By Dr Robyn Vines FAPS, Chair, APS Regional, Rural and Remote Advisory Group and Adjunct Senior Research Fellow, Faculty of Medicine, Nursing and Health Sciences, Monash University
The demographer Bernard Salt has stated that the unfolding story of our continent indicates that there are progressively becoming “two Australias” separated by a Great Divide stretching between Port Douglas in Far North Queensland and Eucla on the Great Australian Bight. To the east lies “heartland Australia”, a globally connected nation of 19 million people; to the west lies “frontier Australia”, a vast resource-rich state with only three million people (Salt, 2011).
Key to this “frontier Australia” are our primary industries. Australia ranks tenth in the world as a major agricultural producer and exporter, and the mining industry contributes significantly to the economy of our country. Hence our regional, rural and remote (RRR) industries are at the core of the financial security of the nation. Given the overall reliance of Australia on the productivity of its regions, the health and wellbeing of those outside the metropolis is crucial to the overall prosperity of the nation. In stark contrast to the increasing wealth generated by these RRR-based industries, the health and wellbeing of our Indigenous population – primarily located in rural areas – has continued to deteriorate, during a time of rising prosperity for the country as a whole.
There are large inequities in health service provision across Australia and enormous difficulty in recruiting and retaining health practitioners to rural, and particularly remote, areas. This article presents an overview of current population distribution and incidence of general and mental health problems in rural communities, and demonstrates why ‘RRR’ matters both to our country as a whole and to us as practising psychologists. There are unique and interesting opportunities for broad experience and service delivery innovation ‘in the bush’, often not feasible in metropolitan centres. Yet many of us remain limited and ‘metro-centric’ in our view of what constitutes worthwhile work. This needs to change if psychologists as a profession are to contribute to the overall health and wellbeing of our nation.
As an island continent of approximately eight million square kilometres, Australia is a geographically huge country with a population of approximately 22.7 million people. It is relatively sparsely populated and is densely urbanised, with one per cent of the continent containing 84 per cent of the population clustering mainly in the key capital cities, major metropolitan, outer-metropolitan and large regional areas. In contrast, the widespread regional, rural and remote areas (commonly referred to as ‘the bush’ or ‘the outback’) have a low population density.
National trends have consistently highlighted the shift of people and services from rural to metropolitan areas. In 1911, 43 per cent of Australians lived in rural areas, but in 1976 the corresponding population was only 14 per cent. The 1996 census showed that the rural population again decreased as a proportion of the total population (Salt, 2011), although the exact proportion varies from State to State.
On the whole, Australia’s rural and remote populations have poorer health than those in the city. Life expectancy declines with increasing remoteness (more so amongst men than women). The gap is widening between urban and rural people, with life expectancy increasing more than 20 per cent faster for residents of metropolitan local government areas (LGAs), compared to rural LGAs (Cresswell, 2008). These figures are affected by higher overall Indigenous mortality rates (on average, 17 years less than the rest of the population) as well as a possible drift/migration of the frail aged to some regional and rural areas (National Rural Health Alliance [NRHA], 2007).
National figures indicate that people are significantly more likely to die of heart disease if they live in rural areas, with rural patients having overall poorer health as well as being disadvantaged in relation to access to new investigation technologies and treatment techniques (Rural Doctors Association of Australia, 2008). People living in rural and remote communities also have particular risk factors and mental health needs associated with isolation and exposure to environmental hazards such as drought, flood and fire. The impact of drought alone, and the consequent enormous financial stress on farming families, has been found to lead to anxiety, depression, family breakdown, grief and anger (Australian Government, 2000). Unpredictable weather (intrinsic to rural life) forms a back-drop to other occupational hazards – such as working with dangerous machinery and farming accidents, equipment breakdowns, exposure to dangerous chemicals, changing government regulations/legislation, lack of leisure time/long hours, difficulties for couples in balancing roles with the increasing need for off-farm work – all of which combine to create higher health risk levels for rural and remote people.
There are numerous additional factors which make rural and particularly remote life more challenging and represent risk factors for poorer health and wellbeing. These include small groups of people, enormous areas, unpredictable socioeconomic and ecological circumstances, ageing communities with the migration of young people to cities for education and work, and declining public infrastructure (e.g., health service and bank closures) (Rajkumar & Hoolahan, 2004). Risk-taking attitudes to health, illness and behaviour are also known to be more prevalent in the outback, with more rural people drinking at risky levels, and more likely to smoke, be overweight and unfit (AIHW, 2006).
