Journal of Rural Community Psychology               Volume E7   Number 1   Spring 2004

 

 

Utilisation of Mental Health Services in

Rural and Remote Communities

 

Robyn A. Findlay, & Mary C. Sheehan

 

ABSTRACT

 

This study reports findings from a rural and remote area survey on the use of health services by people with symptoms of mental illness. Eight hundred participants were interviewed in their homes and classified according to the nature of their most serious illness in the four weeks prior to the survey. A minority reported a mental health problem as their most serious condition (8.5%, n = 68), one-fifth of the sample reported mental health problems with a physical condition as their most serious illness (20%, n = 160), and 37.9% (n = 303) reported a serious physical condition and no mental health problems. People whose most serious illness was a mental health problem were the least likely to access professional health services, c2 = 6.4, df = 2, p < .05, and they were even less likely to do so if their condition had only recently occurred. Lack of appropriate services, distance from suitable help, and the stigma associated with mental illness were major barriers to service utilisation. The results indicate that professional services are less likely to be sought for mental health problems than for physical illnesses by persons living in rural and remote areas. Strategies to improve the mental health status of these communities are discussed. Finally, this study provided further validation of the SF-36 as a useful measure of mental health status in large-scale surveys.

 

 

Approximately one in five people suffer from a mental health problem at some time in their life (Arons, 2000; ABS, 1997; Taylor et al., 2000). However, a large proportion of people, especially in rural and remote areas, do not receive any form of professional mental health care unless their illness reaches crisis stage (Flaskerud & Kviz, 1982; Fortney, Owen, & Clothier, 1999).

 

Commonly identified barriers to service utilisation in rural and remote areas are a lack of resources and long distances (Blank, Fox, Hargrove, & Turner, 1995; Burdekin, 1993; Human & Wasem, 1991; Merwin, Goldsmith, & Manderscheid, 1995; Roberts, Battaglia, & Epstein, 1999; Shelton & Frank, 1995; Yellowlees & Hemming, 1992). Another issue that may be a problem in rural and remote areas is the stigma associated with mental illness (Mulder & Chang, 1997). In these communities views on mental illness are often more negative (Bacharach, 1983) and the physical and social nature of the communities can make it difficult to maintain anonymity and confidentiality (Arons, 2000; Merwin et al., 1995; Solomon, Hiesbergr, & Winer, 1981). As a result, many people with mental health problems may either choose not to access health care or present to the local doctor with some other ailment rather than the mental health condition (Chimonides & Frank, 1998). For example, (Booth, Briscoe, & Powell, 2000) in a study of suicide by farmers in rural England and Wales, found that 30% of those farmers who committed suicide sought medical help exclusively for physical ailments in the three months prior to death. 

 

Booth et al’s results suggest that general practitioners in rural and remote areas need the skills to identify and respond to psychiatric problems in their patients because they are often the first and only point of health care contact by people in these communities. However, the formal training of medical doctors usually does not include a systematic analysis of the assessment and treatment of psychological dysfunctions (Zvolensky, Eifert, Larkin, & Ludwig, 1999). This issue is complicated by the fact that non-metropolitan doctors are often so under-resourced that they are unable to devote the necessary time to mental health care (Curran, Hatcher, & Kirby, 2000). In addition, there is often reluctance by general practitioners, especially in non-metropolitan areas, to refer mental health problems to specialised care (Rost, Humphrey, & Kelleher, 1994; Shelton & Frank, 1995). Consequently, a large proportion of rural and remote mental health problems may remain undetected and untreated (Van Hook & Ford, 1998; Watts et al., 1999).

 

Substantial improvements to mental health care in rural and remote communities are needed. In rural and remote Australia and in rural England and Wales, for example, suicide and mental illness are major and ever-increasing problems (Australian Institute of Health & Welfare, 2000; Booth et al., 2000). In the USA as in most other countries, improvements in metropolitan mental health services have far surpassed those in non-metropolitan areas (Goldsmith, Wagenfeld, Manderscheid, & Stiles, 1997). One of the reasons for the lack of progress in the area of rural mental health may be the comparative dearth of research addressing rural rather than urban mental health issues (Bjorklund & Pippard, 1999; Gregoire & Thornicroft, 1998; Murray & Keller, 1991; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994).

