Interview with Jennifer Blossom

The 11th Australian Rural and Remote Mental Health Symposium Communiqué.

Working to make rural health matter.

To assess levels of agreement on priority areas among state and local rural health leaders nationwide. Analysis of responses to a mail survey sent to 999 rural health leaders, with 501 responses. Respondents were asked to rank importance to rural health of focus areas named in Healthy People 2010. There was substantial agreement on top rural health priorities among state and local rural health leaders across the 50 states. "Access to quality health services" was the top priority among leaders of state-level rural agencies and health associations, local rural public health agencies, rural health clinics and community health centers, and rural hospitals. It was the top priority across all 4 major census regions of the nation as well. The next 4 top-ranking rural priorities--"heart disease and stroke," "diabetes," "mental health and mental disorders," and "oral health"--were selected as 1 of the top 5 rural priorities by one third or more of respondents across most groups and regions. At the same time, some observed differences in rural health priorities suggest opportunities for community partnership strategies or for regional multistate policy initiatives by states sharing similar rural health priorities.

One health the future of rural health?

This edition of the Australian Journal of Rural Health is a thematic issue with a special focus on rural mental health. In 1993, the Human Rights and Equal Opportunity Commission’s Human Rights and Mental Illness report (The Burdekin Report) focused public attention on many mental health problems including those in rural areas. 1 Two chapters of that report presented findings regarding people in rural and isolated areas and Aboriginal and Torres Strait Islander people. They highlighted issues including the distribution of services, difficulties for health professionals and historical and cultural issues regarding Aboriginal and Torres Strait Islander people. More recently, The Burden of Disease and Injury in Australia report found that mental illness is a major cause of morbidity and disability. 2 To date, there is little available research evidence detailing mental health morbidity and mortality patterns in rural and remote areas. As everywhere, environmental and cultural factors are likely to be key determinants of mental health in these areas. When asked, people in small rural communities describe a range of positive and negative aspects of the rural lifestyle that affect health and wellbeing. 3 Generally, however, they do not recognise the impact of the rural culture with its combination of close-knit communities emphasising mutual support, together with independence and self reliance. Often mental illness is seen as ‘weakness’ and those suffering more serious mental illnesses are stigmatised by the rural community. Three of the articles in this edition explore conceptual aspects of rural mental health. Wainer and Chesters 4 explore the distinction between mental illness and mental health in the rural context, drawing on historical perspectives and personal experiences of individual case examples. Subsequently, they describe the determinants of positive mental health in a rural context before concluding that there is a need for balanced social and economic developments as well as improved mental health services in rural and remote areas. Fuller et al. explore the ‘definition’ of mental health problems as perceived by people in rural and remote areas. 5 This research report confirms the reluctance of rural people to acknowledge mental health problems and the stigma associated with formal mental health services as well as the influence of rural and remote circumstances. The third conceptual article explores the gender roles and the emotional distress of women in urban, rural and remote areas of Queensland. 6 The study found that positive gender roles are more frequent in rural and remote areas and associated with lower levels of emotional distress. The authors’ conclusion is that an understanding of rural and remote mental health requires more sophisticated analysis than that based only on geographical location. The authors suggest that factors such as gender roles and other aspects of the rural culture may be important. Three of the articles are focused on clinical service delivery in rural and remote areas with a common emphasis on mutual support of rural health-care providers. Allison et al. evaluate a pilot clinical intervention in a rural setting. Their findings suggest that targeted short-term specialist interventions may often bring substantial improvements for mild to moderate mental health problems in rural and remote areas. 7 Malcolm, in her paper entitled A primary mental health-care model for rural Australia: Outcomes for doctors and the community, describes a successful mental health services delivery model with an emphasis on multidisciplinary teamwork in the rural setting. 8 Harvey describes the genesis and development of the rural psychologists’ network, which provides professional support and communication for counselling psychologists in rural and remote areas. 9 A recurring theme through several of the articles is the need for mental health service delivery models that are effective and successful in the context of rural community attitudes, geographically dispersed populations and serious workforce shortages. Local generalist nurses and doctors are the main providers of mental health care in small rural and remote communities. The quality and effectiveness of their services are likely to be enhanced where they are supported by distant specialist services and health-care providers. These specialist services and providers should fulfil a true consultant role, providing support, guidance and training to the on-the-ground practitioners in small communities. The final article in this thematic issue reports an initiative that is expected to assist workforce recruitment in the medium to long term. 10 The placement of nursing students in rural and remote mental health clinical attachments not only improves the students’ knowledge and understanding of rural and remote mental health issues, but is likely, in some cases, to raise the students’ interest in pursuing their careers in a rural setting. All the articles raise challenging questions that should stimulate considerable thought and discussion among readers. As always, letters to the editor responding to and debating issues raised by these articles are most welcome. I look forward to your comments.

