Rapid change, climate adversity and the next 'big dry': older farmers' mental health

Objective: To describe the experiences of older farmers in the face of prolonged drought and rapid change. Design: Content analysis of issues and priorities raised in semi‐structured community forums. Setting: Rural centres in NSW. Participants: One hundred and fifty older farmers, their families, Industry and Investment NSW, rural financial and mental health services, the Country Women's Association and other non‐government agencies. Intervention: Five public forums organised under the Rural Adversity Mental Health Program. Results: Prolonged drought caused pressures on farmers that compounded the usual stresses of farming and of ageing. These were experienced in the context of rapid social and industry change, fuel price volatility and the insidious threat of climate change. Three main themes were articulated: loss, government compliance pressures and difficulties accessing and/or inappropriate services. Conclusion: Older farmers felt an overwhelming sense of loss: of profitability and professional success, community status, physical well‐being and comfort, the ability to participate in the modern world and, above all, of relationships (partners, children and friends moving away). They interpreted government compliance requirements as evidence of community and government loss of trust in famers. They resisted using the few mental health services that might be available, fearing being labelled as ‘crazy’ and discouraged by the culturally inappropriate way in which services were offered. Older farmers would benefit from joint services related to health and well‐being simultaneously with modern business management offered in trusted, comfortable settings.     

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.     

In their own words: young people's mental health in drought-affected rural and remote NSW

Objective: To record the drought‐related experiences of young people and to contrast these with their teachers' and other adults' observations. Design: Content analysis of issues and priorities raised in semistructured school‐based forums. Setting: Rural schools in NSW centres. Participants: Young people, their teachers and service providers. Intervention: Six youth and community forums organised under the Rural Adversity Mental Health Program. Results: Participants welcomed increased community connectedness in response to prolonged drought but reported that drought's mental health impact was mainly negative. Adults observed children's distress, wondering if anyone else noticed it. They witnessed young people worrying about their families, increasingly isolated, at risk of harm, unable to obtain help and facing educational and employment limitations. Young people disclosed many mental health and relationship difficulties at school and at home. They worried about their families, communities and futures and about money and being isolated. Conclusion: Adults and young people reported similar effects of prolonged drought on young people's mental health. But, while adults were more concerned with risks to young people (of harm, abuse, homelessness, problems with the law and constrained opportunities), young people were simply overwhelmed, wanting help for their immediate worries. They sought coordinated support within schools, schools working together, more information about mental health and where to seek help for them and their friends, and support people who understood drought and rural circumstances and on whose discretion they could rely. Mental health programs that are developed in and for metropolitan contexts need to be adapted before being deployed in rural settings.     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.     

Securing and retaining a mental health workforce in Far Western New South Wales

OBJECTIVE: To identify strategies local managers can use to optimise recruitment and retention of mental health staff in rural locations. DESIGN: Forty-one staff were interviewed about factors that attracted them to work in remote locations, their initial intentions and factors that encourage them to stay. SETTING: The former Far West Health Area of New South Wales. RESULTS: Overall job satisfaction was high (68%). Key attractors were rural lifestyle and environment. Family reasons, the field of work and the rural lifestyle were factors that keep staff in their positions. Some mentioned the desire to achieve professional goals and see projects completed. Many staff reported that their initial intentions to stay had remained the same (43.9%). Reasons for extended intention to stay were: greater career opportunities; a desire to complete professional goals; extension of positions; and personal factors. The most common reason for leaving was better career opportunities. Other reasons included: changes to personal commitments; heavy workloads or burnout; service management; and workplace politics. A large number of respondents mentioned key differences when comparing rural and metropolitan areas: more travel (greater distances); less service options for referral; greater spectrum of illnesses and conditions; more autonomy and responsibility. CONCLUSIONS: Strategies to recruit and retain staff must take account of personal needs and aspirations. While there is room for state strategies to improve employment incentives, there is also considerable scope for local managers to improve the design and attractiveness of jobs.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

How definition of mental health problems can influence help seeking in rural and remote communities

ABSTRACT: The present study sought to understand the rural and remote influences on people's identification of, and response to, mental health problems. Twenty-two key informants living in northern and western South Australia were interviewed. They included mental health and generalist health professionals, other human service workers and mental health consumers. Three themes are reported here: reluctance to acknowledge mental health problems and the avoidance of appropriate help; stigma and the avoidance of mental health services; and the influence of rural and remote circumstances. Most informants considered that many mental health problems were amenable to help from generalist workers, with backup support from mental health specialists. Informants thought this intervention to be appropriate because a common view of mental health problems as 'insanity' and a culture of self-reliance created a reluctance to seek help from a mental health specialist. These themes need to be taken into account when designing mental health interventions for rural and remote communities.     

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.     

The Orange Declaration on rural and remote mental health

Rural mental health outcomes have been persistently poorer than those in larger cities suggesting that the prevailing investments to improve matters are not working. Mental health researchers and service providers from New South Wales, Victoria, Western Australia and the Australian Capital Territory met in Orange in October 2018 to explore issues pertaining to rural mental health and well‐being. The group recognised and acknowledged that rural residents experience a series of interconnected geographical, demographic, social, economic and environmental challenges which are not addressed adequately by the current mix of services. This declaration has been endorsed by those listed below and we welcome further support. We list ten interrelated problems and ten solutions. As a group, we take this declaration as an opportunity to invite discussion about how we can collectively improve the mental health of rural residents through research, service design and delivery. We invite the reader to consider endorsing this declaration. A short summary of supporting evidence is available online at https://www.crrmh.com.au/ .     

