Opinion article

Rural and remote mental health after COVID-19

Swinburne University Social Innovation Research Institute Foundation Director, Professor Jane Farmer; Royal Flying Doctor Service (RFDS) Director of Public Health, Fergus Gardiner; RFDS Research and Projects Director, Lara Bishop; and University of Western Australia Rural Clinical School Associate Professor, Mat Coleman, discuss the ways COVID-19 has heightened the mental health gap in rural and remote areas and look at how we can scale successful community-based interventions, with the help of philanthropy, NGOs and data, to make progress.

Rural Australia often conjures up images of beautiful deserts and coastlines, but away from the romanticism, life for many rural residents is an ongoing endurance test to access the services they need.[1] Lack of access to mental health services is a key driver of poor mental health outcomes in rural areas, and COVID-19 has only worsened this problem. The COVID-19 crisis has also given us time to pause and re-think our approach to old problems. We should use it as an opportunity to take a fresh, coordinated and evidence-backed response to providing mental health services in regional Australia.

Mental health service access in rural and remote Australia 

The prevalence of mental illness is around 20 per cent across all of Australia.[2] However, rates of suicide and emergency admissions for mental illness increase with remoteness. The reasons for the mental health challenges of those in rural areas are driven by multiple factors. Rural areas are often culturally different – stigma and stoicism are more prevalent, delaying service access. Living in a rural area comes with unique challenges. Rural residents tend to experience higher levels of socio-economic disadvantage, have lower levels of tertiary education and there is a tendency to lower incomes, with significant variations across different rural places, A significant issue is isolation, meaning few employment options, lack of access to amenities and the knowledge that services, opportunities and friends might be very distant. Climate change and climate events increase the potential for pressure on mental health. We have seen evidence that periods of drought increase stress, particularly for younger male farmers.[3]

Evidence also suggests that although some farm incomes are increasing, this is generally aligned with fewer workers, meaning farmers are increasingly working in isolation. [4] All of these factors combine with inaccessibility to a range of health services, to contribute to poorer outcomes.

All populations need a range of mental health services, from efforts to promote community wellbeing, through to supporting those with acute mental health conditions. Mental health exists on a continuum. People experiencing social isolation or emotional distress may advance to mental illness, but not necessarily so. In this respect, rural Australia is not different to cities. However, in rural areas, the drivers of ill-health butt up against challenges in accessing services. In regional Australia, mental health services are often distant, a skilled workforce harder to come by, and cultural complexities create barriers and additional hurdles.[5]

Confounding matters is the challenge of finding out about the mental health needs of people in rural areas and the extent to which existing mental health services meet those needs. Surveying or consulting people across remote places is expensive and it can be hard to engage mental health consumers to talk openly about their experiences, especially in smaller communities where confidentiality is an ever-present concern.

Working with the Royal Flying Doctor Service, Beyond Blue, SANE and careopinion.org, our team recently completed an innovative study to spatially map data about consumer experiences.[6] This highlighted that issues like relationship breakdown, bullying, family violence and experiences of racism, can be exacerbated in rural towns due to issues of isolation and poor employment opportunities. People experiencing these challenges need a mix of supportive communities and suitable services to address their wellbeing issues. This provides opportunities for early intervention, so their health is not eroded – particularly important in rural areas where crisis support is harder to access.

Medicare data shows that there is a lower uptake of subsidised mental health services in rural areas.[7] Due to gaps in services of the right type in the right places, many people do not seek treatment until crisis point, often requiring aeromedical retrieval.

A more appropriate service mix could help to pre-empt and stabilise people with mental health problems in communities. The Royal Flying Doctors Service already provides social and emotional wellbeing services and programs across rural Australia and telepsychiatry and video consultations[8] but our research shows that more needs to be done.

How communities and philanthropy can help 

As it stands, the system of service provision is not efficiently responding to the mental health needs of rural communities.[9][10] Rural service design and configuration is often modelled by, and for, metropolitan communities and health system managers. Consequently, it can be argued that rural mental health services are not enabled to be “fit for purpose”. As a result, some individual communities are taking matters into their own hands, often partnering with local services to collaboratively improve local mental health awareness, service navigation and social connection.

Community wellbeing initiatives are springing up in parts of rural Australia, which tend to be prevention-focused and driven by the community. Examples include Our Healthy Clarence, a program run by a rural NSW town that came together to say ‘enough’ in response to a wave of suicides.[11] In other towns, communities have partnered with local health services and local government to create initiatives based on self- or neighbour-referral, with a focus on support and pre-emption through ‘having that first friendly chat’. Schemes like the Rural Outreach Workers (in Victoria’s Wimmera)[12] and the Rural Adversity Mental Health Program (in NSW)[13] are examples of such schemes that reduce the stigma of speaking about mental health and open the door to service navigation or referral.

Some service and community partnerships are trialling innovative approaches, like ‘skills escalators’ and ‘grow your own’ approaches, to recruit, train and skill-up existing local healthcare practitioners to better deal with mental health conditions locally.[14] These are driven by an ethos of building capacity among local people, for local people, rather than trying to recruit from outside. Government and philanthropic investment could support these initiatives by enabling investment in local training that fosters collaboration and skills in applying evidence to develop appropriate and implementable solutions that are co-designed and co-implemented with local communities, with buy-in from service providers.[15]

While our research found examples of these community initiatives, they are dotted across Australia and not joined up or informing each other. We risk constantly reinventing the wheel, using up scarce community energy. Promising interventions should be identified and then systematically scaled and evaluated. This is a prime space for an ambitious philanthropic-funded evaluation, research and implementation program.