1. Rural Health Policy: Past as a Prelude to the Future K.J. Muller. 2. Methodological Issues in Rural Health Research and Care S. Loue, H. Morgenstern. 3. Public Health Issues J.B. Conway. 4. Equity in Rural Health and Health Care L.A. Aday, et al. 5. Ethnic Issues R.D. Baer, J. Nichols. 6. The Health of Migrant and Seasonal Farm Workers B.W. Goldberg, M. Napolitano. 7. American Indian and Alaska Native Health Services as a System of Rural Care E.R. Rhoades. 8. Rural Women's Health P. Winstead-Fry, E. Wheeler. 9. Pediatric and Adolescent Health N. Abbott, K. Olness. 10. Infectious Diseases K.B. Armitage, G.I. Sinclair. 11. Chronic Disease in Rural Health L.K. Dennis, S.L. Pallotta. 12. Rural Occupational Health and Safety L. Stallones. 13. Oral Health R. Isman. 14. Mental Health Services B.L. Levin, A. Hanson. 15. Substance Use L.A. Rebhun, H. Hansen. 16. No Safe Place to Hide: Rural Family Violence S. Murty. 17. Theories, Models, and Methods of Health promotion in Rural Settings J.P. Elder, et al. 18. Health Education - Community Based Models G.E. Soare. 19. Recruiting, Training, and Retaining Rural Health Professionals J. Robinson, III, J.J. Guidry.

Solutions for rural Mental Health Services.

One parameter of the operational framework of the Australian Rural Clinical Training & Support Program (RCTS) is rural health research, yet there are no published reports of the research outcomes generated by these hallmarks of Australian rural medical education. To assess the contribution of RCTS to rural health research, their MEDLINE-indexed research publications over the last decade was analysed, using a bibliometric method. MEDLINE-indexed RCTS publications from 2004 to 2013 were retrieved using validated PubMed queries. Two authors independently checked all retrieved RCTS publications for validity. Australian rural health (ARH) publications from RCTS were selectively enumerated and their proportion among all Australian rural health publications in each year was determined. ARH publications were defined as Australian publications that explore issues relevant to the health of the regional, rural or remote Australian population.RCTS publications related to medical education, Indigenous health, rural service areas, National Health Priority Areas (NHPA), and National Rural Health Alliance Priority Areas (NRHAPA) were analysed. Frequency of publication in different journals was also compared. A total of 280 RCTS publications were retrieved, increasing from 10 in 2004 to 49 in 2013. ARH topics dominated (177 articles; 67%). RCTS rural health publications increased as a proportion of all ARH publications from 3.4% in 2004 to 7.7% in 2013. Other RCTS publications increased from 2 (20% of total) in 2004 to 19 (39% of total) in 2013, and covered topics such as mental health, cancer, diabetes, obesity and asthma. RCTS medical education publications increased from 3 in 2004 to 14 in 2013. In total, 81 articles were retrieved comprising 28.9% of all RCTS publications. Indigenous health (18; 6%), rural populations (37; 13%) and rural health services (83; 29%) were the other important categories relevant to the RCTS funding parameters. RCTS publications also included NHPA (57; 20%) and NRHAPA (61; 22%). The main journals publishing RCTS research in this time period were Rural and Remote Health (16%), Australian Journal of Rural Health (13%) and Australian Family Physician (9%). This first study to report on the research efforts of RCTS researchers has shown that they are making a valuable contribution to rural health research and increasingly so within the research parameters indicated. These data represent a benchmark of research strengths and highlight research areas that should be strengthened with targeted research to best promote the health of rural Australians.

