THE MENTAL HEALTH OF RURAL AUSTRALIANS: DEVELOPING A FRAMEWORK FOR STRATEGIC RESEARCH

Aust J Rural Health (2002) 10 296ndash301

Blackwell Science LtdOxford UKAJRThe Australian Journal of Rural Health1038-52822002 Blackwell Science Asia Pty Ltd10438AUSTRALIAN JOURNAL OF RURAL HEALTHTHE MENTAL HEALTH OF RURAL AUSTRALIANS F JUDD Et al 101046j1038-5282200200438xOriginal Article BEES SGMLOriginal Article

THE MENTAL HEALTH OF RURAL AUSTRALIANS DEVELOPING A FRAMEWORK FOR STRATEGIC RESEARCH

Fiona Judd12 Greg Murray3 Caitlin Fraser1 John Humphreys4 Gene Hodgins13 and Henry Jackson3

1Centre for Rural Mental Health Bendigo Health Care Group Bendigo 2Department of Psychological Medicine Monash University 3The University of Melbourne Department of Psychology and 4Monash University School of Rural Health Melbourne Victoria Australia

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

KEY WORDS mental health place research rural

INTRODUCTION

Although rural Australians are recognised as an lsquoat riskrsquogroup for mental health problems there has been limitedresearch into their mental health problems1 In additionthe research that has been undertaken has focused simplyon delineating in prevalence rural urban differencesrather than providing an in-depth analysis of the mentalhealth problems of those living in rural areas2 RuralAustralia is diverse with wide variations in economicdemographic environmental and other conditions that arelikely to influence the mental health status of rural resi-dents In this paper we provide a plan to advance rural

mental health research This plan is based on a modelthat emphasises place as a variable in mental well-beingand mental disorder and aims to identify factors relatedto the onset maintenance termination and recurrence ofmental health problems Importantly we use place as aninclusive term which integrates geographical locale withcultural social and economic aspects of the environment3

It is important to note that the strategic researchagenda being outlined here is only one component of aconcerted effort to improve the mental health and well-being of rural Australians A relative lack of mentalhealth services outside metropolitan Australia has beenidentified as the most pressing problem in this areaAttempts to redress this imbalance through both politicalmeans and astute management of limited resources cannotwait upon research findings Similarly many innovativeservice delivery programs are currently under way inrural Australia and local research aimed at evaluating

Correspondence Professor Fiona Judd Centre for RuralMental Health PO Box 126 Bendigo Victoria 3552 AustraliaEmail fjuddbendigohealthorgau

Accepted for publication December 2001

THE MENTAL HEALTH OF RURAL AUSTRALIANS F JUDD ET AL 297

and expanding existing programs is critical Howeverlong-term improvement of mental health demands thedevelopment of a strategic research agenda that can iden-tify gaps in our current understandings and offer supportfor both clinical activities and lobbying efforts for therural constituency Without a coherent framework forinvestigation and evaluation systematic progress towardsimproving mental health and well-being outcomes isunlikely to occur

We propose therefore that the broad goal of improvingthe mental health and well-being of rural Australiansmust be supported by a strategic research agenda Thisresearch agenda can be subdivided into four domains ofinvestigation (i) pathways to care (ii) prevention andearly intervention (iii) outcome of illness and (iv) aetio-logy of mental illness These broad areas are relevant toany investigation of population mental health and in thefollowing sections we will identify ways that ruralitymight impact on these domains either as a main effect orin interaction with other variables To reiterate there isyet little systematic knowledge about the rural dimensionin mental health and this paper aims to identify meaning-ful questions rather than speculate about answers In thepaperrsquos penultimate section we present a provisionalmodel that draws the four domains of investigation into asingle proposed framework for strategic research Themain features of the model are discussed and avenues forfurther research highlighted

Pathways to careThe recent Australian National Survey of Mental Healthand Wellbeing identified a high level of unmet need2