Much of the challenge in creating a systematic approach to community wellbeing and mental health in rural Australia lies in the absence of specific advocacy, policy leadership and philanthropic funding for rural and remote mental health. Our research confirmed this. Rural mental health tends to fall between rural health and mental health and doesn’t have its own sustained focus. Strengths-based advocacy, local successes and sustainability, suggest that this is a problem that can be solved. If these efforts a properly focused, it could help to catalyse a movement focused on improving national rural mental health.

Much remains a mystery

One of the most significant challenges in achieving sustained advocacy for rural communities is the lack of data and research around their needs and behaviours. Specific gaps include the out-of-pocket costs of mental illness, long-term tracking of the mental health effects of climate change, and understanding the adoption of online and telehealth in rural communities. As an example, telehealth and online access are often assumed to be a rural health panacea, but rural and remote communities have lower levels of digital literacy, internet use and access,[16][17] poorer connectivity and broadband bandwidth.[18] Furthermore, the investment in the workforce to provide these telehealth services can undermine the viability and sustainability of residential rural health services. This is the kind of nuance missing in rural and remote mental health research.

In particular, innovative research methods could help to understand how to most effectively provide rural mental health services, underpinned by collaborations where people are open to using their data collectively and creatively. Our own study incorporating diverse datasets from different NGOs showed the insights that can be gained from applying cutting edge techniques to shared data, allowing us to build up a more data-rich picture of rural peoples’ experiences.

[1]Gardiner F, Gale L, Ransom A, Laverty M. Looking Ahead: Responding to the health needs of country Australians in 2028- the centenary year of the RFDS. The Royal Flying Doctor Service. https://rfds-media.s3.amazonaws.com/documents/RN064_Looking_Ahead_Report_D3.pdf?Signature=3Z60TPlMc%2F8BwsdLpC7qIfezZX4%3D&AWSAccessKeyId=AKIAJJRKZ3AFU5ZOK5FQ&Expires=1571113335. Published 2018. Accessed.
[2]Health AIo, Welfare. Australia's health 2018. Canberra: AIHW;2018.
[3]Austin EK, Handley T, Kiem AS. et al. (2018) Drought-related stress among farmers: findings from the Australian Rural Mental Health Study. Medical Journal of Australia, 209(4), 209.
[4]Austin EK, Handley T, Kiem AS. et al. (2018) Drought-related stress among farmers: findings from the Australian Rural Mental Health Study. Medical Journal of Australia, 209(4), 159-165.
[5]Productivity Commission (2017) Transitioning regional economies. Canberra. Productivity Commission
[6]Parliament of Australia (2018) Senate Inquiry into Accessibility and quality of mental health services in rural and remote Australia.
[7]Farmer J., McCosker A., Kamstra P. et al. (2020) Mapping the hidden voices in rural mental health: a pilot study of online community data. Swinburne University Social Innovation Research Institute. https://apo.org.au/node/303092
[8]Bishop L et al (2017) Mental health in remote and rural communities. Royal Flying Doctors Service
[9]Henderson J, Dawson S, Fuller J. et al. (2018) Regional responses to the challenge of delivering integrated care to older people with mental health problems in rural Australia. Aging and Mental Health, 22(8), 1031-7.
[10]van Spijker, B, Salinas-Perez, JA, Mendoza, J et al. (2019) Service availability and capacity in rural mental health in Australia: analysing gaps using an integrated mental health Atlas. Australian and New Zealand Journal of Psychiatry, 53(10) 1000-12
[11]Powell N, Dalton H, Perkins D. et al. (2019) Our Healthy Clarence: a community-driven wellbeing initiative. International Journal of Environmental Research and Public Health 6(19), 3691; [https://doi.org/10.3390/ijerph16193691]
[12]Wimmera Primary Care Partnership (2019) The rural outreach project: a rural Victorian community wellbeing initiative. Swinburne University Social Innovation Research Institute. https://s3.ap-southeast-2.amazonaws.com/hdp.au.prod.app.vic-rcvmhs.files/1915/6697/1013/West_Wimmera_Shire_Council_02.pdf
[13]University of Newcastle Centre for Rural and Remote Mental Health (2019) Rural Adversity Mental Health Program. [www.crrmh.com.au/programs-and-projects/ramhp/]
[14]Mid North Coast Local Health District (2015) Mental health service models of care. (obtained from Mid North Coast LHD).
[15]Farmer J., White, C, McCosker, A., et al. (2020) Reviewing activities aiming to improve rural Australian’s mental health. Swinburne University Social Innovation Research Institute. https://apo.org.au/sites/default/files/resource-files/2020-04/apo-nid303323.pdf
[16]Moffatt J, Eley DS. Barriers to the up-take of telemedicine in Australia-a view from providers. 2011.
[17]Park S. Digital inequalities in rural Australia: A double jeopardy of remoteness and social exclusion. Journal of Rural Studies. 2017;54:399-407.
[18]Islam AR, Selvadurai N, Town G. Wireless Broadband technologies for regional and rural Australia: A last-mile perspective. Telecommunications Journal of Australia. 2008;58(2/3).
About the authors

Jane Farmer

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Jane Farmer is Director of the Social Innovation Research Institute at Swinburne. She has a distinguished track record of research in rural health services, innovations in health workforce and technology, community participation, coproduction and social enterprise.  Addressing disadvantage and social and health inequity is central to her research activity.

Professor Farmer is currently leading an Australia Research Council Discovery Project examining the impact of social enterprise on regional city disadvantage. She is involved as a research partner in other ARC-funded Discovery and Linkage projects including on increasing inclusion in rural, generalist health services and on youth health improvement through social enterprise.