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. 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. A rural Area Health Service in NSW. Rural health and welfare service providers, consumers with co-morbid D&A and mental health disorders. 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. 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.

A fundamental feature of rural communities in Australia is the interconnected relationships of the people in them and how these are harnessed for the benefit of the community. This is never more evident than in times of difficulty or crisis; many have noted the prevailing resilience and stoicism of rural communities. However, even the most determined communities can be challenged by accessing health services. As a General Practitioner and a Mental Health Nurse, the difficulties rural Australians have in accessing evidenced-based mental health services is particularly concerning. Obtaining psychological therapies in rural Australian communities can be almost impossible due to the lack, and availability, of trained healthcare professionals. Rates of suicide are 30% higher in the bush, unacceptable for one of the wealthiest countries in the world. The Rural Health Multidisciplinary Training Programme (RHMTP) has built a quality rural training programme which promotes rural academics and communities working together. It is a uniquely Australian approach to generate sustainable workforce solutions in partnership with rural communities. It works with rural communities to provide quality clinical training experiences for the future health workforce, a feature pivotal to the RHMT programme for 20 years. In addition to supporting to health students, in South Australia, we provide professional development for the existing rural health workforce, employ rural clinicians as academics, build rural academic capacity and conduct rural health research of meaning to rural communities. All of this helps to strengthen rural networks and enables rural communities to grow and develop. Our experience as Directors of two RHMTPs is that rural communities are energetic, accepting and receptive to innovative solutions to workforce recruitment and retention to address professional shortfalls in rural communities. In South Australia, to help us attract the next generation of health professionals, we have utilised the expertise of health students to engage rural school communities showcasing the benefits of pursuing a health career. We have worked with our communities to grow unique rural placement experiences that build the social capital of rural communities. We welcome the contribution of the newly appointed Rural Health Commissioner Professor Paul Worley. This appointment presents an exciting opportunity to revisit and think broadly about how to provide the future workforce with alternative clinical training and research experiences and encourage them to ‘go bush’. This might include rural academics and health providers co-locating, to establish joint academic and health service centres. These centres could offer world-class rural clinical training experiences, provide career development, and conduct high-quality rural research built around the needs of rural communities. Co-location of academics with health care providers will provide opportunities for people living in rural Australia to participate in clinical trials and formulate NHMRC partnership grants with academics and rural health partners. The integration of rural academics into rural health centres brings strength in conducting, translating and implementing research. It would also enable rural academics to work with community partners in research capacity building, such as completing ethics application, writing peer review papers and grant writing. As a community of practice, communities would train and guide academics in community engagement activity. This in turn would drive rural student training programmes and rural workforce development. We would ask our Rural Health Commissioner to consider local government involvement in the training experience and working with the private sector to attract investment, and purposeful involvement with rural communities to help ensure community needs fit with broader government strategy. An example would be provision of housing for students with a genuine commitment to return and work in that community. We are reflecting that perhaps two important next steps to for the RMTP progarmme are to focus our attention on supporting rural origin students and showcase the distinctiveness of the rural immersion learning experiences which rural Australia has to offer. Rural origin students are most likely to remain or return to rural Australia. The most challenging work is to bring three different groups together – health service providers, education institutions, and non-health facilities (government and nongovernment) – to work with local communities and develop local contextual solutions. The RHMTP and the leadership role the universities have in ensuring their successful implementation is an exemplar to the global community and helps address the unacceptable health inequalities between metropolitan and rural Australia. We encourage State and Commonwealth providers to place a higher value on community-led solutions, however innovative, as likely to succeed where traditional interventions have not. Communities with a sense of isolation will continue to advocate for conventional answers if they believe this is the only way forward. We should be talking to communities about how to enhance the social capital they invest in our future health workforce. Activity such as this builds the social capital of rural communities and deepens the clinical training experience.

Opportunities in mental health services research.

