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Rural Health Academic Centre, University of Melbourne, Sydney, Australia
Received date: November 17, 2012; Accepted date: December 17, 2012; Published date: December 19, 2012
Citation: Pierce D, Brewer C (2012) Factors Promoting Use of Mental Health Services in a Rural Area of Australia. J Community Med Health Educ 2:190. doi: 10.4172/2161-0711.1000190
Copyright: © 2012 Pierce D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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This paper reports research which identified a number of mental health help-seeking responses in a rural region of Australia. It describes the characteristics of services and of individual health professionals, as well as some Australian government initiatives that may promote help seeking behaviours. Focus group and individual interviews were undertaken. Participants included those who had personally experienced mental ill health, family and professional careers of individuals with mental ill health and individuals from rural culturally and linguistically diverse (CALD) communities. The researchers found that while many previously reported factors, such as stigma, limited confidentiality, cost factors, and previous negative experiences with mental health care continue to inhibit help-seeking, a number of responses and initiatives may actively promote help-seeking behaviours. These include: mental health literacy; targeted government schemes; accessible information; continuity of care and affordable services. The paper concludes that promoting these help-seeking enablers may support more desirable outcomes for those experiencing mental-ill healths in rural areas of Australia.
Promoting mental health help-seeking; Mental health literacy; Targeted interventions; Supportive mental health clinicians
Mental health is widely recognized as an important community health issue. Mental ill health accounts for nearly 30% of all healthrelated disability, with depression being a prominent major cause of disability . In any 12 month period the prevalence of mental health conditions for those aged between 16 and 85 is 20% with many of those experiencing mental health difficulties not seeking help . Failure to receive help for a mental health problem is acknowledged as a widespread problem throughout Western society . In rural Australia less than half of those with a mental health issue seek help for that problem .
Living in a rural or remote location in Australia is negatively associated with use of psychiatrist services and living in a remote area is negatively associated with use of psychologist services . In rural areas, services are spread thinly, making access difficult, especially for those without access to a car .
However, there is some evidence to suggest that recent Australian Government initiatives such as Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule Initiative and Access to Allied Psychological Services (ATAPS) have improved access to mental health assistance. An evaluation of the ATAPS program found that patients gained considerable benefit from the program including patients from disadvantaged groups . Half of all users of the Better Access initiative may be new, not merely to the initiative but new to mental health care . Both programs have been found to be successful and to complement one another .
Cultural factors have been identified as influences on mental health help-seeking behaviour. Shame and stigma associated with strong cultural inhibitions on exposing any personal or family matters to outsiders have been identified as major barriers to help-seeking among immigrant populations, as they have concerns about confidentiality and lack of trust in service providers . It has been noted that culturally and linguistically diverse (CALD) communities are not homogenous, that individuals’ cultural needs should to be taken into consideration, and that professionals should modify their practice to respond appropriately . A further barrier to seeking mental health assistance, especially for recent refugees, may be differences in perspective from that of the broader Australian community towards counselors, psychologists or psychiatrists, with assistance from these professionals being sought only if they were “crazy” or severely disabled .
The lack of anonymity in the close knit culture of small towns may limit help-seeking for sensitive problems, for example when a patient’s car can be seen at a mental health clinic .
The link between homelessness and poor mental health is well established, with 73% of homeless males and 81% of homeless females experiencing mental illness in the past 12 months . Despite mental illness being more prevalent among those who are homeless, residential stability for those who are homeless and successful living with a mental illness is possible, if appropriate housing, effective treatment and flexible support is available .
There is also an emerging literature on approaches that are helpful in improving mental health literacy and promoting subsequent helpseeking behaviours. The past decade has seen an increase in mental health promotion, both in Australia and overseas. Many initiatives promoting mental health are available but not all are effective with many such programs lacking robustness . A meta-analysis has identified strategies that promote help-seeking amongst adolescents and young adults . These include: improving general health literacy, reducing stigma and taking into account the desire of young people for self-reliance.
Continuity of care and a trusting relationship with general practitioners (GPs) facilitated help-seeking for parents of children with significant mental health symptoms . The same study also identified short appointments with general practitioners as a key barrier to helpseeking.