 

The current study adds to the body of research by examining the factors influencing mental health status and related service utilisation in rural and remote Australia. The study also examines patients’ reports of skills used by doctors when managing patients with personal and emotional problems. It was hypothesized that people with mental illness have a low level of professional service utilisation, that there are barriers to service utilisation, and that doctors only occasionally use psychologically-based skills for diagnosing and managing people with personal and emotional problems.

 

METHOD

 

A rural and a remote area in Queensland, Australia were the focus of the study. The rural and remote classifications were based on the DHHCS classifications (Department of Health Housing and Community Services, unpublished). The rural area comprised three shires with populations between 2,800 and 4,000 and covered a total area of 3,000 square kilometres (Australian Bureau of Statistics, 1991). The remote area included eight shires that covered an area of 204,298 square kilometres (Australian Bureau of Statistics, 1991). Four of the remote shires had populations between 1,500 and 3,700 and the other four had populations less than 1,000.

           

The data reported in this study are part of a broader survey of rural health care reported by Veitch (1994). The survey was conducted by a team of specially recruited and trained researchers who contacted 881 selected households in 1994 to ask them if they would participate in the survey. The response rate was 91% (n = 800). One adult (person 18 years of age or over) from each household was interviewed in their home. Three hundred and twenty of the participants were from the rural area and 480 were from the remote area. The sampling procedure used to identify householders is detailed in Veitch.

 

Participants

 

The current study reports on only those 531 people whose survey responses indicated that they had a serious illness in the four weeks prior to the survey, that is 237 rural and 294 remote people. Twenty-nine percent (n = 152) were male; 63% (n = 332) were less than 50 years of age; 69% (n = 368) had year 10 level of education or less; 44% (n = 236) had private health insurance; and 59% (n = 311) had an annual household income of $30,000 or less.

           

Survey

 

           

The survey contained 72 mostly pre-coded questions. The present study reports the findings from questions related to respondents’ most serious illness in the four weeks prior to the survey, and their health care response to that illness. Apart from socio-demographic details, there were five relevant sections of the questionnaire.

 

Mental Health Status

 

This section established the mental health status of respondents. Participants were asked if they had experienced any of a list of illnesses or injuries in the last four weeks, and to nominate which was the most serious. These included:

cuts, abrasions or puncture wounds

sprains or strains

broken bones

cold or flu

asthma

severe backache

bad headache or migraine

felt nervy, tense or depressed

any other illness (which they specified).

 

Those people who reported that they had “felt nervy, tense or depressed” or that they had a condition subsequently coded as psychological using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and also reported these conditions as their most serious illness were classified as having a serious mental health problem. Those who reported that they “felt nervy, tense or depressed” or had a psychological problem, but stated that a physical condition was their most serious condition were classified as having a physical condition and additional mental health problem. Those who did not report that they “felt nervy, tense or depressed” and nominated an illness other than psychological as their most serious condition were classified as having a physical illness. Those who did not report that they “felt nervy, tense or depressed” and had no other serious problem in the four weeks prior to the survey were classified as having no serious illness.

           

The mental health construct was validated using the 5-item mental health scale of the Rand Corporation’s medical outcomes short form functioning and well-being survey, SF-36, (Ware & Sherbourne, 1992).  A summary score in the range of 0 to 100 was obtained with the SF-36 algorithm, with a higher score implying a more positive mental health status.

           

Chronicity of the Illness

 

Respondents were asked whether the most serious illness experienced in the four weeks prior to the survey was (a) a long term problem that they suffer with constantly, or (b) a long term problem that comes and goes, or (c) something that had just happened in the last four weeks. Their illness was considered as chronic if they gave an affirmative response to (a) or (b), and as a recent first-time condition if they gave an affirmative response to (c).