This special issue represents a collaboration involving the New Zealand (NZ) Rural General Practice Network, Rural Health Alliance Aotearoa NZ (RHAANZ) and the National Rural Health Alliance (NRHA) in Australia. It is envisaged that this will be the beginning of an ongoing Australasian focus for the Journal. In this issue, some of Australia's and NZ’s most prominent rural health researchers and leaders have provided complimentary trans-Tasman commentary on a range of important rural health topics. The topics cover rural health delivery, advocacy, policy and education for a range of health professional groups, as well as original research. Few countries have as much in common as Australia and NZ, including the way their health and education systems are organised. Given the commonalities, the differences in rural health highlighted in this special edition are surprising. David Lyle and Jennene Greenhill outline the history and the achievements of the university Departments of Rural Health and the Rural Clinical School Programs, a collective ‘critical mass’ of academic health activity now embedded in rural communities across Australia. John Burton and Martin London have been advocating over a similar period for similar initiatives in NZ,1, 2 where progress has been much slower. The proposals from NZ universities currently being taken to government is a positive step, but there is no immediate prospect that they will receive the funding they need. This underscores the important role of rural health advocacy and the successes of the NRHA that Lesley Barclay and Gordon Gregory outline in their article. This includes the publication of the AJRH. The initiative taken by the RNZGPN and RHAANZ in sponsoring this edition of the Journal is encouraging. At the same time, it is disappointing to hear from Martin London that the NZ equivalent of the NRHA, RHAANZ, has gone into ‘hibernation’ because of a lack of funding. John Wakerman and John Humphreys discuss the development of the Modified Monash Model, an evidence-based rural typology that has been adopted by the Australian Government. In an accompanying commentary, Dave Fearnley discusses the implications of not having a fit-for-purpose rural urban classification in NZ3 and Jesse Whitehead presents early work to help rectify this. Other articles co-authored by Australian and NZ authors suggest that in paramedicine (O'Meara & Duthie) and in efforts to improve the physical health of people living with mental illness (Roberts et al.), the similarities outweigh the differences between the countries. Given the documented disparities, improving health outcomes for rural Māori and Aboriginal communities must be the top priority for all of us working in rural health research or clinical practice. Although Māori students are now entering NZ medical schools in much greater numbers,4 the short report by Yassar Almari raises the concerning possibility that Māori students may be less likely to take up careers in academic medicine. Marara Koroheke-Rogers and Katharina Blattner also remind us that partnering rural Māori communities in research involves much more than following university and ethics protocols and necessitates engaging in the processes that belong to that community. This article is presented alongside the results of the original research into rural point-of-care ultrasound (Nixon et al.) and a commentary by Kate Senior. Two guest editors were appointed, Dr Garry Nixon (University of Otago) and Associate Professor Oliver Burmeister (Charles Sturt University). Associate Professor Burmeister is a technologist who specialises in health care technologies. He has previously published in AJRH5 and has collaborated with various health care professionals for publications in clinical journals,6-9 as well as in technology journals.10-14 Dr Nixon remains in active clinical practice as a rural generalist at Dunstan Hospital in Central Otago, NZ. He was recently appointed as Head of the new Section of Rural Health at the University of Otago. His interests include the vocational training of rural generalists and rural versus urban disparities in NZ, with particular focus on improving access to diagnostic services for rural populations.

Objective To explore new strategies for rural public health reforming so than early prevention for healthy farmers and early detection and treatment at disease on-set stage could be ensured. Methods Based on the integration of New Rural Cooperative Medical Care System(NRCMCS)and rural community health resources, the new rural health management model was implement in Xuebai Township. The results from this implementation and its effectiveness were evaluated. Results The main behavioral health risks were determined based on prevalent major diseases and common diseases. After the implementing the new health management model, the numbers of inpatient visits obviously increased, including in both out of the county and local community hospitals. As a result, the proportion of inpatient visits in the county hospital was decreased. The average costs of inpatient and reimbursement were decreased in out of the county and local community hospitals. The service capacity and equipment usage rate for local community hospitals were improved. In addition, 84. 43% of participants of this new model showed satisfactory. Conclusions Health management is a multi-win strategic choice, which can strengthen the health consciousness of participants, improve the usage rate of health care resources, increase the efficiency of utilization of the funds from NRCMCS and decrease the economic burden of rural residents to treat diseases. Key words: Rural health; Multiphasic screening; Health management; Effectiveness assessment

The authors conducted a survey of 215 rural community mental health centers across the country to determine their unique problems, needs, and resources. From the 92 responses they received, they formulated a composite description of the rural mental health scene. Their description focuses on services offered, skills required to operate effective rural programs, and problems in the delivery of care and of evaluation. From the responses they also analyzed the extent of inservice training available to rural practitioners, the support systems needed, and the functions a proposed national task force on rural mental health could perform.