This research focused on identifying barriers that may limit or enabling factors that may promote use of professional services by those experiencing mental health difficulties in a rural area of Australia. Both barriers and enablers to help-seeking were identified. The barriers identified in this research are similar to those discussed in the literature. A number of enablers that may support help seeking behaviours were identified and are the focus of this paper. The authors aimed to contribute to the emerging literature on this topic and to assist both practitioners and policy-makers develop approaches that assist such behaviours.
The setting for this research was an Australian rural area that included a number of small rural towns and one larger regional centre. In addition, the study location included recent refugee migrants from areas of civil conflict. Many of these migrants had fled persecution, with associated increased potential mental health needs. The research also included consideration of the help-seeking experience of CALD rural residents.
For the purposes of this research a ‘mental health service’ includes: all adult programs provided by public mental health services, agencies providing counseling or support service to people with mental health problems, general practitioners, psychiatrists, psychologists, mental health social workers, and mental health nurses. The terms ‘client’ and ‘patient’ are used interchangeably, typically reflecting comments by participants.
Using a newspaper advertisement and through relevant community groups, volunteers, 18 years or older, who in the past 12 months had personally experienced mental ill health (in particular depression and/ or anxiety) and now felt well or had a family member with mental ill health, were recruited. In addition, using the professional contacts of the researchers, individuals who work with those experiencing mental ill-health issues in rural settings were also recruited. It was anticipated that many participating professional carers would have had contact with both those who had sought help and those who had not sought help for a mental health condition, for example carers who were not mental health professionals. Targeted recruitment of participants from CALD communities was undertaken through relevant community organizations. Recruitment included participants who were able to bring to the research both their experience of working for many years with large numbers of clients who had experienced mental-ill health and their understanding of factors that inhibit and factors that promote mental health help-seeking responses.
Ethics approval for the research was provided by the relevant University of Melbourne committee. All participants gave written consent and were screened for current psychological distress using the K10 (Kessler Psychological Distress Scale)  before participation. Semi-structured interviews were undertaken. Individual interviews and focus groups were used; the former to support participants who were not comfortable talking about sensitive issues in a group setting and the latter to promote data richness that often emerges from the dynamic of a focus group. All interviews were digitally recorded and transcribed. Transcripts were read and re-read prior to thematic analysis being undertaken. Saturation was determined when no additional new themes were identified. Phenomenological principles were used for identifying the lived experience and perspective of participants. Discussion was initiated by reflection on a number of clinical scenarios (Appendix 1). Barriers that limit and approach that promote utilization to mental health services and help-seeking behaviours were identified.
Seventeen participants were recruited. Seven individual interviews were conducted and two focus groups, with five respondents in each, were held. Participants were from larger and smaller rural communities and included: individuals who had personally experienced mental illness; family carers of individuals who had experienced mental illness; professional carers of individuals who had experienced mental illness; and individuals from CALD communities.
Barriers to help-seeking behaviours for mental health concerns were identified. These were consistent with the existing literature and included: stigma and shame about mental ill-health, fear of a lack of confidentiality, previous “negative” experiences of professional mental health care, not recognizing symptoms as a mental health problem, rural stoicism, and not knowing what help was available or how to access it.
Identified enablers of mental ill-health help-seeking behaviours included:
1. Mental Health Literacy
2. Targeted mental health initiatives
3. Readily accessible information on available services and access to services
4. Supportive clinician attitudes and health service structures
5. Continuity of care
6. Free health care (at point of service delivery)
Improved understanding of mental health issues in the community was identified as beneficial in supporting help-seeking behaviours both directly and by reducing the level of stigma associated with mental illness, particularly for high prevalence disorders (anxiety and depression). Nine respondents specifically commented positively on the work of Beyondblue (an Australian national organization promoting understanding of depression and related disorders).
The push to educate and destigmatize, particularly for the men on the land,
I think that has been helpful. ….. (ID 06)
I think Beyondblue stuff is very good for the male stuff, that’s where I’ve seen a real difference even in my partner’s male networks, it gave them permission to talk about it. (ID 07 A)
This participant identifies the link between improved mental health literacy, associated reduction in stigma, and help-seeking responses for depression. Other participants commented that more needs to be done to reduce the stigma associated with low prevalence disorders such as bipolar disorder and schizophrenia and that this requires dissemination of information about these disorders in the community.
