Organization of Mental Health Services in Rural Areas
A large proportion of people live in rural areas of the world especially in the low- to middle-income countries. The services for mental disorders of rural population remain poor even in high-income countries. The treatment gap for mental illness is about 80% in low-income countries and perhaps even worse for rural people. The reasons of treatment gap are complex. Mental health is often given low priority despite constituting nearly one fifth of the overall health morbidity. Low investment in mental health leads to limited mental health resources available to the country’s health service. In low- to middle-income countries, these are concentrated in the cities, depriving rural communities of any specialist mental health services. Stigma, discrimination, poor literacy, and specific cultural belief toward mental illness restrict rural people to accept and access appropriate help.
Integration of mental health at primary care level is the only way forward to address this unmet need. Primary care health workers, however, lack in knowledge and skills to detect and manage mental disorders. The World Health Organization has come up with an ambitious mhGAP initiative to train primary care workers using its intervention guidelines. Recent mental health programs (PRIME) involving primary care workers and local organizations have shown some benefits as well as highlighted challenges in organizing services especially in low-income countries to serve predominant rural communities.
Organizing services for people in the rural areas needs to involve local people by understanding their views and perception of mental disorders, an extensive public health education program addressing the issues of stigma and discrimination existing toward mental illness, investing in adequate mental health resources, but more importantly integrating mental health with general health. This can be achieved by training frontline health workers in diagnosing and managing mental disorders supported by specialists. Modern technology and tools using mobile- and computer-assisted methods could greatly assist frontline workers if well supported by telemedicine approaches by mental health specialists.
KeywordsRural mental health Mental health services Global health Mental health services Mental health
Nearly half (46%) of the world’s population still resides in rural areas. The proportion of the rural population is lower (18–25%) in high-income (developed) countries such as North America and Europe and significantly higher in middle- (50%) and low-income countries (69%) as reported by World Bank data (World Bank 2015).
Mental health services available to people living in rural areas are generally inadequate. Lack of specialist resources available to this population especially in low- to middle-income countries is often blamed for the poor mental health service provision. However, a number of other equally important factors contribute to poor services for this population. Rural communities’ stigma-based views toward mental illness and their understanding of causes and remedies of mental illness influenced by their cultural beliefs in many developing countries may have led to poor acceptance or even rejection of the Western ways of treating mental health problems. A planning of a comprehensive mental service provision to rural communities requires a deeper understanding of their needs, beliefs, and attitudes toward mental illness as well as a good deal of knowledge of existing ways and resources they routinely use in dealing with them.
Rural areas differ significantly from country to country and from one continent to the other. A single global model of services for rural areas will therefore not only be difficult to propose but equally be unwise to implement. A need-based, tailor-made service model for different rural communities will therefore be more advisable.
A general framework of mental health services addressing the needs and ways to address them can be proposed. But that should be modified and adapted from region to region depending on their circumstances.
This chapter outlines the existing mental services available to rural areas around the world and attempts to identify gaps in services and ways to organize services for rural communities.
What Is the Mental Health Service Provision in Rural Areas at Present?
Mental health services are less than satisfactory in rural areas even in the most prosperous country in the world (Wang et al. 2005). Carpenter-Song and Snell-Rood (2016) reported a high rate of depression and suicide in rural communities without adequate care and treatment as compared to their urban counterparts. Substance misuse problems are now equally prevalent. Most people with mental health difficulties seek help from their primary care doctors who have insufficient training in mental health. Those who have more severe problems such as psychosis that require specialists’ services or inpatient care have to travel long distances (Gamm et al. 2010).
Limited resource to provide mental health services in Latin American countries has led to 70% treatment gap for mental disorders in these countries (Epstein 2017). This is even more so for rural and remote areas. In 1990, Pan American Health Organization (PAHO) outlined proposals for improving mental health services in the region under Caracas Declaration. The document emphasized on providing comprehensive and participatory community mental health services, taking account of human rights issues. Latin American countries have taken some steps in setting up necessary policies and strategies for delivering comprehensive mental health services to their communities, but just about a third of these countries have partially implemented such policies (PAHO 2016). Rural and remote areas are still deprived of adequate mental health services.
Rural communities in Europe are generally considered well off and less prone to mental health problems. A UK-based public health research (Riva et al. 2011) supports this view that the life expectancy and general well-being including mental health are better compared to urban dwellers. Another research report from Northern Ireland (Donaghy 2012) however paints a different picture. In the Northern Irish SWARD region, people living in rural areas had poor mental health and poor access to services, higher self-harm, and negative views toward mental illness. Changing economic realities have put a considerable financial pressure on farming communities. Media, as a result, routinely highlight a frequent and high suicide acts among European farmers.