In addition, on average Australian rural people are poorer and attain lower levels of education than people in urban areas: 56 per cent of rural households fall into the two lower income quintiles, compared to 36 per cent of capital city households and 45 per cent of other urban households (AIHW, 2006). In rural and remote communities the cost of basic food is also often up to at least 10 per cent higher than in metropolitan and regional centres, giving a “double deprivation” effect, resulting from lower levels of income combined with higher basic costs. Lower levels of education and higher levels of poverty are reflected in poor physical and mental health status (Wainer & Chesters, 2000).
The factors outlined above combine to create what is termed ‘social exclusion’ within a community, indicating what can happen when people (or areas) suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime, bad health and family breakdown. Such social exclusion disadvantages communities in many ways, and rural communities are considered to be the most socially disadvantaged in relation to this global index (Saunders, 2003).
The National Survey of Mental Health and Wellbeing of Adults (ABS, 1997) indicated that mental health is a significant health issue in Australia with almost 1 in 5 people suffering from a mental disorder in a 12-month period. One of the key limitations of the survey, however, was that rural, remote and Indigenous groups were not included (Whiteford, 2000) and accurate data on the distribution and determinants of mental health and wellbeing in rural and remote populations in Australia is still largely unavailable.
Current research suggests again, however, that there is a significant rural-urban health status differential and that a number of key mental health issues in rural and particularly remote areas require special attention and intervention. These include comorbid mental health and alcohol and other drug disorders, higher levels of attempted and completed suicide, unique stressors amongst farming communities, and Indigenous mental health issues. Research also indicates that rural women in remote areas are more exposed to violence in personal relationships than urban women and many are isolated without public transport. Both females and males aged 20-29 in rural/remote areas are twice as likely to consume alcohol in hazardous or harmful quantities when compared to their metropolitan counterparts (alcohol has been implicated in up to 50 per cent of all suicides in Australia).
Suicide rates amongst rural communities are known to be consistently higher than in urban communities, with recent research indicating that 15-24 year old males in regional areas are 1.5-1.8 times more likely to end their life by suicide than their urban counterparts. The incidence is up to six times higher in very remote locations. Inter-regional comparisons are also poor for 25-44 year old and 45-64 year old non-metropolitan males (NRHA, 2009).
Recruitment and retention of health professionals (GPs, medical specialists, psychologists and others) in regional, rural and remote communities in Australia are major challenges, with the majority of health service providers residing and working in the large cities. Access to specialist mental health professionals is particularly limited beyond the main metropolitan centres, and rural residence has been found to be negatively correlated with frequency of use of both psychologists and psychiatric services (Parslow & Jorm, 2000).
Despite attempts to increase recruitment over the past ten years, the availability of specialist mental health professionals in rural areas is still inadequate. Analysis of Medicare statistics in 2001 indicated that only four per cent of psychiatrists practised in regional, rural and remote Australia, while the majority of the remaining 96 per cent practised in the upper-middle class suburbs of Melbourne, Sydney and Adelaide. This figure has increased over the decade since to eight per cent, still leaving a large gap in psychiatric service delivery outside major cities. Distribution of psychologists is better, with approximately 21.5 per cent of psychologists providing services in regional, rural and remote locations (for more detailed information on the psychology workforce in RRR Australia, see page 12).
Despite recent changes in modes of practice and accessibility of services (such as the Better Access to Mental Health Care initiative), the incidence of psychological and mental health problems managed by GPs still decreases significantly outside the major capital cities (Caldwell, Jorm & Dear, 2004), suggesting either a lack of presentation or unwillingness to deal with these complex issues, for which little help is available. Both help-seeking and service use rates (i.e., actual presentation for treatment and use of services) for mental health issues are lower in rural areas, with those suffering from mental difficulties facing more barriers to help-seeking than in the city. These include poor availability and accessibility of services (primary, secondary and tertiary), as well as a number of characteristics specific to rural communities such as lack of choice of health providers, high workloads of available GPs, geographic distance, and lack of knowledge about, and negative view of, mental health problems (and/or practitioners) by those living in rural areas and amongst their social networks (Jackson et al., 2007).
