What Is Rural Adversity, How Does It Affect Wellbeing and What Are the Implications for Action?

Patterns of service provision in child and adolescent mental health care in Australia

Standard description of local care provision is essential for evidence-informed planning. This study aimed to map and compare the availability and diversity of current mental health service provision for children and adolescents in Australia. We used a standardised service classification instrument, the Description and Evaluation of Services and DirectoriEs (DESDE) tool, to describe service availability in eight urban and two rural health districts in Australia. The pattern of care was compared with that available for other age groups in Australia. Outpatient care was found to be the most common type of service provision, comprising 212 (81.2%) of all services identified. Hospital care (acute and non-acute) was more available in urban than in rural areas (20 services [9.7%] vs 1 [1.8%]). The level of diversity in the types of care available for children and adolescents was lower than that for the general adult population, but slightly higher than that for older people in the same areas. Standardised comparison of the pattern of care across regions reduces ambiguity in service description and classification, enables gap analysis and can inform policy and planning.

Characteristics and outcomes of emergency department presentations brought in by police with and without an emergency examination authority: A state-wide cohort study

BACKGROUND

The aim of this study was to describe and compare the demographic characteristics, clinical characteristics and patient and health service outcomes of emergency department (ED) presentations brought in by police with and without an emergency examination authority.

METHODS

A retrospective cohort study of adult (≥ 18 years old) presentations brought in by police to EDs in Queensland, Australia from 01 January 2018 to 31 December 2020. Routinely collected ED data were used to describe and compare the demographic characteristics, clinical characteristics, and outcomes of people brought in by police with and without an emergency examination authority.

RESULTS

A total of 42 502 adult ED presentations were brought in by police over the three-year period, of which 22 981 (44.7%) had an emergency examination authority. Compared with presentations brought in by police without an emergency examination authority, those brought in by police with an emergency examination authority had a higher proportion of presentations for mental health problems, were from major cities, and were allocated more urgent Australasian Triage Scale categories. Presentations brought in by police with an emergency examination authority were less likely to be seen within their Australasian Triage Scale timeframe and experienced a longer length of stay than those brought in by police without an emergency examination authority whether admitted (217 mins vs. 186 mins, p < 0.001) or discharged (212 mins vs. 97 mins, p < 0.001).

CONCLUSIONS

The characteristics and outcomes of people brought in by police with emergency examination authorities differed to those brought in by police without emergency examination authorities. Further research is required to enhance understanding of this relatively unexplored group of people and foster interagency collaborations.

Co-creating community wellbeing initiatives: what is the evidence and how do they work?

BACKGROUND

Addressing wellbeing at the community level, using a public health approach may build wellbeing and protective factors for all. A collaborative, community-owned approach can bring together experience, networks, local knowledge, and other resources to form a locally-driven, place-based initiative that can address complex issues effectively. Research on community empowerment, coalition functioning, health interventions and the use of local data provide evidence about what can be achieved in communities. There is less understanding about how communities can collaborate to bring about change, especially for mental health and wellbeing.

METHOD

A comprehensive literature search was undertaken to identify community wellbeing initiatives that address mental health. After screening 8,972 titles, 745 abstracts and 188 full-texts, 12 exemplar initiatives were identified (39 related papers).

RESULTS

Eight key principles allowed these initiatives to become established and operate successfully. These principles related to implementation and outcome lessons that allowed these initiatives to contribute to the goal of increasing community mental health and wellbeing. A framework for community wellbeing initiatives addressing principles, development, implementation and sustainability was derived from this analysis, with processes mapped therein.

CONCLUSION

This framework provides evidence for communities seeking to address community wellbeing and avoid the pitfalls experienced by many well-meaning but short-lived initiatives.

A qualitative exploration of online forums to support resilience of rural young people in Australia

Introduction

Prevention and early intervention are crucial strategies for improving young people's mental health and well-being. Building resilience is a key component of these strategies, especially among young individuals in rural areas who face well-documented mental health disparities. This study aimed to investigate how online mental health forums can contribute to enhancing individual resilience in young rural users.

Methods

A sample of forum posts (n = 1,000) made by Australian rural users (18-25 years) on an online peer support mental health forum were qualitatively analyzed. The analysis was guided by themes derived from the literature on indicators of rural resilience.

Results

Analysis of forum posts showed evidence of rural resilience in forum users. Online peer support forums offered a virtual space for individuals to establish social connections, experience a sense of belonging, share information, acquire knowledge, and offer mutual support. There were indications of increased self-efficacy among forum users, as they demonstrated their ability to implement strategies for better managing their mental health.

