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.     

Housing and health in Indigenous communities: key issues for housing and health improvement in remote Aboriginal and Torres Strait Islander communities

Indigenous people living in remote communities face some particular difficulties with regard to housing and its impact on their health. This paper reviews the contemporary international understanding of the relationship between housing and health, the history of settlement and housing conditions in remote Aboriginal and Torres Strait Islander communities, and some of the recent initiatives to improve housing in these communities.     

The mental health of rural Australians: developing a framework for strategic research

ABSTRACT: This paper argues that lack of adequate research is a barrier to the long-term improvement of the mental health and well-being of rural Australians. Following from national mental health policy, potential research avenues in four broad domains (prevention and early intervention, pathways to care, outcome of illness and aetiology) are defined. These four broad domains are interdependent and research into them can be brought together into a simple framework or model. This model could be used to guide research into rurality and mental health. The proposed model uses the inclusive concept of place to capture the potential complexities of the rural locale as a variable in mental health and disorder. The model's predictor variables include both risk and resilience factors, and the outcome variables extend beyond morbidity to positive psychological wellness. It is proposed that this provisional model, and the strategic research that it directs, will act as a useful counterpoint to the more immediate evaluation and resourcing needs that confront rural mental health.     

Indigenous health and community services employment in remote Northern Territory: a baseline examination of 2006 and 2001 Census data

Objective: To establish a baseline of levels of Indigenous professional engagement in the health and community services sector in remote Northern Territory. Design: Analysis of data from 2001 and 2006 Census. Setting: Northern Territory – Balance Statistical Division. Participants: Persons employed in health and community services sector in 2006. Main outcome measures: Indigenous status, level of education, current education status, occupation type and residential mobility. Results: Indigenous employment grew by 137% between 2001 and 2006. In 2006, 42% of Indigenous employees were labourers and 9% professionals, in contrast to non‐Indigenous workers of whom 41% were professionals and 5% labourers. Over 50% of workers who moved into the region between 2001 and 2006 were professionals, compared with 20% of those who had remained in the region. Indigenous in‐migrants were twice as likely as Indigenous people who had stayed in the region to be professionals. Indigenous workers were much less likely to have post‐school educational qualifications than non‐Indigenous workers. Indigenous workers were also less likely to be studying for a post‐school qualification. Indigenous in‐migrants were three times as likely to have post‐school qualifications than Indigenous people who had remained in the region and were also more likely to be enrolled in post‐school education. Conclusions: The baseline is low Indigenous engagement as professional labour, and low Indigenous engagement in formal education. Mobile Indigenous people have higher levels of engagement. The situation might be addressed by increased formal education in remote areas and increased mobility of Indigenous health labour.     

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/ .     

Collaboration and referral practices of general practitioners and community mental health workers in rural and remote Australia

OBJECTIVE: To assess an important part of Australia's National Mental Health Strategy by examining the collaboration and referral practices between general practitioners and community mental health workers in rural and remote areas. DESIGN: Semistructured interviews. SETTING: Rural and remote health service region in Australia. PARTICIPANTS: In total, 31 general practitioners and 14 mental health workers. RESULTS: Meaningful collaboration and referral practices between general practitioners and mental health workers are prevented by contradictory and ambiguous definitions involving professional roles and mental health. A pattern of negative collaboration was further magnified by the rural and remote context. CONCLUSION: The implementation of Australia's National Mental Health Strategy faces serious problems in rural and remote area due to the negative collaboration and referral practices between general practitioners and mental health workers.     

Sampling and recruitment methodology for a national eye health survey of Indigenous Australians

Objective: To review the process of sample selection and highlight the methodological difficulties encountered during a nationwide survey of Indigenous Australians, to determine the prevalence and causes of vision impairment and evaluate access to and utilisation of eye care services. Methods: Using a multi‐stage, random cluster sampling methodology, 30 geographic areas stratified by remoteness, were selected to provide a representative population of approximately 3,000 Indigenous Australians aged 5–15 and 40 years and older, and a small non‐Indigenous sample in selected remote areas. Recruitment was adapted to local conditions. The rapid assessment methodology included a questionnaire, tests of visual acuity, trachoma grading, frequency doubling perimetry and non‐mydriatic fundus photography. Results: The number of people examined was 2883/3662 (78.7%) Indigenous and 136 (83.4%) non‐Indigenous. The percentage of the expected population who were enumerated during the survey varied; discrepancies were largest in urban areas (34.5%) compared to very remote areas (97.1%). Conclusions: The unexpected variation in predicted population numbers and participation rates could be explained in part by local circumstances, degree of urbanisation, interpretation of the definition of ‘Indigenous’ and time constraints. Implications: For successful recruitment, a community‐specific approach is essential, including collaboration with local organisations and liaison with health workers of each gender.     