           

Use of Professional Health Services

 

Respondents were asked whether they had used any of 10 nominated health services for their most serious illness in the past month. These services were private general practitioner (GP), hospital nurse, hospital doctor, private specialist, hospital specialist, ambulance, pharmacist, dentist, social worker/ counsellor, or any other specified health worker. The utilisation of professional services was classified dichotomously. Respondents who had visited at least one of these services were classified as utilisers, and respondents who had used none of the services were deemed non-utilisers.

 

           

Barriers to Utilisation of Professional

Services for Mental Health Problems

 

Respondents were asked to rate as no problem, a minor problem/nuisance, or a major problem, the difficulty posed by lack of appropriate services, lack of anonymity and confidentiality in local services, and distance from suitable help when getting assistance for mental health problems. Because of the stigma that is often attached to a diagnosis of mental illness, throughout the survey there was no explicit use of the term mental health problems. They were referred to as personal and emotional problems so that participants would be less inhibited with their responses.

 

Perceptions of Doctors’ Use of Skills for Dealing

With Personal and Emotional Problems

 

This question was designed to determine the extent to which doctors when dealing with mental health problems used a traditional medical style rather than skills generally acquired through study in the behavioural sciences. The latter are referred to as psychological skills in the remainder of this paper. Respondents rated how often doctors, when handling mental health problems, provided a listening ear, provided counselling and support, prescribed medication, and made referrals to a specialist. Each of these four items was rated on a 5-point scale ranging from 0 (never) to 4 (a great deal). Scores for the first two items were summed to give a measure of the use of psychological skills, and the last two items summed gave a measure of traditional medical skills.

 

RESULTS

 

Mental Health Status

 

Of the total sample of 800 respondents, 8.5% had a serious mental health problem (n = 68), 20% had a physical condition and an additional mental health problem (n = 160), 37.9% had only physical illnesses (n = 303), and 33.6% had no serious illness (n = 269) in the four weeks prior to the survey. One-way ANOVAs and follow up Scheffe tests revealed that there was no significant difference in the SF-36 mental health scale scores between the group with a serious mental health problem and the group with a physical condition and an additional mental health problem, but both of these groups had significantly lower mental health scores than the other two groups, at the .001 level. The groups with physical illnesses and no serious illness did not differ significantly from each other on this measure. Mean scores for each group are shown in Table 1. The group who reported no serious illness in the last four weeks was excluded from subsequent analyses.

 

Table 1

Mean Scores on the Mental Health Scale of the MOS-SF-36

 

 

SF-36 Mental Health Score

Mental Health Status

Mean

SD

SE

95% CI

Serious mental health problem (n = 68)

59.0

20.4

2.5

54.0-63.9

Physical illness and additional mental health problem (n = 160)

 

62.0

 

17.2

 

1.4

 

59.3-64.7

Physical illness (n = 303)

77.0

12.8

0.7

75.6-78.5

No serious illness (n =269)

77.1

12.9

0.8

75.5-78.6

Note.  The mental health scale was scored on a 0-100 scale with higher scores

representing better mental health.

 

Chronicity of Illness

 

The groups differed significantly in the chronicity of their illness, (c2 = 15.2, df = 2, p < .001). Seventy-one percent with a serious mental health problem, 64% with a physical condition and an additional mental health problem, and 49% with physical illnesses had a chronic rather than a recent first time condition.

 

Utilisation of Professional Medical Services

 

A 2x3 chi square analysis of service utilisation (at least one service used or no services used) by mental health status showed significant differences in utilisation rates between groups, (c2 = 6.4, df = 2, p < .05). Only 26.5% of those people with a serious mental health problem accessed professional health services compared with approximately 43% in each of the other two groups. The professional services used by each group are shown in Table 2. The most commonly used service by all groups was private general practitioners. Pharmacists were another popular choice, but not by the group with a serious mental health problem. Only five people with a serious mental health problem had visited a private specialist, social worker or counsellor.