Mental Health First Aid (MHFA, an Australian training program to promote awareness and initial support for those experiencing mental health problems)  was also identified by many participants as an appropriate way to promote enhanced help-seeking behaviours though greater mental health literacy. One participant commented that:
I went away from that (MHFA) thinking …..now I’m more empowered, far more empathetic (ID07B)
The Better Access program (an Australian government initiative that provides counseling sessions for mental illness by an accredited mental health practitioner) was identified by a number of participants as having reduced barriers to care for many people.
I know from the new Better Access program far more people are willing to take the recommendation of their GP to go that next step (for counseling). (ID 07, A)
Prolonged waiting times to see a clinician and health system structures such as GPs having a gatekeeper role for access to such services were identified as potential barriers that may limit the benefits of this imitative. Targeted support for groups with increased risk of mental ill health such as homeless people was felt by a number of participants to be an important approach to increase help-seeking behaviours. The Supported Accommodation Program (an Australian government initiative to support homeless people) was identified as an initiative providing such support, with its emphasis on the needs of those experiencing both homelessness and mental health difficulties. Directly supporting those experiencing mental health difficulties to attend consultations was suggested as an approach that may overcome barriers for receiving help. One participant referring to a homeless person with a mental health issue identified benefits from targeted interventions, with connection to mental health services and later connection to accommodation services. However, he went on to note the need for persistence and flexibility in contacts with those experiencing homelessness and risk of mental ill-health .
“By being available and staying in contact and using the strengths of engagement and having the flexibility to do so, I was able to gently engage that man”. (ID 02)
In addition to national initiatives, targeted local initiatives were identified as potentially helpful in supporting help-seeking behaviours. Participants identified a local mental health literacy program, designed for coaches of sporting teams, as a valuable support to mental health help-seeking by young people. In the context of this initiative, the difficulty of ongoing funding requirements to continue valuable local support initiatives was noted by two participants. An initiative from a local mental health service, specifically designed to increase mental health literacy amongst the CALD community, was identified by participants from those communities as very valuable. Its success was attributed to presentation to one CALD group at a time, including in language of that group, allowing for specific responses to the mental health literacy needs of that community. An identified specific focus that was felt to support help-seeking was reducing perceptions of shame associated with the experience of mental illness.
A local program, designed to promote healthy lifestyles, resilience and mentoring in young people and set up as a response to a number of suicides amongst young people in the local community was identified as positive. Its benefit was at least in part attributed to its structure, using a community development model as illustrated in the following quotation.
“Some of them had approached the mental health service because of quite severe mental health issues. Some of them had not and would not but saw a group process with mates which addressed the same kinds of things as a mental health services, ……(They) felt quite comfortable to talk about the issues….because as a group they were facilitated to do it together, so it became part of a friendship, an exploration with friends about issues which were important to all of them, which the ones who had approached the mental health services didn’t have. (ID 09)
Whilst many recognize the importance of mental health, following through with a help-seeking desire often requires knowledge of available services and how to access them. This difficulty was noted in the following quotation:
It (mental health service) is a maze of services and trying to wind your way though that has been very difficult in the past. (ID 01)
One participant reported the relief felt by a carer when they discovered a mental health telephone information service and was told by that service that they could go to a GP and gain access to a mental health clinician.
For them, that (a referral under Better Access to a private provider) was far less stigmatizing and they were able to come to terms with that a lot more so for them it was very helpful. (ID 01)
Making services accessible also requires them to be acceptable to potential patients/clients if they are to be used. The issue of social visibility, especially in a small community, was identified as a concern to be addressed as a further factor to promote help-seeking behaviours (for example if it is widely known in a community that the mental health worker visits the library between 3.00 p.m. and 5.00 p.m. each Wednesday, this could be an inhibitor to help-seeking behaviour). Therefore, mechanisms to limit this social visibility may assist active response to mental health difficulties. A number of respondents felt that online information and self-directed tests on mental health may promote help-seeking especially amongst young people. One young respondent felt that there could be more targeted information for young people on television using presenters that were young. Extensive advertising of hotlines and free call telephone numbers was stressed as very useful. One young participant commented:
I didn’t realize at the time that the hotlines are out there but I think I would definitely have given that a try had I known. (ID 05)
Significant adverse events (such as drought) may have an unexpected beneficial community impact by providing the impetus to make services more accessible as a response to the community distress of drought:
Organizations (are) doing better, particularly since the drought. (ID 06)
Social media was identified as a tool that may be effective in promoting mental health literacy and access to services, especially for young people, but for that to be effective, significant planning is likely to be required:
I think you probably have to play on a lot of stereotypes that might be around with boys playing football, male “toughness”….