Comparison of the results of two rural allied health workforce surveys in the Hunter New England region of New South Wales: 2005 versus 2008

Objective: To compare the results of the 2005 and 2008 surveys of the rural allied health workforce in the study region. Design: Comparative analysis of two cross‐sectional surveys. Setting: The rural, northern sector of the Hunter New England region of NSW, Australia. Participants: Both surveys targeted 12 different allied health professions. There were 225 respondents in 2005 and 205 in 2008. Main outcome measures: Comparison is made for 15 dependent variables. Results: There was no significant difference for most variables between 2005 and 2008. Mean age and mean years qualified decreased slightly, from 43 to 41 years and from 20 to 17 years, respectively. The proportion of respondents of rural origin was about two‐thirds in both studies and about half had a rural placement during training. While more than half supervised students, only about one‐third had received training for that role. In both 2005 and 2008, the proportion working 35 or more hours each week was about 66% but the proportion working more than 40 hours had doubled to about 36%. In both surveys about half intended leaving their job within 10 years, while the proportion satisfied with continuing professional development access had halved, from 70% to 35%. Conclusions: Most results of the 2005 Hunter New England survey were verified. It was confirmed that a large proportion of the allied health workforce in the region intend leaving their job in the next 5 to 10 years. This is a concern for the development of new service delivery models.     

Using cohort studies to investigate rural and remote mental health

This paper, presented at the 2010 rural health researchers' National Scientific Symposium on Rural and Remote Health, provides an overview of large Australian population mental health cohort studies which have a focus on climate-related and environmental adversity, social factors and mental health. These studies highlight the value of exploiting multiple exceptional datasets to better understand the drivers of rural health, including how to use population-level research to improve health resources in non-metropolitan areas. We show how the key characteristics of rural and remote mental health might be explored by exploiting the following cohort studies: Household, Income and Labour Dynamics in Australia Survey; Australian Rural Mental Health Study; Hunter Community Study; and Extending Treatments, Education and Networks in Depression study. Existing cohort studies that focus on significant rural and regional characteristics can be creatively analysed to better understand geographic variation in mental health. They have the potential to move understanding beyond simple prevalence to building knowledge about the trajectories of psychological distress and determinants of mental disorders and outcomes over time.     

Partnerships to promote mental health of NSW farmers: the New South Wales Farmers Blueprint for Mental Health

Objective: To describe the process and outcome of development of a framework for planning and implementation of a range of interventions aimed at improving the mental health and wellbeing of farmers and farm families in New South Wales (NSW). Design: In response to a major drought in New South Wales (NSW), key agencies were invited to participate in a longer-term collaborative program aimed at improving the mental health and well-being of the people on NSW farms. These agencies became the NSW Farmers Mental Health Network. Setting: The Australian National Action Plan for Promotion, Prevention & Early Intervention for Mental Health 2000 proposed a population health approach base encompassing the range of risk and protective factors that determine mental health at the individual, family and community and society levels. It incorporated three traditional areas of health activity into programs aimed at achieving improved mental health for the Australian population – mental health promotion, prevention activities and early intervention. Although the farming population was not identified as a priority population, research has identified this population to be at high risk of suicide, and of having difficulty in coping with the range of pressures associated with life and work in this industry. Participants: Participants were agencies providing services across rural NSW in the fields of farmer and country women's organisations, financial counselling services, government departments of primary industries and health, mental health advisory and support services, charitable organisations and others. Results: The NSW Farmers Blueprint for Mental Health ( http://www.aghealth.org.au/blueprint ) was developed to be ‘a simplified summary of key issues that need to be addressed, and the major actions that we can be confident will be effective in achieving our purpose’. It has identified ‘steps’ along ‘pathways to breakdown’ from the range of known mental health and suicide risk factors that are relevant to the NSW farming population, and 23 areas of current and potential action that would contribute to improving mental health, as key steps along ‘pathways to health’. For each of the areas of action there is described the rationale and basis for action, and the lead agency or individual who has accepted responsibility for coordinating and reporting further activity to the Network. Conclusion: It is suggested that the NSW Farm Blueprint and the activities being implemented by the NSW Farmers Mental Health Network partners represent a model for implementation of a mental health promotion in identified at-risk Australian populations.     

Profile of the rural allied health workforce in northern New South Wales and comparison with previous studies

Objective: To survey allied health professionals in one region of New South Wales. Design: A questionnaire designed to give a profile of the allied health workforce was mailed to 451 practitioners from 12 health professions between July and September 2005. Setting: The region included the upper Hunter Valley, Liverpool Plains, New England Tablelands and North-west Slopes and Plains of New South Wales. Main outcome measures: The overall response was 49.8%, although the response rates varied between disciplines. Data were collected for a wide range of dependent variables. Results: Pharmacists were the most numerous respondents (21.8%), followed by physiotherapists (17.3%), psychologists (12.4%), radiographers (11.1%) and occupational therapists (10.6%). These five professions made up 73.3% of respondents. Approximately 75% of the sample worked in Rural, Remote and Metropolitan Areas (RRMA) 3 and 4 sized towns. The female to male ratio was 3:1. The mean age was 43 years, the average time since qualification was 20 years and the mean time in the current position was 10 years. Half of the respondents said they intended leaving within 5 years. Some 65% were of rural origin. The ratio of private to public sector employment was 0.75:1, with 64.0% working full-time. Conclusions: Comparison is made between this and previous studies. The results highlight the need for further regional allied health workforce profiling and for a recruitment and retention strategy that targets new graduates of rural origin and encourages them to stay.     

完善农村卫生医疗服务质量管理的思考

文章通过对河南省卫X I项目县的实地调查,发现县、乡、村三级医疗机构在医疗服务质量管理方面存在一些问题,建议①建立健全医疗质量管理组织机构;②建立并完善医疗服务质量管理制度;③合理划分质量管理职责;④进一步完善乡村卫生一体化管理;⑤为医务人员创造良好的成长环境。     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.