Rural and Remote Issues
People with a mental illness and their family and friends who live in rural and remote areas are faced with unique pressures and stresses and are also isolated from mental health services. In rural areas, 24-hour services such as bulk billing medical centres or after-hours services are not as commonly available as they are in cities and mental health services are often understaffed. In recognition of this lack of resources, the National Mental Health Plan (1992) aimed to provide equity to all mentally ill individuals. There have been a variety of incentive schemes developed to entice health professionals into rural areas, and Rural Health Support Education and Training grants have supported rural education, training and research (Anderson 1997, Fahey 1996). However, these actions have had little effect in rural health care and the National Mental Health Strategy aim has yet to be realised (Edwards-Davies 1996).
Experiences of people living in rural and remote areas
Rural communities have characteristics that are both beneficial and conversely detrimental to the lives of those people with a mental illness. Some of the strengths include a strong sense of identity with regards to family and a supportive social environment. This identity could help cultivate an attitude of inclusion and acceptance for people with a mental illness. Unfortunately opinions concerning mental illness are usually more negative and stigma is magnified within the tight-knit rural communities (Bjorklund & Pippard 1999). Some of the other difficulties associated with living in a rural community include:
- fewer services and mental health workers imply a lack of choice available to individuals and carers. Lack of options and dependence on the few services available can restrict the ability of people with schizophrenia and their carers to complain about the service being provided;
- social factors, for example, there can be a limited guarantee of privacy and confidentiality when accessing mental health services in a small community and consequently the services available could be under-used (although many mental health services do attempt to ensure privacy by driving unmarked cars and making home visits). Stigma may be produced simply by accessing services and being associated with self-help groups (Bjorklund & Pippard 1999).
- geographic isolation resulting in a potential lack of support and resources;
- the 'travelling band' of people with long-term mental illness who move around the country from one area to the next are very noticeable in rural areas (in cities they may move from one hostel to the next and not be so easily identified);
- people with a mental illness are at increased risk of attempting suicide, and this risk is increased dramatically particularly for young men living in rural and remote areas; and
- the effects of severe rural recession, for example, economic hardship, and job loss, may lead to an increase in stressful events and consequent aggravation of the symptoms of mental illness.
(Elliot-Schmidt & Strong 1997)
Difficulties in providing mental health services
Lack of service
Rural and remote areas are sparsely populated and consequently services in these areas are utilised intermittently. Specialist mental health services, hospital psychiatric services and follow-up care facilities (for example, supported accommodation, day care or drop-in centres or toll free numbers to call for support) are very limited (Edwards-Davies 1996).
It is difficult to attract mental health workers to rural and remote areas. Services are usually limited to local hospitals, general practitioners and periodic visits from mental health professionals. It is also difficult to retain these workers due to lack of professional, educational and social opportunities compared with urban areas (Anderson 1997). For example, there is a major difficulty providing professional support and supervision for mental health workers. Telemedicine could be used to address this problem.
Availability of mental health services within rural communities is restricted because of the low population levels. Mental health workers in rural areas are often responsible to deliver services to large geographical regions and are prevented often by the physical and geographical isolation of some consumers, who may not be aware of that there are services available. Due to the low population levels and isolation there is little economic justification for having all the necessary resources to set up mental health programs (Bjorklund & Pippard 1999).
Reduced ability or inclination to access services provided
Services are generally only available in regional centres, and these may have difficulties coping with the large number of people accessing their service.
It may be difficult for people with mental illness and their families to access services without other members of the community knowing. Discrimination may result due to lack of information or education about schizophrenia and because of the involvement of police in the restraint or transport of a person experiencing a psychotic episode (Elliot-Schmidt & Strong 1997).
Members of small and remote communities may mistrust those from outside their community, primarily due to the issue of confidentiality. As most psychiatric services are in the form of visiting health professionals, this presents a potential problem (Elliot-Schmidt & Strong 1997).
In rural and remote areas, ongoing support groups that rely on consumer and family initiatives may not be developed due to concerns about confidentiality as well as financial and geographic limitations.
Regional centres are often a long distance from the rural and remote areas they provide services to, resulting in potential transportation difficulties for people with schizophrenia.
What is needed by people living in rural and remote areas
The following ideas have been put forward to help redress the problems faced by people with schizophrenia living in rural and remote areas.
- Using technologies such as 'telemedicine' and the internet can help bridge geographical distances. Schizophrenia is one of the most heavily identified disorders on the Internet, thus providing a range of web-sites to assist people with schizophrenia who live in isolated areas to obtain relevant information (Yellowlees 1997). Telemedicine provides a means through which there can be increased access to services by consumers who might otherwise not receive sufficient services. Its use is likely increase as it is becomes more widely accepted as an alternative to face-to-face treatment. With further technological development it may become increasingly cost-effective and also ensures higher levels of confidentiality and privacy (Rohland 2001).
- Developing and implementing outreach programs including the use of 'fly-in' services for people living in very remote areas.
- Establishing consumer and carers networks and support groups.
- Introducing specialised programs relevant to rural people with a mental illness.
- Training general practitioners and other general health workers in recognising the signs and symptoms of mental illness, and providing effective interventions (Carr 1997). Programs which promote the communication between mental health workers and general health workers, such as 'Shared Care' programs, may be particularly useful.
- Providing incentives for mental health professionals to work in rural and remote areas, for example professional supervision through tele-psychiatry (Kamien 1997).
- Ensuring there is an independent body to whom people with a mental illness and their carers can take complaints and suggestions about mental health services and workers.
- Publicising all services and programs available for rural people with a mental illness.
- Rural and remote Area Health Services could develop and distribute regular newsletters to local health services and individuals that have had contact with them in the past.
- Providing education and information about mental illness to communities, families, carers and people with schizophrenia. People with schizophrenia and carers could be involved in delivering the community education programs. Schools, teachers and local police could also be utilised in community education programs.
For a list of references for this quality of life section on rural and remote issues, click here.
The Schizophrenia Fellowship of NSW runs several programs in rural and remote areas of NSW. The include Carer Advocates (located in Central Sydney, Mid North Coast, Macquarie, South West Sydney, Greater Murray, Hunter, Illawarra and Northern Sydney). The Fellowship also has several Community Development Officers working in the Hunter Region and the Greater Murray. The Fellowship aims to have Carer Advocates and Community Development Officers located in each Area Health Service of NSW. To find out more about the Carer Advocates, call the Carer Support Unit on (02) 9879 2600 or email them. To find out more about the Community Development Officers, call (02) 9879 2600 or email the Director of Support Services.
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