While approximately one in five Australians had a mentalillness less than half of these individuals sought anyprofessional help This finding highlights that improvingthe mental health of rural Australians does not restentirely on improving the availability of services Seekingprofessional help requires that services are not onlyavailable but also accessible and acceptable (ie offeredin a manner congruent with local values using a modelof delivery appropriate to the setting)

Research is required to identify those factors thatdetermine whether an individual in a rural communitydecides to seek professional help for distressing psycho-logical symptoms This is a particular priority in ruralareas where limited availability and accessibility of ser-vices is likely to exacerbate any other impediments toseeking help4 Key factors that influence the decision toseek care may include severity and type of symptomspsychological stress learned patterns of illness behav-iour availability of medical services the ability to pay for

treatment5 the knowledge and attitudes of the person withthe mental disorder and those of their family and friendsand the broader society in which the individual lives Arange of knowledge and attitudinal factors may influencehelp-seeking These factors include the ability to recog-nise the problem as a mental disorder knowledge ofservices available beliefs about the effectiveness ofvarious sorts of treatments beliefs about causes of theproblem and stigmatising attitudes67 These factors maywell vary between rural and urban settings and within ruralcommunities8

Help-seeking pathways (ie the sequence of contactswith individuals and organisations prompted by the dis-tressed personrsquos efforts and those of his or her significantothers to seek help) as well as the help that is supplied inresponse to such efforts may provide the critical linkbetween the onset of mental health problems and theprovision of mental healthcare9 Help-seeking pathwaysfunction in the context of social networks that are charac-terised by particular beliefs and attitudes and serve as avehicle for transmitting them9 The social network of theperson has two tasks The first is to detect the problem anindividual may have and the second is to be able to directthe individual towards receiving appropriate treatmentThe promotion of mental health literacy is important inimproving peoplersquos abilities to detect the problem andattenuate the pathways to effective care There appear tobe objective features of rural environments (eg physicalremoteness) that may be important variables in help-seeking pathways

Clearly understanding such pathways which arelikely to vary between communities offers a uniqueopportunity to identify the points where progress may bedifferentially impeded or facilitated This is particularlyimportant in rural communities where both the level ofspecialist services and psychosocial and cultural factorsplay an important role in how a mental health problem isdefined and whether services are accessed10 An import-ant component of research in this domain is of courselocal contextual knowledge Consumers and staff ofmental health services are well placed to identify patternsand develop hypotheses about barriers to help-seeking ina particular community Such research should also encom-pass the informal networks and links that exist outsideof the formal sector including such groups as extendedfamilies young mothers groups adolescent lsquogangsrsquo andsmall male enclaves sometimes found in the local pub

Prevention and early interventionGovernment policy states that research focusing onprevention and early intervention in rural communities

298 AUSTRALIAN JOURNAL OF RURAL HEALTH

should be a priority1 Preventive interventions can occurat three distinct levels11 Universal interventions pro-vided to whole populations involve implementation ofmeasures regarded as desirable for everyone (eg seatbelts encouragement of exercise) Selective interventionsare targeted at those individuals who have an increasedrisk of developing a disorder (eg parenting skills forunmarried teenage mothers) Indicated interventions aretargeted at those already showing minor signs and symp-toms of disorder While these three levels of preventiveintervention are clearly desirable there are insufficientdata on the distribution of risk resilience and symptoma-tology within and between rural communities to permitthe effective targeting of selective and indicated inter-ventions Even universal interventions for mental healthdemand an understanding of rural residentsrsquo perceptionsof mental health problems and no inter and intra ruraldata on this question have yet been collected

The aim of early intervention is to reduce the durationof untreated disorder and is important in both firstepisode of illness and also at the time of relapse in thosedisorders that are characterised by recovery and relapse(eg affective disorder) Early intervention also aims toattenuate the possible disability (problems in performingacts) and handicap (the cultural social environmentalconsequences of the illness and associated disability)which may accompany mental health problems andreduce or prevent possible secondary morbidity (eg inpatients with psychosis reduce or prevent secondarydepression)12 Early intervention in rural areas wouldneed to be informed by an understanding of particularrisk factor profiles that might be important in rural loca-tions No published studies have yet investigated thisissue