The self-sufficiency, self-reliance and stoicism known to be characteristic of rural people and communities, strict boundaries on self-disclosure (e.g., “what is considered family is private business” – Roufeil & Lipzker, 2007) and the limited anonymity present in smaller towns, all act as disincentives to help-seeking (Boyd et al., 2008). The small size of country communities (i.e., the ‘small town’ phenomenon) impacts both on client privacy and on boundary issues for practitioners, with concerns about confidentiality acting as a further disincentive to seeking help. The issue of stigma in relation to mental health issues remains a key factor in people’s postponement or avoidance of getting help, particularly in smaller rural communities where it is thought that “everyone knows everyone else’s business”. Sensitivity to such common beliefs and knowledge of rural culture is crucial in successfully providing help, whilst remaining aware of dangers inherent in false stereotyping of this population.
Most people, both in rural and metropolitan areas, have been found to be more likely to seek help from a GP than a mental health professional, particularly people with lower educational levels (Tijhuis, Peters & Foets, 1990), with consultation rates amongst women being considerably higher than those of men. Rural males are 30 per cent less likely to consult a GP than their urban counterparts, and rural females are 16 per cent less likely, due to a greater perceived stigma associated with help-seeking amongst men than amongst women (Gunnel & Martin, 2004). Despite improvements in mental health literacy in many of our communities, this trend still exists.
Given that Australia is dependent on the productivity of our rural regions, the inequities in incidence of general and mental health problems in RRR Australia, and the service delivery options available to treat them, remain of considerable national concern. For “frontier Australia” to thrive, these inequities need to be addressed and we, as psychologists are a unique part of the solution. As mental health specialists with diverse areas of expertise beyond that of straightforward clinical intervention (e.g., community resilience building, health and wellbeing, etc) we have a key part to play in the revitalisation of our regional, rural and remote areas. There are unique opportunities for service delivery innovation and funding not found in city locations, and many of those practising outside the metropolis find that their capacity to ‘make a difference’ as part of their local community is enhanced by working in these areas. Lifestyle factors also make the choice to work outside big cities attractive to many.
Some insights as to how to enhance psychology’s contribution to RRR Australia through addressing service inequities can be gleaned from those psychologists who have chosen to reside in rural and remote Australia. The APS Regional, Rural and Remote Interest Group and the APS Regional, Rural and Remote Advisory Group have implemented a pilot study of non-metropolitan members of the APS, with preliminary data suggesting that those who have chosen to work outside metropolitan areas do so largely because of pre-existing connections to rural locations and a strong appreciation of the rural lifestyle. This includes being brought up in a regional, rural or remote location, or having family connections in such areas. These findings are similar to those for medical practitioners (Henry, Edwards, & Crotty, 2009), pharmacists and social workers (Allan, et al., 2007) in that for all these professions, rural background appears to be a critical factor in the choice to work outside capital cities. The preliminary data also suggest the potential utility of adopting a ‘grow your own’ approach to the rural psychology workforce. This approach to training has been adopted with some success by the medical profession (Henry et al., 2009). Further work is underway to better understand the factors associated with recruitment and retention of psychologists to rural Australia in order to inform strategies to build the rural psychology workforce.
The pilot study also sought to understand some of the core competencies required to work effectively as a psychologist in rural Australia. Interestingly, many respondents identified personality traits such as independence and flexibility as well as professional competencies as facilitators of successful practice. Again, this finding is commensurate with research on rural medical professionals that suggests certain personalities may be drawn to rural practice (Eley, Young, & Przybeck, 2009). Other facilitators for effective rural psychology practice that were identified included breadth of professional knowledge and experience, as well as an ability to maintain boundaries and effectively manage dual relationships.
These findings are currently being explored in more depth, with the study extended to a comparison between the urban and non-urban workforce in order to better identify any key differences. What these preliminary findings suggest, however, is that practice in rural areas may require the development of unique competencies – as illustrated in the types of ethical challenges outlined in the APS Ethical Guidelines for Psychological Practice in Rural and Remote Settings (see www.psychology.org.au/Assets/Files/EG-Rural-remote.pdf).
People living in regional, rural or remote locations are subject to a number of pressures and causes of stress and illness not experienced by their metropolitan counterparts. Overall, it is envisaged that the Australian population will grow by 14 million people over the next 40 years and that “ignoring the development of regional Australia is no longer an option this country can afford” (Maher, 2008). We as psychologists have a crucial role to play in ensuring that our productive regional, rural and remote areas thrive as communities and remain a resilient core at the heart of our nation.
The author can be contacted at firstname.lastname@example.org
Thank you to all APS members in regional, rural and remote Australia who completed the recent survey on the needs of non-urban psychologists. The survey results will inform planning and will also be used as a pilot for a larger nation-wide survey of registered psychologists that will investigate the differing needs of rural and urban psychologists, particularly in relation to continuing professional development.