The mental health of rural people in Aotearoa (New Zealand) has been a major concern for decades. Red flag issues such as isolation, population decline, barriers to help-seeking, and high suicide rates have all raised concerns for the mental health of our rural communities. Despite elevated rates of suicide, there has been a drought of research into the processes that contribute to the current state of mental health in rural Aotearoa. We set out to expand our knowledge and address the rural mental health crisis by unpacking the intersection of rurality and mental health using a mixed methods approach (quantitative and qualitative research methods). In our first study, we conducted a quantitative analysis using data from the New Zealand Attitudes and Values Study (N = 47,951) to examine the mental health of rural people across two competing measures of rurality: the Urban Rural Indicator (URI) and the Geographical Classification for Health (GCH). Additionally, we added a measure of social connectedness to test the significance of social factors in the rural-mental health relationship. Our main findings yielded nil or very small statistical relationships between rurality and mental health. The lack of statistical evidence suggests there may in fact be no relationship between rurality and mental health, or possibly that the relationship is more complicated and requires further research (i.e., involving multiple additional variables). Our unadjusted analysis yielded very small statistically significant relationships which suggested that psychological distress was lower for rural populations across both measures when compared to urban populations. However, significant differences were observed in mental wellbeing across rurality measures, with the URI suggesting better wellbeing for rural people and the GCH suggesting worse wellbeing. Social connectedness did not meaningfully mediate the rural-mental health association in either model. More generally, findings regarding trends in rural mental health changed depending on which measures were used to define ‘rural’ and which aspects of mental health were in focus, indicating a hidden complexity in the concept of rurality itself. In our second study, we conducted reflexive thematic analysis on 10 semi-structured interviews with rural people from the North Island of Aotearoa. We developed an overarching thread suggesting that rural Aotearoa suffers from problems with access (to land and community), where gatekeepers maintain the status quo, making conditions difficult for those on the outside. We developed three distinct themes to describe rural life for those on the inside (i.e., part of the rural in-group), where group norms and expectations can have both enhancing and compromising effects on wellbeing. Our first theme describes the centrality of occupation and its unfortunate tethering to uncontrollable economic conditions, which creates mental health challenges for those who embed occupation into their identity. Our second and third themes describe the cultural barriers from either side of a ‘mental health fence’ (i.e., help-seeking and offering help). Our study generated several intervention targets that can be used by mental health providers (e.g., GoodYarn) to increase psychoeducation and mental health literacy. Our final study transformed findings from our first and second studies into a battery of quantitative questions presented in the Politics and (Mental) Health State of the Nation Survey (n = 6,609). We aimed to compare the correlations between three subjective rurality measures (including our rural identity), mental health, and the moderating effects of five psychosocial factors. Although we found no evidence of a significant association between rurality and mental health in any of the three rurality measures, we found correlations between psychosocial factors and mental health (independent of rurality). For example, we found compelling evidence that psychosocial factors such as loneliness and impostor syndrome predict poorer mental health outcomes, and that increases in mental health knowledge predict higher engagement in mental health conversations. We conclude that the relationship between rurality factors and mental health is complex, and further research into the mechanisms that drive rural mental health difficulties is needed. Overall, our research shows the impacts that different metrics of rurality can have on mental health outcomes. Hence, we recommend selecting a rurality metric that increases the explanatory power of research findings and contains aspects of rurality that are appropriate for the research question. Rural people in Aotearoa face significant barriers to accessing and offering mental health support, which are both systemic and sociocultural. Mental health stigma, gatekeeping, and access inequality combine to form difficult mental health conditions in rural communities. When these overlapping factors are considered, current disparities in rural mental health outcomes become easier to understand. Despite failing to provide statistical support for the role of psychosocial factors in rural mental health conditions, we contribute novel and Aotearoa-specific empirical evidence that has practical application.