Mind fields: rural mental health

Published on 08 July 2020 Go back to The ACU Review
A white 4x4 drives along a remote dirt road at golden hour

Fire, flood, drought, and economic adversity have taken a tragic toll on Australia’s rural and remote communities, with suicide rates twice that of its capital cities. But universities are fighting back – and saving lives.

By David Perkins, University of Newcastle, Australia

Around 30% of Australians live outside its major cities. These rural and remote communities make a critical contribution to the country’s economic prosperity – through agriculture, fishing, mining, and more – and to the social and cultural life of the nation. Their stories and images, at times romanticised, remain nonetheless woven through Australia’s national identity.

But these rural communities confront a distinct set of social, economic, and environmental challenges that put them at greater risk of mental ill health: extreme weather events – such as fires, floods, drought, cyclones, and dust storms – can have a catastrophic impact on people who live and work in rural areas. Those whose livelihoods depend on the variability of the seasons experience higher levels of financial uncertainty, as do those in areas of rural decline. Rural communities often have smaller hospitals and schools, irregular public transport, and a scarcity of local resources and opportunities. And while rural residents experience the same range of health problems as city dwellers, their outcomes are poorer and suicide rates can be twice that of Melbourne or Sydney.

The solution to these problems is usually framed in terms of improved access to services, incentives for health professionals to locate to the bush or, more recently, the adoption of telehealth solutions. But are these services actually meeting the needs of Australia’s rural communities?

Beyond city thinking

My job as Director of the University of Newcastle’s Centre for Rural and Remote Mental Health is based in Orange, New South Wales, four hours west of Sydney by car. We work to promote rural mental health and wellbeing, improve support services, and reduce the number of rural people who die by suicide. But to do so effectively means understanding the distinct needs and circumstances of the communities with which we work.

My first job in Australia was a rural research study in Broken Hill – a mining town in Australia’s outback – which led to me living and working in a remote community ten years later. There, I experienced first-hand the millennium drought, which gripped whole swathes of Australia for the first decade of the 20th century. I saw the intellectual and practical challenges of supplementing remote medical healthcare with fly-in fly-out services such as the Royal Flying Doctors. It became clear to me that conventional city thinking and policy were not fit for a rural context.

This need to think differently and flexibly about the distinctive mental health challenges of rural settings, as opposed to simply replicating strategies accepted as successful in urban areas, has been a key learning from my research and practice. Rural-urban service comparisons have not served rural Australians well – in fact, international comparisons of rural health challenges provide a more fertile starting point. Many rural communities have experienced little in the way of sustained health system progress in the last 50 years, despite a plethora of initiatives and expenditures which, while well intentioned, have been poorly designed and badly implemented.

Evidence-based policy, similarly, is not straightforward. We have to consider what we mean by evidence. There needs to be a place for consumer evidence, provider evidence, observational evidence, and the careful consideration of context – in other words, the thoughts, ideas and experiences of those living in rural communities and the people actually using and delivering mental healthcare. Co-design – a process by which those using or affected by the service and issues are involved in its design – is also crucial and challenges the assumptions of design by experts.

Perhaps the approach of Aboriginal people – who seek social and emotional wellbeing rather than medical and clinical solutions – has broader application here. Rural people have a bond to land, place, and community that is often very similar to that of First Nations people, as demonstrated by rural responses to Australia’s recent bushfires that coincided with the second major drought of our century so far.

A metal field gate opening onto a field at golden hour

Political responses to rural adversity usually take the form of financial aid, either from government or charitable sources. The recent fires provoked unprecedented levels of giving from individuals and celebrities. But money in itself is not a solution. Increased expenditure does not inevitably lead to better outcomes and may end up reducing local rural autonomy and increasing dependence on visiting or virtual services. The short-term attention of political and media cycles does not enable us to address complex problems with long-term causes and consequences.

Connected communities

So, what does work? Successful projects led by the Centre include the development of a team of Rural Adversity Mental Health Program Coordinators. Aware that people living in rural areas are more likely to seek help from those they trust, the coordinators live and work in the heart of rural and remote communities where they educate, encourage, and connect people to mental health support. Their local knowledge, connections, and levels of trust enable them to play an important role in assisting community recovery after droughts, fires, or floods have struck.

Community, rather than professional, leadership in suicide prevention offers a promising approach that complements conventional medical care. One great example of this has been seen in Clarence Valley in northern New South Wales, which in 2015-2016 experienced a spate of deaths by suicide, including a number of young people. The community’s grief was exacerbated by unhelpful press coverage, which portrayed a suicide 'contagion' in the area.

The Clarence Valley community resisted an external suicide prevention committee and, with academic support, developed instead a community-led initiative called ‘Our Healthy Clarence’ – a unique collaborative model that brings the community and organisations together to foster mental, physical and social wellbeing, and that is not beholden to any stakeholder apart from the community itself. Stakeholders have reported increased community agency, collaboration, optimism, and willingness to discuss mental health and help-seeking. In this, Our Healthy Clarence has changed the narrative around mental health, encouraging participants to see the strengths inherent in their community, and shifting the focus away from suicide towards resilience-building and hope.

Knowledge and action

How can universities help to promote mental health and wellbeing in the context of rural adversity and the growing number of climate-related events? In the first instance, universities are stable and capable organisations with a commitment to the development and use of knowledge for the public good. We use and value scientific knowledge and we evaluate action with transparency and rigour. This commitment blends an interest in short-term action with a concern for longer-term outcomes, which are often missing in the media and politics.

The challenges of rural and remote mental health are not unique to Australia and we are engaged in the development of international university partnerships. One such initiative is the Orange Declaration for Rural and Remote Mental Health – a statement identifying ten actions to improve rural mental health outcomes and calling for collective action in this area. Such partnerships will enable us to harness the international power and rigour of academics to deliver grassroots impact in rural mental health and wellbeing.

Professor David Perkins is Director of the Centre for Rural and Remote Mental Health at the University of Newcastle, Australia.

The Orange Declaration for Rural and Remote Mental Health, and the study that underpins it, identifies ten actions to improve rural mental health outcomes and calls for collective action in this area. Read and endorse the statement at www.crrmh.com.au/research/the-orange-declaration

Images (from top) by Francesco Ricca Lacomino and f.ield_of_vision, both at iStock