If it’s done the right way, I think it would be definitely beneficial. (ID 05)
The attitudes of clinicians and the structures of the health system were identified by participants as both potential barriers and enablers to help-seeking for mental health. This was seen to be important, especially at the initial contact, most often in general practice. Most participants identified the importance of a “good doctor” in assisting people with a mental illness. One respondent whose clients include homeless people experiencing a mental illness described a good doctor as being:
One who has good training and experience, genuinely cares for the patient, works holistically, not just from the medical model, observes the whole person and spends time with the client. (ID 02)
Consultations in which adequate time was spent with the patient were highly valued, with participants noting the difficulties many people experience raising emotional or mental health issues and the benefit of having these issues addressed immediately. Approaches that limited long delays in obtaining help, or include support until such help becomes available were seen as important in supporting help-seeking behaviours. One participant emphasized this issue with the example of a young woman, who rang six private providers for mental health care, only to be told to call back in three months because of work load. The absence of support during such a long waiting period may diminish or even extinguish mental health help-seeking behaviours.
GPs who put effort into communicating well with their patients, especially those for whom English is not their first language, and make it easy for patients to request different medication or a different counselor if previous medication or therapy had not been beneficial, were seen as positive and encouraging of help-seeking responses. Confidence in complete confidentiality was seen by many participants as an important factor in promoting help-seeking and that this could be helped if patients/clients could access a counselor without attending a GP first.
Services that are easily accessed and focus on responding to patient/ clients’ immediate needs in an empathetic manner are appreciated by those experiencing mental health conditions. One participant emphasized that professionalism alone may not be enough and that respect and compassion are also required to encourage help-seeking:
It’s commendable to be very professional but… it’s also commendable to be compassionate. (ID 06)
This participant also recognized the stresses mental health professionals are under and expressed the view that they should be well supported in the work they do to adequately support help-seeking behaviours. Other participants emphasized the need for services to remain sensitive to clients at all times as this promotes help-seeking, commenting that one negative experience can inhibit help- seeking for a long time.
Health services that are organized to be locally available were seen as important to promote help-seeking responses. Comparison was made between services for a physical health problem at times being more readily available locally in rural areas than help for mental health issues.
Confidence in and knowledge about recommended services was seen as important in encouraging help-seeking. A participant reported the experience of a young woman who did not follow through on a mental health referral as her perception was that it would probably be staffed by:
Volunteers from the church. (ID 05)
It was also suggested by participants that counselors, whether social workers, psychologists or others do not always have an approach that is a good ‘fit’ with the client requirements.
It was as if they were working out of a textbook, and that practitioner just talked about her own problems. I might as well have been there talking to them. (ID 09)
The specific needs of members of the CALD community were noted by participants stressing the importance of taking time to listen to the person, hear his or her story, build up trust and understand the client’s culture.
Let him talk and then you have his background and what his religion is. (ID 03, 3c)
When those from a CALD background needed an interpreter, there was appreciation of those services that were able engage one, even if this slowed the consultation process.
Continuity of care is often seen as a valuable component of health care especially in primary care. It was identified by participants as valuable in supporting help-seeking behaviours noting the associated confidence and trust that often develops. Patients with mental health problems may find they have a long wait to see a familiar and trusted GP, especially if that GP works part-time. This situation was felt to be particularly difficult for those experiencing social disadvantage, especially homelessness.
One of the advantages of continuity of care is that it removes the necessity to tell one’s story again and again. One volunteer carer stated that she has observed that:
A person in great distress finds it very difficult to continue to answer lots of questions. (ID 06)
This participant, who has been a volunteer for many years, further observed that a good case worker in the mental health system can make a positive difference:
To have a case worker that builds up a connection, has good rapport,….a good relationship with the client and checks up on that client……..Checks up on their living conditions and are they eating? Are they socializing? It’s a very big job to do that but you can be saving someone’s life by doing that. ID 06)
Promoting health system structures that facilitate continuity of care may support positive help-seeking responses.