Outcome of illnessAny consideration of the course and outcome of illnessmust consider factors that enhance or impair responseto acute treatment and increase or decrease the likelihoodof relapse (return of symptoms of the index episode of ill-ness) or recurrence (onset of a new episode of illness)13

There is a lot of research examining the role of socio-economic status environmental stress life events andsocial support as predictors of poor outcome1112 It seemslikely therefore that some parameters of rurality mightimpact on outcome but there has been little considerationof how place variables may influence the course of mentalhealth problems

Mental health problems are generally accompanied bydisability (restriction or lack of ability to perform activit-ies) affecting social and occupational function Research

has demonstrated there is not a simple linear relationshipbetween symptoms and disability14 but little work hasbeen directed to delineating what factors mediate therelationship Various models have been proposed tounderstand the interaction between disability and func-tioning In seeking to understand how place variablesinfluence outcome two key models are of interest Onethe medical model views disability as the direct resultof disease or trauma The other the social model viewsdisability as a socially created problem able to beresolved by social change

Research in rural communities will need to integratethese two contrasting models A personrsquos functioning anddisability will need to be seen as an interaction betweenmental health conditions and contextual factors (bothpersonal and environmental) Environmental (contextual)factors may be facilitators leading to improved functioningor barriershindrances that increase the likelihood oforlevel of disability15 Research is required to identify thoseaspects of the rural environment that increase the likeli-hood of positive psychological wellness andor facilitateresponse to treatment in people with mental disorders andthose factors that serve as impediments to these goals

Aetiology of mental illnessA focus on the development of effective early interventionand preventive strategies assumes that factors contribut-ing to onset (precipitation or causation) of illness areknown These factors may be quantitatively or qualitat-ively different in rural versus urban locales For examplerural and remote communities in Australia have beenidentified as having particular mental health needs due toisolation the impact of economic restructuring and expos-ure to environmental hazards like drought flood andfire1 Although these are lsquocoarsersquo markers they highlightthat investigation of potential interactions between biolog-ical psychological and location-specific factors is neces-sary to inform effective public health interventions Both apopulation and an individual perspective must informresearch in rural communities an individualrsquos risk ofillness cannot be considered in isolation from thepopulation to which they belong and the environmentalcontext in which they live their daily lives

A provisional model for mental health research in AustraliaIt is possible to develop a model that integrates many ofthe issues raised here and provides a potential frameworkfor strategic research into mental health in Australia(Fig1) This model does not aim to present a comprehen-sive survey of evidence concerning variables that impact


on mental health Rather it aims to be a frameworkfor assembling such evidence The components of thepresented model are multifaceted categories not singleentities or variables The selection of variables that bestrepresent these categories and the selection of appropri-ate methodologies for their investigation will be a criticalnext step in the advancement of the model The arrows inthe figure represent hypothesised links between the com-ponents of the model ndash the presence and magnitude ofany links is an empirical question yet to be considered

A number of features of the model are important Thepredictor factors share features with the generic biopsy-chosocial model of health16 A refinement over thebiopsychosocial model is an emphasis on the importanceof and an enriched definition of place To understandwhy rural Australians might be lsquoat riskrsquo we need todevelop a systematic and detailed appreciation of placenot just as a geographical construct but as an environmentthat shapes the social worlds that individuals experienceIn particular it is important to describe the locations ofrural residents not only geographically but also in termsof (i) the patterns of social connections that link anindividual residing in a rural location to other individualsand to group and community settings and (ii) the socio-economic and cultural constraints and opportunitiesassociated with that rural location