Preserving rural school health during the COVID-19 pandemic: Indigenous citizen scientist perspectives from a qualitative study

This qualitative study is part of Smart Indigenous Youth, a digital health community trial involving rural schools in Saskatchewan, Canada. Secondary school administrators and educators were engaged as citizen scientists in rural Indigenous communities to understand rapid decision-making processes for preserving school health during the COVID-19 pandemic, and to inform evidence-based safe school policies and practices. After COVID-19 restrictions were implemented, key informant interviews and focus groups were conducted with school administrators and educators, respectively, to understand the impact of school responses and decision-making processes. Two independent reviewers conducted thematic analyses and compared themes to reach consensus on a final shortlist. Four main themes emerged from the administrator interviews, and six main themes were identified from the educator focus group discussions which revealed a pressing need for mental health supports for students and educators. The study findings highlight the challenges faced by schools in rural and remote areas during the COVID-19 pandemic, including school closures, students'' reactions to closures, measures taken by schools to preserve health during the pandemic, and different approaches to implement for future closures. Citizen scientists developed a set of recommendations, including the need for structured communication, reflection meetings, adequate funding, and external monitoring and evaluation to guide evidence-based safe school policies and practices during the pandemic.     

Systematic review to inform prevention and management of chronic disease for Indigenous Australians: overview and priorities

Objective: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians. Methods: We searched databases for systematic reviews meeting inclusion criteria. Two reviewers assessed quality and extracted characteristics using pre‐defined tools. Results: We identified 14 systematic reviews. Seven synthesised evidence about health intervention effectiveness; four addressed chronic disease or risk factor prevalence; and six conducted critical appraisal as per current best practice. Only three reported steps to align the review with standards for ethical research with Indigenous Australians and/or capture Indigenous‐specific knowledge. Most called for more high‐quality research. Conclusion: Systematic review is an under‐utilised method for gathering evidence to inform chronic disease prevention and management for Indigenous Australians. Relevance of future systematic reviews could be improved by: 1) aligning questions with community priorities as well as decision maker needs; 2) involvement of, and leadership by, Indigenous researchers with relevant cultural and contextual knowledge; iii) use of critical appraisal tools that include traditional risk of bias assessment criteria and criteria that reflect Indigenous standards of appropriate research. Implications: Systematic review method guidance, tools and reporting standards are required to ensure alignment with ethical obligations and promote rigor and relevance.     

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.     

It's enough to make you sick: the impact of racism on the health of Aboriginal Australians

BACKGROUND: Experience of interpersonal racism has been neglected as a mechanism by which inequalities between Aboriginal and non-Aboriginal people are created and maintained. METHODS: Cross-sectional survey of randomly selected residents of a rural Australian town (n=639). Interpersonal racism was measured by two questions on experiences in the past four weeks of negative racially based treatment that evoked an emotional or physical response. Health was measured with the mental and physical health component scores of the Short-Form 12 and self-reported fair or poor general health. Linear and logistic regressions modelled the effects of interpersonal racism on health, controlling for age, sex, socio-economic status and Aboriginality. FINDINGS: The 183 Aboriginal respondents had lower health component scores, were more than twice as likely to report fair-to-poor general health (34% compared with 17%, p<0.001), and 2.6 to 5.0 times more likely to report negative racially based treatment. Demographic and socio-economic characteristics were not associated with reporting negative racially based treatment. After controlling for other variables, Aboriginal respondents who reported negative treatment were more likely to have poor health on all three measures. Non-Aboriginal respondents who reported experiencing negative treatment had lower mental health component scores. IMPLICATIONS: Experiencing racist treatment should be recognised as a social determinant of health. Improved health care and other initiatives may not eliminate health inequalities in the absence of fundamental changes in how non-Aboriginal people behave towards Aboriginal people.     