China and India are the most populated countries in the world and have over half of their population still living in rural areas. Poverty, lack of mental health resources for rural communities, distances from mental health facilities, and stigma toward mental illness are the main barriers of mental health service provision for rural people. In rural China, primary care health professionals are the only people who can take care of their mental health, but they are ill equipped to deal with mental health problems due to their poor training in mental health (Ma et al. 2015). In India, despite of the government’s District Mental Health Programme and Rural Health Mission, mental health of rural communities remains a neglected area (Kumar 2011; Sharma 2015). A high suicide rate by Indian farmers is well recognized. Financial debt, lack of adequate health care, and poor support system are the main reasons for farmers’ suicide (Behere and Behere 2008).
Rural population in the African region is poorly served by mental health services, the main reason being that the limited mental health specialists either leave the region or settle in cities. Attempts have been made to integrate mental health services in primary care by training the frontline health workers in mental health (Jenkins et al. 2010). Poor literacy and specific cultural beliefs toward mental disorders and their treatments are other challenging issues in planning services for rural communities. Negative attitude toward mental illness with a feeling of shame, cultural belief that mental illness is caused by bad deeds, long distance travel for treatment, and poor financial resources are found as main barriers in one of the Nigerian studies (Jack-Ide and Uys 2013).
Indigenous population reside largely in rural Australia and poorly served by mental health services. There is a substantial high rate (twice compared to urban population) of suicide among young men in this population (National Rural Health Alliance 2017). Most specialists live in cities. A high suicide rate among farmers in New Zealand led to the study commissioned by Farmsafe (Walker 2012) and highlighted the stressors encountered by rural communities particularly farm and dairy workers and their families.
Major Gaps in Service Provision and Their Reasons
A broad evaluation of mental health services for the people living in rural areas in different parts of the world gives rise to some common themes responsible for the poor mental health services to their communities. These are outlined in the following section.
A Low Priority Given to Mental Health
Mental health generally receives lower priority in the overall health spending despite the fact that mental health constitutes a substantial proportion (20%) of overall health morbidity in any population. This is even worse for rural communities especially of low- (Monteiro et al. 2014) and middle-income countries, where a large proportion (over half) of people live in rural areas. Lack of governments’ sustainable initiatives and programs on rural mental health leads to poor distribution of mental health-related resources and somewhat demoralization in health workers who are keen to provide services for mentally ill people.
Mental health professionals are very few for rural areas even in high-income countries. They get scarce in low–middle-income countries and even worse in low-income countries. Figures produced by Mental Health Atlas (WHO 2015) show that whereas high-income countries spend around $57 per capita on mental health, the figures for low- to middle-income countries are below $2 per person per year and most of that is spent on inpatient facilities. Rural communities of low–middle-income countries are therefore left with hardly any mental health resource. The number of psychiatrists in high-income countries is over 7 per 100,000, whereas in low–middle-income countries, their number is less than 0.4 per 100,000, and some places have just one or two psychiatrists for the whole country. Distribution of these meager resources in low–middle-income countries is limited to cities, leaving rural population with hardly any specialist resource.
As outlined above, rural population has no local mental health facilities. Travelling to cities to seek help for mental health problems is inconvenient and expensive. Accessibility to mental health services by rural population remains a problem even in high-income countries as there are very few specialists in rural counties (Gamm et al. 2010) and primary care physicians have little skill and knowledge needed to manage mental health problems. This is a huge problem for rural dwellers of low-income countries where distances are greater, transport facilities are poor, and affordability is very limited.
Social Attitudes and Acceptability of Services
Rural communities still have their shared cultural beliefs and misconceptions toward behavior resulting from mental illness as being caused by supernatural causes or bad spirits (Ngui et al. 2010). Poor literacy largely plays an important part in such deeply held beliefs. They often seek help from faith healers. People with mental illness are stigmatized believing they are being possessed by evil spirits (Mohit 2001). As a result they avoid getting help from mental health specialists even if that help is made available.
Lack of Mental Health Knowledge and Skills Among Frontline Health Workers
Health workers and primary care doctors serving rural communities are not equipped to identify and manage mental disorders (Sharma and Copeland 2009). Inadequate training on mental health is well recognized by the WHO and considered as an important reason for treatment gap for mental disorders (WHO 2010, 2016).