In effect the model brings together two existingresearch streams to construct a somewhat novel frame-work for the study of rural mental health The classicalapproach to investigating determinants of mental well-being and mental disorder has focused on individualbiological psychological and social factors Morerecently an alternative approach has developed a broad

conceptualisation of social locations as complex andinterdependent geographical social economic and culturalentities17 We argue that such a comprehensive frameworkis essential if we are to understand the means by whichmental well-being and mental distress are affected byplace and particularly by rural locations

The model emphasises the need to examine the wayplace factors interact with or influence biological (egproducing or reducing stress) and psychological (egaffecting cognitive and emotional states such as selfesteem self confidence self efficacy depression andanxiety) processes and behaviours that affect healthThese influences might include shaping accepted beliefsattitudes and behaviours and enforcing patterns of socialcontrol providing or not providing environmental oppor-tunities to engage in certain behaviours (including help-seeking behaviours)1819

The outcome factors (mental health and well-being)extend beyond morbidity disability and handicap toinclude positive psychological wellness (operationalisa-tions of these factors might include for example DSMdiagnosis and self-reported life satisfaction) Similarly itshould be inferred that the modelrsquos predictor variablesinclude not only risk (eg the personality trait neuroticism)but also resilience factors (eg the personality trait extra-version) We consider this shift away from a narrow focuson pathology and its risks to be an important strategy indeveloping a complete picture of rural mental health Aconsequence of this shift is attention to quality of life andadjustment the promotion of cognitive resilience factorssuch as problem solving skills and positive illusions20

and the enhancement of social resilience factors such asincreasing social connectivity to others It also encourages

FIGURE 1 A model for mental health research


the measurement of positive emotions such as happiness21

interest pride love and contentment22

The modelrsquos intermediate components (individualhealth behaviour and healthcare systems) are points ofleverage for change in the outcome factors These inter-mediate factors include health promoting behaviours of theindividual (eg exercise constructive socialising) and ofthe healthcare system (eg prevention early interventionand treatment) An important point of interaction betweenthese two components is the match between an individualrsquostreatment preferences and the available services

The model asserts that there may be direct linksbetween predictor factors and outcomes (eg specificqualities of onersquos genetic make-up or the physical charac-teristics of a place may adversely affect mental health)The influence of predictors on outcome may also be medi-ated and moderated by specific actions of the individualand their healthcare system The power of such inter-mediate factors to affect outcome over and above the directeffects of predictor factors is unknown but understandingthem might play an important role in the development ofrural mental health policy

As mentioned there may also be important inter-actions between predictor variables (eg depending uponthe degree of social connectedness in a locale a geneticvulnerability may translate into a more or less severemental health handicap) These effects may not only differbetween rural and urban settings but also within ruralsettings Acknowledgement of this and examination ofsuch effects is likely to enhance our understanding of therisks (or positive effects) of rural life Indeed it may be inthe domain of interactions between predictive factors thatwe find support for the common assumption of importantdifferences between rural and urban environments

DISCUSSION

A strategic research framework is a necessary componentof an adequate rural mental health research effort whichin turn is necessary to support the long-term improvementof mental health and well-being of rural Australians Wehave considered four broad areas in which research isrequired (i) pathways to care (ii) prevention and earlyintervention (iii) outcome of illness and (iv) aetiology Atheme in each of these domains is the need to understandhow place variables contribute to psychological wellnessor morbidity A model that emphasises the construct ofplace alongside individual psychological and biologicalfactors will facilitate the development and testing ofhypotheses and hence provide information needed byclinicians researchers and policy makers to improve the

mental health of rural Australians We have suggested aprovisional version of such a model We look forward torefinement and revision of the model based on the con-tinuing efforts of rural mental health researchers andpractitioners

REFERENCES

1 Commonwealth Department of Health and Aged CareNational Action Plan for Promotion Prevention and EarlyIntervention for Mental Health Canberra AGPS 1999

2 Andrews G Hall W Teeson M Henderson S The MentalHealth of Australians Canberra Mental Health BranchCommonwealth Department of Health and Aged Care 1999