 

Table 2

Professional Health Services Used for the Most Serious Conditions in

the Four Weeks prior to the Survey

 

 

 

Service

 

Serious mental health problem

 

n = 68 (%)

Physical illness and additional mental health problem

n = 160 (%)

 

Physical  illness

 

 

n = 303 (%)

Private GP

16  (24)

48  (30)

  77  (25)

Hospital nurse

0  (0)

8  (5)

10  (3)

Hospital doctor

1  (1)

8  (5)

20  (7)

Private specialist

3  (4)

8  (5)

 7  (2)

Hospital specialist

0  (0)

4  (3)

4  (1)

Ambulance

0  (0)

2  (1)

 3  (1)

Pharmacist

2  (3)

23  (14)

 44  (15)

Dentist

0  (0)

0  (0)

 2  (1)

Social worker/ counsellor

2  (3)

1  (1)

 0  (0)

Other

0  (0)

8  (5)

16  (5)

No service

50 (74)

92 (58)

173 (57)

                                Note.  A person may have used more than one service.  The items

                                when added together therefore may not add to the total shown.

 

To determine whether the perceived chronicity of their illness influenced respondents’ use of professional services, cases were selected first for those who considered their serious illness as chronic. Then a 2x3 chi square analysis was performed on utilisation of professional services by mental health status. This analysis was repeated, but with cases selected for those whose illness was a recent first time condition. Five people with a serious mental health problem, 20 with a physical condition and additional mental health problem, and 14 with physical illnesses did not indicate whether their condition was chronic or a recent first time condition, so they were excluded from analyses. There was no significant difference in utilisation rates between groups if their condition was chronic. Specifically, one-third of the group with a serious mental health problem and 42% of each of the other two groups sought professional help. However, utilisation rates differed if the illness was a recent first time condition, (c2 = 10.0, df = 2, p < .01). Of those people who had a recent first time condition, only 17% of those with a serious mental health problem sought professional help for that problem. In contrast, 60% of those with a physical condition and additional mental health problem sought help for a physical problem (n = 30), and 48% (n = 70) with physical illnesses sought help.

 

Barriers to Utilisation of Professional Health Services

for Personal and Emotional Problems

 

A greater proportion of the group with a physical condition and additional mental health problem rated lack of appropriate services as a major barrier to professional help. Specifically, 80% of this group compared with 69% of the group with a serious mental health problem and 64% with physical illnesses considered this issue a major problem, (c2 = 10.3, df = 2, p < .01). Approximately 60% of all groups regarded distance from suitable help as a major barrier, and approximately 40% of each group rated lack of anonymity and confidentiality as a major barrier.

 

Doctor’s Technique for Dealing with

Personal and Emotional Problems

 

            There were no significant differences between groups in their ratings of doctors’ use of skills for handling mental health problems as shown in Figure 1. All groups thought that doctors used traditional medical skills such as prescribing medication and referral to specialists (M = 4.7, SD = 1.9) more than psychological skills such as providing a listening ear, counselling and support (M = 3.6, SD = 2.1). The mean rating for psychological skills indicated that doctors only occasionally used these skills.

 

                                Figure 1.  Patients’ perception of doctors’ skills for treating people

                                with mental health problems. (Rating scale: 0 (never) to 8 (a great deal).

 

 

DISCUSSION

 

The results show that in rural and remote communities, people with mental health problems utilise professional services for these conditions less than for physical conditions. Only one in four people who reported a serious mental health problem sought professional help for that problem in the four weeks prior to the survey compared with a 43% utilisation rate by people who reported physical health problems. Some comparable data for the same state is the 38% utilisation reported in the Australian Bureau of Statistics profile of mental health in Queensland (ABS, 1997). The ABS figure, however, was an overall proportion of urban as well as rural and remote people with mental health problems and was measured over a 12-month period.

 

People with a serious mental health problem were even less likely to present for professional help if their condition was something they had experienced for only a short time. Compared with the 48 to 60 percent utilisation rate by those with other recent first time conditions, only three out of 18 people who had a recent first time serious mental health problem accessed professional help within the first four weeks of its manifestation. On the other hand, the utilisation rate by those with chronic conditions was similar across groups, and in particular, one-third of those people with a chronic mental health condition sought professional help. The greater proportion of people in this study with a chronic rather than a recent first time mental health condition and the comparative chronic/ recent utilisation rates support the findings of Flaskerud and Kviz (1982) and Fortney et al., (1999) who showed that most people with mental health problems endure the illness for a long time before they seek professional help. The present findings indicate that people with mental health problems in rural and remote communities need to be encouraged to seek help in the early stages of their illness. Early intervention may resolve many patients’ mental health issues before they become too acute.