How to Organize Mental Health Services for Rural Areas
A proper planning of mental health services for people living in rural areas needs a multipronged approach. A thorough understanding of the population’s needs is crucial for such planning. Thornicroft, Deb, and Henderson (2016) outlined that community mental health services should take account of socioeconomic context, individual- and population-based preventative approach, open and easy access, team-based approach, long-term and sustainable approach, and the cost-effectiveness of the services provided. The services should focus on strengths and aspirations of people with a focus on recovery and fulfillment (Jacobson and Greenley 2001), should strengthen from family to communities and organizations’ support, and should apply evidence-based interventions with genuine involvement of people. The Mental Health Action Plan 2013–2020 (WHO 2013) set out its objectives for most countries around the world to implement in their service organisation. These objectives are: (1) effective leadership and good governance in providing community-focused mental health services; (2) comprehensive, integrated, and responsive mental health and social care in the communities; (3) implementing mental health promotion and prevention strategies; and (4) developing and strengthening integrated information systems to gather evidence and carry out applied research in collaboration with academic institutes. organization.
Community Involvement: Users, Families, and Village Leaders
A broad understanding of rural communities’ mental health needs is only possible by speaking to people, families, and key community leaders to find out what they know about mental health problems, their causes, and remedies. This knowledge would be valuable to develop appropriate public educational programs for mental health. Community involvement in organizing health services is a widely recommended essential approach (WHO 2001, WHO 2013, Thornicroft et al. 2016). User involvement is well advanced in the Western world and has made a real impact on effective service development (Simpson and House 2002).
Public Policies and Education About Mental Health
UK government’s policy and strategy on “No health without mental health” (Department of Health 2011) has really taken a lead in making mental health a mainstream health issue. It sets out ambitious goal to consider mental health at parity with general health and emphasize on integrated approach of care for better health outcome. This approach is relevant to all countries, rich or poor, even more so where large proportion of population lives in rural areas.
Everyone in the communities should be made aware of mental ill health and its impact of peoples’ lives. Teachers at school, employers at workplace, police, families, friends, and relatives in social interactions often notice change in people’s behavior, performance, etc. Having some understanding through mental health public education that mental ill health may be attributable to the change of behavior can prompt them to get the right help at the earliest opportunity.
There should therefore be tailor-made public mental health education programs as a part of government’s initiative by involving communities in formulating and delivering it. With advancing technology now available to rural people, media including social media could be used for this purpose. Public health education program should also address the issue of stigma and discrimination and misconceptions associated with mental disorders. A simple message should be effectively conveyed to people that mental illness is a health issue and people with timely and right care and treatment recover and function well.
Integrating Mental Health with Primary Care: Upskilling Existing Workers: Training and Education
Integrating mental health in general health at primary care level is the only solution to meet the mental health needs of population, especially that of the rural communities around the world. The World Health Organization (WHO 2010, 2016) in the Mental Health Gap Action Programme (mhGAP) highlighted that four out of five people with mental disorders in low–middle-income countries fail to receive treatment for their mental conditions. This proportion is even higher for rural communities in low-income countries which form nearly one third of the world’s population. As a result, training of frontline health workers in mental health so that they can identify, diagnose, and manage mental health problems of rural people themselves as far as possible is the only answer. The mhGAP therefore has provided intervention guidelines (mhGAP-IG, WHO 2017) for nonmental health workers on identifying and managing priority conditions such as depression, psychosis, bipolar disorders, epilepsy, developmental and behavioral disorders in children and adolescents, dementia, substance misuse, self-harm, and other emotionally or medically unexplained complaints. Lund et al. (2012, 2016) developed a program to reduce treatment gap for mental disorders (PRIME) for low–middle-income countries and a detailed evaluation process. The program incorporates mhGAP-IG aimed at upskilling health workers. The PRIME package targeted community level (frontline workers), health-care facility level (health center), and organizational level (district health administration). Initial PRIME field trials in five countries, Ethiopia (Fekadu et al. 2016), India (Shidhaye et al. 2016), Nepal (Jordans et al. 2016), South Africa (Petersen et al. 2016), and Uganda (Kigozi et al. 2016), have shown some promising findings. Three of the five trials (India, Nepal, and Ethiopia) included mostly rural population. These studies identified various challenges of integrating mental health in primary care level. A sufficient length of mental health training, ongoing support from specialist, making medicines, and other resources available at primary care level are some of them.