3 Fraser C Judd F Jackson H Murray G Humphreys JHodgins G Does one size really fit all Why the mentalhealth of rural Australians requires further researchAustralian Journal of Rural Health

4 Parslow RA Jorm AF Who uses mental health services inAustralia An analysis of data from the National Survey ofMental Health and Wellbeing Australian and New ZealandJournal of Psychiatry 2000 34 997ndash1008

5 Goldberg D Huxley P Mental illness in the communityThe Pathway to Psychiatric Care London Tavistock Publi-cations 1980

6 Sims A The scar is more than skin deep the stigma of depres-sion British Journal of General Practice 1993 43 30ndash31

7 Jorm AF Korten AE Rodgers B et al Belief systems of thegeneral public concerning the appropriate treatments formental disorders Social Psychiatry and Psychiatric Epi-demiology 1997 32 468ndash473

8 Rost K Smith GR Taylor JL Ruralndashurban differences instigma and the use of care for depressive disorders TheJournal of Rural Health 1993 9 57ndash62

9 Rogler LJ Cortes DE Help-seeking pathways a unifyingconcept in mental health care American Journal of Psychiatry1993 150 554ndash561

10 Salgado de Snyder NV Diaz-Perez MJ Maldonado MBautista E Pathways to mental health care among a Mexi-can village Health and Social Work 1998 23 249ndash261

11 Mrazek PJ Haggerty RJ (eds) Reducing Risk for MentalDisorders Washington DC National Academy Press 199419ndash29

12 Birchwood M Early intervention in psychosis the criticalperiod In McGorry PD Jackson HJ (eds) The Recognitionand Management of Early Psychosis A Preventive ApproachCambridge Cambridge University Press 1999 226ndash264

13 Kupfer DJ Frank E The minimum length of treatment forrecovery In Montgomery S Rouillon F (eds) Long-TermTreatment of Depression Perspectives in Psychiatry Vol 3Chichester John Wiley amp Sons 1992 33ndash52

14 Andrews G Meeting the unmet need with disease manage-ment In Andrews G Henderson S (eds) Unmet Need inPsychiatry Problem Resources Responses CambridgeCambridge University Press 2000 11ndash38


15 World Health Organization ICIDH-2 International Classi-fication of Functioning Disability amp Health World HealthOrganization 2000 Pre final draft (online)middot WHO httpwwwwhoint icidh

16 Sarafino EP Health Psychology Biopsychosocial Interac-tions 3rd edn New York Wiley 1998

17 Robins GL Pattison P Elliott P Network models for socialinfluence processes Psychometrika 2001 66 161ndash190

18 Lynch JW Kaplan GA Salonen JT Why do poor peoplebehave poorly Variation in adult health behaviours andpsychological characteristics by stages of the socioeconomiclife course Social Science and Medicine 1997 44 809ndash819

19 Berkman LF Glass T Social integration social networkssocial support and health In Berkman LF Kawachi I(eds) Social Epidemiology New York Oxford UniversityPress 2000 137ndash173

20 Taylor SE Kemeney ME Reed GM Bower JE GruenewaldTL Psychological resources positive illusions and healthAmerican Psychologist 2000 55 99ndash109

21 Headey B Wearing A Understanding Happiness a Theory ofSubjective Well-Being Melbourne Longman Cheshire 1992

22 Frederickson BL The role of positive emotions in positivepsychology The broaden-and-build theory of positiveemotions American Psychologist 2001 56 218ndash226


and expanding existing programs is critical Howeverlong-term improvement of mental health demands thedevelopment of a strategic research agenda that can iden-tify gaps in our current understandings and offer supportfor both clinical activities and lobbying efforts for therural constituency Without a coherent framework forinvestigation and evaluation systematic progress towardsimproving mental health and well-being outcomes isunlikely to occur