Rural and remote mental health placements for nursing students

Clinical placements can be instrumental in encouraging nursing students to consider a future career in rural Australia. Twenty nursing students from a metropolitan university were provided with the opportunity to undertake a clinical placement in mental health in a rural or remote setting. The majority of placements were between 2 and 4 weeks in length. They took place in community health centres and rehabilitation centres in New South Wales and in hospital inpatient facilities, remote areas and community health services in the Northern Territory. On return from the placement, students completed an open-question pro forma giving their views and impressions of their experiences and contrasting this with clinical experience gained in urban settings. The content of the students' responses was analysed and presented under the following themes: scale relating to urban and rural differences in population; geographical and health facility size; staffing matters; the environment; the students' perception of the clients; and professional interaction. Additional material relating to remote area placements is presented. Questions are raised about the maintenance of students' interest and the development of rural careers.     

Creating a database to facilitate multilevel analyses of mental health determinants and outcomes in rural and remote areas

Objective:  The lack of consistent findings regarding comparisons of mental health between rural and urban areas has been attributed in part to methodological shortcomings, including poor conceptualisation of 'rurality'. To address the diversity of rural and remote communities, an interdisciplinary collaboration sought to establish a database incorporating a range of domains hypothesised to be major influences on the mental health of individuals, families and communities.
Design:  The database domains included health (physical and mental), health service utilisation, sociodemographic characteristics, climate patterns, agricultural activity and primary industry. Important steps in the development of the database were addressing issues related to ethics, ownership, accessing data sources, sustainability of the database and integration of differing outcomes sought by the collaborators.
Results:  The paper describes the database while an illustrative example of analysis demonstrates its application. The potential for multilevel analyses between the database and other datasets is discussed as well as challenges for the future development of this valuable resource for rural mental health research.
Conclusion:  The Centre for Rural and Remote Mental Health database will be a valuable resource for rural mental health research.     

Extending rural and remote medicine with a new type of health worker: physician assistants

The purpose of this paper was to demonstrate that the medical workforce shortage is an international phenomenon and to review one of the strategies developed in the USA in the late 1960s: the physician assistant model of health service provision. The authors consider whether this model could provide one strategy to help address the medical workforce shortage in Australia. A systematic review of the literature about medical workforce shortages, strategies used to address the medical workforce shortage, and the physician assistant role was undertaken. Literature used for the review covered the period 1967-2006. Physician assistants provide safe, high-quality and cost-effective primary care services under the direction of a doctor and respond to workforce shortages in rural and remote areas, family practice medicine and hospital settings. This model of health care provision has been adopted in several other developed countries, including England, Scotland, the Netherlands and Canada. The physician assistant concept might provide Australia with a novel strategy for addressing its medical workforce shortage, particularly in rural and remote settings.     

Collaboration and local networks for rural and remote primary mental healthcare in South Australia

This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.     

Approach to treatment of mental illness and substance dependence in remote Indigenous communities: Results of a mixed methods study

Objective:  To develop and evaluate a culturally adapted brief intervention for Indigenous people with chronic mental illness.
Design:  A mixed methods design in which an exploratory phase of qualitative research was followed by a nested randomised controlled trial.
Setting:  Psycho-education resources and a brief intervention, motivational care planning (MCP), were developed and tested in collaboration with aboriginal mental health workers in three remote communities in northern Australia.
Participants:  A total of 49 patients with mental illness and 37 carers were recruited to a randomised controlled trial that compared MCP ( n =  24) with a clinical control condition (treatment as usual, n =  25).
Intervention:  The early treatment group received MCP at baseline and the late treatment group received delayed treatment at six months.
Main outcome measures:  The primary outcome was mental health problem severity as measured by the health of the nation outcome scales. Secondary measures of well-being (Kessler 10), life skills, self-management and substance dependence were chosen. Outcome assessments were performed at baseline, six-month, 12-month and 18-month follow up.
Results:  Random effects regression analyses showed significant advantage for the treatment condition in terms of well-being with changes in health of the nation outcome scales ( P <  0.001) and Kessler 10 ( P =  0.001), which were sustained over time. There was also significant advantage for treatment for alcohol dependence ( P =  0.05), with response also evident in cannabis dependence ( P =  0.064) and with changes in substance dependence sustained over time.
Conclusions:  These results suggest that MCP is an effective treatment for Indigenous people with mental illness and provide insight into the experience of mental illness in remote communities.