The author of this chapter has long-standing interest in integrating mental health services in primary care (Sharma 2015) and in developing mental health assessment tools suitable for primary care, the Global Mental Health Assessment Tool (GMHAT) (Sharma and Copeland 2009). The primary care version-GMHAT/PC is a semi-structured, computer-assisted clinical assessment tool that is developed to assist health workers in making quick, convenient, and comprehensive standardized mental health assessments in both primary and general health care. The assessment program starts with basic instructions giving details of how to use the tool and rate the symptoms. The first two screens help in getting brief background details including present, past, personal, and social history including trauma, epilepsy, and learning disorder. The following screens consist of a series of questions leading to a comprehensive yet quick mental state assessment. They start with two screening questions about every major symptom complex followed by additional questions only if the screening questions are answered positively. The series of questions cover the following symptom areas: worries; anxiety and panic attacks; concentration; depressed mood, including suicidal risk; sleep, appetite, and eating disorders; hypochondriasis; obsessions and compulsions; phobia; mania; psychotic symptoms; disorientation; memory impairment; alcohol misuse; illegal drug misuse; personality problems; and stressors. The questions proceed in a clinical order along a tree branch structure. The GMHAT/PC has been widely tested and now being tried to detect and manage mental disorders in primary and general health settings in English, Hindi, Arabic, and Spanish (Sharma et al. 2004, 2008, 2010, 2013b; Krishna et al. 2009; Tejada et al. 2016). Further translations in various languages are in progress. The GMHAT team has also developed a 2- to 3-day mental health training program for frontline workers to provide knowledge and skills to identify, diagnose, and manage mental disorders at primary care level. The findings of field trials are promising and detailed in a book recently published by Indian Psychiatry Society (Behere et al. 2017). GMHAT/PC may prove to be a very useful clinical tool for frontline health workers in association with mhGAP-IG.
Making Treatments and Support Available at Community Level
All recent PRIME field studies’ findings (Lund et al. 2016) highlighted that poor supply of medicines particularly in rural areas caused problems in treating people with mental illness. A need of ongoing support from mental health specialists was also considered necessary. These matters require a strong commitment at a higher governmental level.
Using Technology in Diagnosing and Managing Mental Health Problems
Technology such as mobile phones and tablets is increasingly getting affordable to people of even low-income countries. The mobile network is now available in the remote areas of these countries. It is therefore necessary to explore the ways to reach out to people living in rural and remote areas using smartphones and computers. Health workers following training may use tools such as GMHAT/PC that is now available in android app and can easily be used for mental health assessment using android phone.
Advancement of telemedicine is very promising. People from remote areas can easily communicate with specialists from any part of the world (Rathod et al. 2017). The governments should invest in technology to maximize the health-care benefits for rural and remote population.
Maximize Efficiency of Specialists: Supporting Roles Than Just Service Provider Role
The number of specialists in mental health available in low–middle-income countries and even in high-income countries such as the USA and Australia for rural population will always be insufficient in number to provide direct mental health care to sufferers. Frontline workers who provide general health care will be best suited to serve rural population for their mental health needs. Mental health specialists therefore have to take more and more roles of providing training and education on mental health and support them in managing people with mental health problems of rural areas. This should be a part of health strategy and policy of the country and not merely a voluntary gesture on specialist’s part.
Human Rights and Legislation
In the twenty-first century, it is heartbreaking to see the neglect and mistreatment of people with severe mental illness in some rural communities. Patients’ human rights are often ignored and treated without much respect or dignity (Ngui et al. 2010). It is important that in organizing and planning mental health services for the rural communities, patients’ human rights issues are duly considered and health workers are trained in treating patients with mental illness and their relatives with respect and dignity. Mental health sufferers’ rights should also be protected by appropriate legal framework. In a recent Lancet communication, Patel et al. (2016) highlighted that despite of high-level initiatives taken by Lancet in 2007 (Patel et al. 2008) with a follow-up in 2012 (Patel et al. 2011) and by WHO (2013) in its Mental Health Action Plan 2013–2020, people with mental illness are still deprived of their right to receive evidence-based treatment as well as that of their basic human rights mostly in low-income countries with a large rural population.
People who live in rural areas deserve good-quality services for their mental health problems. Skilling frontline workers and primary care physicians in treating people with respect and dignity, diagnosing correctly their mental illness, and providing them with evidence-based treatments and care is the only way forward. This can be achieved by investing in mental health by developing fit-for-purpose strategies at government level, providing effective public mental health education, mobilizing health work force, and integrating mental health in general health. Modern technology and mobile- and computer-assisted tools and programs can further assist in this mission.
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