We propose therefore that the broad goal of improvingthe mental health and well-being of rural Australiansmust be supported by a strategic research agenda Thisresearch agenda can be subdivided into four domains ofinvestigation (i) pathways to care (ii) prevention andearly intervention (iii) outcome of illness and (iv) aetio-logy of mental illness These broad areas are relevant toany investigation of population mental health and in thefollowing sections we will identify ways that ruralitymight impact on these domains either as a main effect orin interaction with other variables To reiterate there isyet little systematic knowledge about the rural dimensionin mental health and this paper aims to identify meaning-ful questions rather than speculate about answers In thepaperrsquos penultimate section we present a provisionalmodel that draws the four domains of investigation into asingle proposed framework for strategic research Themain features of the model are discussed and avenues forfurther research highlighted

Pathways to careThe recent Australian National Survey of Mental Healthand Wellbeing identified a high level of unmet need2

While approximately one in five Australians had a mentalillness less than half of these individuals sought anyprofessional help This finding highlights that improvingthe mental health of rural Australians does not restentirely on improving the availability of services Seekingprofessional help requires that services are not onlyavailable but also accessible and acceptable (ie offeredin a manner congruent with local values using a modelof delivery appropriate to the setting)

Research is required to identify those factors thatdetermine whether an individual in a rural communitydecides to seek professional help for distressing psycho-logical symptoms This is a particular priority in ruralareas where limited availability and accessibility of ser-vices is likely to exacerbate any other impediments toseeking help4 Key factors that influence the decision toseek care may include severity and type of symptomspsychological stress learned patterns of illness behav-iour availability of medical services the ability to pay for

treatment5 the knowledge and attitudes of the person withthe mental disorder and those of their family and friendsand the broader society in which the individual lives Arange of knowledge and attitudinal factors may influencehelp-seeking These factors include the ability to recog-nise the problem as a mental disorder knowledge ofservices available beliefs about the effectiveness ofvarious sorts of treatments beliefs about causes of theproblem and stigmatising attitudes67 These factors maywell vary between rural and urban settings and within ruralcommunities8

Help-seeking pathways (ie the sequence of contactswith individuals and organisations prompted by the dis-tressed personrsquos efforts and those of his or her significantothers to seek help) as well as the help that is supplied inresponse to such efforts may provide the critical linkbetween the onset of mental health problems and theprovision of mental healthcare9 Help-seeking pathwaysfunction in the context of social networks that are charac-terised by particular beliefs and attitudes and serve as avehicle for transmitting them9 The social network of theperson has two tasks The first is to detect the problem anindividual may have and the second is to be able to directthe individual towards receiving appropriate treatmentThe promotion of mental health literacy is important inimproving peoplersquos abilities to detect the problem andattenuate the pathways to effective care There appear tobe objective features of rural environments (eg physicalremoteness) that may be important variables in help-seeking pathways

Clearly understanding such pathways which arelikely to vary between communities offers a uniqueopportunity to identify the points where progress may bedifferentially impeded or facilitated This is particularlyimportant in rural communities where both the level ofspecialist services and psychosocial and cultural factorsplay an important role in how a mental health problem isdefined and whether services are accessed10 An import-ant component of research in this domain is of courselocal contextual knowledge Consumers and staff ofmental health services are well placed to identify patternsand develop hypotheses about barriers to help-seeking ina particular community Such research should also encom-pass the informal networks and links that exist outsideof the formal sector including such groups as extendedfamilies young mothers groups adolescent lsquogangsrsquo andsmall male enclaves sometimes found in the local pub

Prevention and early interventionGovernment policy states that research focusing onprevention and early intervention in rural communities


























DISCUSSION



REFERENCES

















































DISCUSSION



REFERENCES







































DISCUSSION



REFERENCES






























DISCUSSION



REFERENCES

































Documents

THE MENTAL HEALTH OF RURAL AUSTRALIANS: DEVELOPING A FRAMEWORK FOR STRATEGIC RESEARCH