Out of pocket costs at the point of health service provision was seen as a barrier to help-seeking and the absence of such costs as an enabler. Participants commented that medical clinics that do not charge the patient directly were seen to greatly support help-seeking responses by those experiencing mental health difficulties. Participants noted that such ‘free clinics’ are limited, especially in rural areas, (including the region where this research was undertaken). Addressing this identified financial barrier and for many rural patients the barrier of travel distance and cost was seen as important in supporting help-seeking behaviours.
The research supports the view that initiatives to promote mental health literacy may promote help-seeking behaviours for mental ill health. The role of national initiatives to promoter mental health literacy, such as those undertaken in Australia by Beyondblue, was recognized, with professional carers reporting that efforts to promote understanding of high prevalence disorders of depression and anxiety have been beneficial. The need to promote similar understanding of low prevalence disorders as a way to promote help-seeking behaviours was also identified. Similarly, the training program Mental Health First Aid was described as helpful, with participants reporting the development of empowerment to recognize and respond to mental illhealth. Increasing the number of those in the community with mental health awareness is seen as a valuable support to others seeking help for mental health concerns.
The Australian Government Better Access program was felt by participants to promote easier access to mental health assistance, providing an avenue for help-seeking responses. The approach to mental health care provision in this program was viewed positively because it provided choice to people and supported local primary care based counseling. The large uptake of community psychological treatment provider under the Better Access program , suggests this approach is meeting a need for ready access to local community based services. It may also be that the wide positive community response to the Better Access initiatives could in part have resulted from changed attitudes to mental health as promoted by Beyondblue, Mental Health First Aid and similar initiatives. Participants felt there was less stigma and wider acceptance of mental illness than in the past possibly reducing reluctance to access help. It has been suggested that future research on the effectiveness of mental health literacy initiatives include promotion of help-seeking behaviours as a component of such research .
Strengthening and expanding support for homeless people with a mental illness through government initiatives such as supported accommodation programs was identified as likely to be beneficial in supporting help-seeking behaviours for mental ill-health as was the need for adequate funding, integration and coordination of services to achieve a significant impact .
In addition to wider government initiatives this research suggests that local mental health initiatives, planned with insight into local demographics and responding to the needs of local communities can be well received and assist help-seeking behaviours. This research also supports the view that CALD communities are not homogenous and that professionals can best provide mental health care and promote help-seeking behaviours by modify their practice to respond appropriately to individuals and groups within their community.
Having an understanding of mental health is only one part of the equation. Another part is being aware of available services and how to access them if help-seeking behaviours are to be facilitated. The perception of there being a ‘maze of services’, as referred to by one participant illustrates the need to make available services visible and ways to access them understandable if help-seeking behaviours are to be encouraged. Social media may have a role in promoting mental health with associated facilitation of help –seeking responses.
This research highlights a potential conflict in providing readily accessible local mental health services to small communities. This may be helpful by reducing travel and transport costs but may result in helpseeking responses being very visible, an ongoing issue even though progress is being made to reduce stigma. Related to the barrier of stigma, is that of having access to no cost counseling, without having to go through a GP for referral. This finding of the research is supported by the work of Boyd et al. who found in a study of rural adolescents’ experiences of accessing psychological help that most would prefer to access counseling without the need to see a GP first [21,22].
Ensuring that services provided by GPs and other mental health professionals are free at the point of service is likely to be a positive incentive to help-seeking actions. Continuity of care, especially when an established trust relationship exists with a GP or other health professional, was identified as important to support help-seeking as was being able to spend time with their GP to discuss mental health and sensitive emotional issues. A positive relationship with a supportive health professional is a valuable promoter of help-seeking behaviours.
The number of participants in this study was relatively small but as indicated above, a number of participants had worked for many years with considerable numbers of patients/clients who had experienced mental health issues, bringing to the research a broad depth of knowledge and experience. Recruitment may have resulted in some participants being more aware of the mental health care system than the wider community. The findings should not be regarded as definitive but as contributing to debate and further research in addressing barriers to and enablers of help seeking behaviour for mental health difficulties amongst those living in a rural setting.
This research identified both previously identified barriers and a number of enablers that may support help-seeking behaviours for mental health issues. These identified enablers include improved mental health literacy, local and national initiatives that facilitate access to mental health care, readily accessible information on services, supportive clinician and health service approaches, continuity of care and free health care at point of service delivery.
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