design: A qualitative phenomenological study conducted through focus group discussions. Setting: Remote Australian mining town. Participants: Sixteen women living in a remote Australian mining town with a partner undertaking shiftwork at one of the local mines. Main outcome measures: Women in a remote Australian mining community revealed, through focus group discussion, the factors influencing their psychological well‐being. Results: Four themes were identified to be of importance for the women. These were the impacts of mining work, isolation, culture and the social environment on their happiness and well‐being, and that of their families and the broader community. Conclusions: Psychological well‐being of women in a remote mining community might be improved through better local medical services, increased efforts at social inclusion and community connectedness, greater access to child care and better community infrastructure and pleasant surrounds. The findings also question the stereotypes of strong masculinist cultures and limited activities and services in such communities. Further research is highly recommended.     

Rural maternity care and health policy: parents' experiences

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty‐three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re‐evaluated in order to improve rural Australians' access to vital health services such as maternity care.     

Community Health Monitoring: Taking the Pulse of America's Children

Objective: To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991–1996). Methods: A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-per-son and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting. Results: All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children. Conclusions: Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.     

Lukumbat marawana: a changing pattern of drug use by youth in a remote Aboriginal community

Objective: To examine marijuana use by youth in a remote Aboriginal community in Northern Australia over a 5‐year period. Design: Participant observation, structured and unstructured interviews. Setting: Remote Indigenous Australian community. Participants: Young Aboriginal people and adult community members. Main outcome measure: Emergent themes of the attitudes towards marijuana use among remote Indigenous residents are reported. Results: Restrictions in the availability of alcohol and petrol have led to increased use of marijuana with serious social and community consequences. Conclusions: Efforts to control licit substances, such as alcohol, in remote communities need to be addressed in the context of understanding of the dynamics of alcohol and drug use in totality as well as interventions that address underlying structural and social inequalities.     

Towards a health career for rural and remote students: cultural and structural barriers influencing choices

Objective: To promote tertiary health careers to rural and remote young people. Design: Qualitative research using large and small group discussions and semistructured interviews. Setting: Fifteen secondary schools in rural and remote Western Australia including five senior secondary schools and 10 district high schools. Subjects: One hundred and twenty students from eight year 10 groups, 35 students from three year 11 groups, 54 students from five year 12 groups, 52 parents, 10 grandparents, 76 teachers and four Aboriginal and Islander Education Officers (AIEO). Results: Students prefer information about the range of health careers to be delivered interactively. Choices to follow a health career at tertiary level were constrained by structural and cultural issues including geographical isolation, financial cost, stereotyping of health professions, insufficient information about the diversity of health careers, obligation to family, community and place and a devalued rural culture. Conclusions: The under representation of rural and remote students in health related university courses needs to be addressed by long‐term strategies taking into account both structural and cultural barriers when making career choices. Health policies should include the provision of financial support for rural and remote students and promote a broad range of health careers as challenging and rewarding life choices that offer much needed services to rural communities. What this paper adds: In 1997, only 19.2% of Australian university students came from rural and remote areas, a figure dramatically below the equity reference point of 28.8% of the population living in rural areas derived from the 1996 census data. 1 In 2001, the figure remained steady with 19.1% of rural students attending university. 2 These data highlight the need for developing higher education opportunities for all Australians regardless of where they live. However, despite ongoing concern about attracting rural and remote students to health careers, limited success has been achieved to date. Barriers to students choosing health careers at tertiary level include lack of information about the range of health careers available, the cost of tertiary education for families, social dislocation and a perceived lack of support structure for students at university. These are underpinned by cultural assumptions about gender, occupational roles in rural communities and professed lack of academic ability. Strategies to overcome barriers must be situated within a broad socio‐cultural context to understand the complexity of issues underpinning students’ choices.      

The benefits of a tailor-made pilot primary health-care course for Indigenous high school students in remote Queensland

Objective: This study highlights the benefits of a tailor‐made course for an Indigenous high school in a remote North Queensland community. Design: Qualitative research study using a Grounded Theory approach to allow thematic analysis of participant's responses to a researcher‐administered, pre‐defined, semistructured questionnaire. Setting: Remote community college in Abergowrie, North Queensland. Participants: Four male high school students and eight key stakeholders were interviewed over the telephone (n = 12). Results: Thematic analyses of the feedback from students and stakeholders showed a variety of benefits from the course for Indigenous students: increased knowledge of health issues, greater awareness and interest in health career pathways, increased pride, self‐esteem and self‐confidence, positive role‐modelling and leadership behaviour in the students, and hope for future career development. Weaknesses identified were mainly associated with a lack of resources and support for the course. Conclusions: This study demonstrates that a tailor‐made primary health‐care education course can create opportunities for Indigenous people to pursue health careers, promote health knowledge and leadership skills, inspire pride and self‐esteem, and strengthen links within the community.     

From 'problem-describing' to 'problem-solving': challenging the 'deficit' view of remote and rural health

Objective: Rural and remote health research has highlighted the many problems experienced in the bush. While attention to problems has raised awareness of the needs of rural and remote health, embedding a deficit perspective in research has stereotyped rural and remote health as poor environments to work in and as inherently problematic. The objectives of this paper are to challenge this thinking and suggest that a more balanced approach, acknowledging strengths, is beneficial. Design: This discussion identifies why the deficit approach is problematic, proposes a strengths‐based approach and identifies some key strengths of rural and remote health. Results: This study suggests alternative ways of thinking about rural and remote practice, including the rewards of rural and remote practice, that rural and remote communities can act as change agents, that these disciplines actively address the social determinants of health, that rural and remote areas have many innovative primary health care services and activities and that rural and remote contexts provide opportunities for evaluation and research. It is proposed that rural and remote health can be viewed as problem‐solving, thus dynamic and improving rather than as inherently problematic. Conclusion: Critical of a deficit approach to rural and remote health, this paper provides alternatives ways of thinking about these disciplines and recommends a problem‐solving perspective of rural and remote health.     

Constructing health capital in ecological systems: A qualitative evaluation of community‐based health workshops in the refugee community

Refugee communities face numerous health and mental health concerns both during and after resettlement. Health issues, already deteriorated by chronic poverty, malnutrition and poor living conditions, are exacerbated by acculturative challenges, such as cultural and language barriers, stigma, and lack of resources and information. Since such needs in refugee communities affect both individual and collective capacity, it is important to consider policy environment and socioecological contexts for cultural adjustment and community resources for navigating systems, rather than individual health behaviours and communication skills only. To expand our understanding of health promotion capacity and resources, a broad and context‐dependent concept will be necessary. Adopting a concept of health capital, this study aims to explore the impact of community‐based health workshops, while expanding and redefining the framework in the context of health promotion efforts for the refugee community in resettlement. As part of community‐based participatory research, this qualitative study conducted seven focus group discussions (FGDs) with 22 Bhutanese refugees in 2014. Using a hybrid thematic analysis, themes emerged from the FGD data were organised and categorised into health capitals in ecological systems. The participants reported enhanced confidence and capacity for health promotion at individual, family and community levels. Given the interdependent coping and lifestyles of refugee communities, impacts on the participants’ interactions and relations with family and community were significant, which emphasises the importance of assessment of interventions beyond an individualistic approach. The findings of this study underscore the vital role of varied forms of health capital in promoting health in the refugee community and connecting members to needed health resources and information. Health capital is an old and yet still new concept with a great potential to broaden our understanding of health resources by elaborating the impacts and interactions in individuals, family and community for health promotion.