           

However, some major barriers to professional service utilisation need to be overcome. This study confirmed previous findings that physical factors such as lack of appropriate services and distance from suitable help are important obstacles in rural and remote areas.

The present findings also suggest that the stigma associated with mental illness may be a major factor in whether help is sought. There was a sizeable group, 20% of the entire sample, whose self-report and SF-36 mental health scale score indicated they had a mental health problem, but they did not report this as their most serious condition. Forty-three percent of this group compared with only 27% of those who stated that their most serious illness was a mental health problem, sought medical help, but not necessarily for a mental health condition. This result is consistent with the findings of Booth et al. (2000) who found that one-third of rural people with mental health problems present for help with physical rather than mental problems. These people appear to use a physical illness as a ticket of entry into health care, but whether their mental health condition is diagnosed and whether they continue to get treatment depends on the patient’s satisfaction with the services provided and the skill of the health professionals who examine them. However, if the results of the present study are any indication, then neither of these conditions is fulfilled. Firstly, four out of five respondents who had a physical condition and additional mental health problem stated that lack of appropriate services was a major barrier to professional help, and they were significantly more likely than the other two groups to make this claim. If they were dissatisfied with the initial service experienced when getting help for the physical condition, they might be reluctant to pursue further help for the mental health condition.  

           

Secondly, the results showed that the most utilised professional health service is general practitioners, but that they do not use appropriate skills for diagnosing and treating mental health problems. According to the respondents in this survey, doctors rarely use empathetic skills such as counselling and support. Instead, they tend to resort to prescribing medication and referring patients to specialists. Consequently, as has been suggested, a large proportion of rural and remote mental health problems may be left undiagnosed and untreated (Van Hook & Ford, 1998; Watts et al., 1999).   

           

Although the deployment of more resources, doctors, specialists and so on to rural and remote areas might improve the status of mental health in these communities, the results of this study suggest that there are other strategies, also relevant for urban communities, that could be employed to facilitate change. Firstly, as general practitioners are often the only point of contact for rural and remote people with mental health problems, a substantial component of medical training for rural practice should involve the assessment and treatment of psychological dysfunctions.            Secondly, there needs to be a concerted campaign to destigmatise mental illness especially in rural and remote communities. In countries such as New Zealand, Australia and the USA, advertising campaigns have been used in metropolitan areas to attempt to change people’s attitudes towards mental illness. These advertisements have usually drawn on at least three ingredients essential for reducing prejudice and its resultant behaviour, discrimination. They challenge stereotypes of people with mental illness, raise the visibility of mental illness, and invite people to cooperate towards the achievement of a common goal. The advertisements usually end with the slogan: “One in five people suffer from mental illness. How much they suffer depends on your attitude.” Campaigns of this nature should be extended to reach rural and remote communities, but the advertisements will not necessarily work by themselves. To affect real change, local leaders may need to be identified and trained to diffuse the message through their communities. Adequate and appropriate resources then need to be available for people who become empowered to access help.

           

The results obtained in this study both confirm and extend those from previous research. Although there are some oft-cited, but costly options involving increases in resources to improve the rural and remote mental health problem, there are other options identified in this study. These revolve around increasing knowledge, and changing beliefs, attitudes and behaviour not only to change perceptions of mental illness, but also to widen the range of skills used by medical practitioners. This does not imply that medical doctors should adopt the role of psychologist or psychiatrist, but that they need the skills to elicit and identify mental health problems in their patients, and then have the expertise to manage them appropriately either by themselves or by referral to relevant services.

           

Finally, this study provided further validation of the SF-36 as a useful measure of mental health status in large-scale surveys.

 

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