Discussion

These findings significantly contribute to our understanding of how online forums can enhance resilience factors that are beneficial for young people living in rural communities. In the context of prevention and early intervention, this study illustrates the intricate connections between forum design and user activity with resilience outcomes, providing valuable insights into the underlying causal mechanisms. Consequently, it emphasizes the importance of incorporating such digital interventions as integral components of mental health service ecosystems.

The Role of Resilience in the Impact of Family Economic Adversity on Youth Emotional Distress over Time

Previous research has highlighted the enduring negative impact of family economic adversity on youth emotional well-being. However, the longitudinal mechanism underlying the link between economic adversity and emotional distress is less explored. The present study examined the longitudinal pathway of parent economic adversity, and parent and adolescent emotional distress at age 16, parental support at age 21, youth self-esteem and mastery at age 23, and adult emotional distress at age 27. Data came from the Family Transitions Project (N = 441, 57% female), a 30-year study of families from the rural Midwest. Structural equation models revealed that economic adversity exerted a long-term negative influence on adult emotional well-being through parent and adolescent emotional distress and youth self-esteem and mastery. Additionally, parental support was associated with adult emotional distress through youth self-esteem and mastery. The current study advances our understanding of youth emotional well-being by suggesting a longitudinal family process and resilience pathways from adolescence to early adulthood.

Western Australia remote aeromedical substance use disorders outcomes

INTRODUCTION

Substance use disorders (SUDs) cause significant harm to regional Australians, who are more likely to misuse alcohol and other drugs (AODs) and encounter difficulty in accessing treatment services. The primary aims of this study were to describe the demographics of patients aeromedically retrieved from regional locations and compare hospital outcomes with a metropolitan-based cohort.

AIMS

Retrospective case-controlled cohort study. Participants were aeromedically retrieved within Western Australia for SUDs between 1 July 2014 and 30 June 2019. Retrieved patients were case-matched based on age and hospital discharge diagnosis. Descriptive statistics and χ2 analysis were used to summarise the findings.

RESULTS

One hundred thirty-six (91.3%) aeromedical retrievals were found, with the majority being male (n = 95; 69.9%). These were case-matched to 427 metropolitan patients, the majority male (n = 321; 75.2%). Retrieved patients were more likely (all P < 0.05) Indigenous (odds ratio [OR], 9.35 [95% confidence interval (CI), 5.96-14.85]), unemployed (OR, 2.9 [95% CI, 1.41-6.80]), referred to a tertiary hospital (OR, 2.18 [95% CI, 1.24-3.86]) and to stay longer in hospital (OR, 1.08 [95% CI, 1.02-1.14]).

DISCUSSION

Findings highlight that unmarried and/or unemployed males were overrepresented in the retrieval group, with over half identifying as Indigenous. Regional variation in retrievals was noted, while amphetamine-type stimulants featured prominently in the retrieval cohort, who experienced longer hospital stays and more restrictive treatment.

CONCLUSIONS

Comparing clinical outcomes for retrieved regional patients experiencing SUDs, service design and delivery should focus on offering culturally safe care for Indigenous people, catering for regional health care catchment areas, while ideally adopting collaborative and integrated approaches between AODs and mental health services.

Online Mental Health Forums and Rural Resilience: Mixed Methods Study and Logic Model

BACKGROUND

Rural mental health is a growing area of concern internationally, and online mental health forums offer a potential response to addressing service gaps in rural communities.

OBJECTIVE

The objective of this study was to explore and identify pathways by which online peer support mental health forums help to build resilience for rural residents experiencing mental ill-health by contributing to overcoming their specific contextual challenges.

METHODS

We developed a Theoretical Resilience Framework and applied it to 3000 qualitative posts from 3 Australian online mental health forums and to data from 30 interviews with rural forum users.

RESULTS

Drawing on the findings and an abductive approach, a logic model was developed to illustrate links between the resilience resources built and enabling features of forums that make them spaces that facilitate resilience.

CONCLUSIONS

The study demonstrated that online forums make valuable contributions to social well-being and access to a range of timely support services for rural people experiencing mental ill-health, and, while doing so, involve users in the processes of resilience building. The study provides a new way for practitioners to frame the work of and value produced by forums. It gives a logic model that can be used in evaluation and audit as it facilitates a causal framing of how forums, as an intervention, link with resilience outcomes. Ultimately, the study contributes to developing new knowledge about how rural resilience building can be conceptualized and measured while showing how forums are part of contemporary health service provision in rural places.

Prevalence and factors associated with mental health problems of psychological distress and depression among rural Victorians - analysis of cross-sectional data (Crossroads II)

BACKGROUND

Research suggests that rates of mental illness are similar in rural and urban Australia, although there are significant workforce shortages in rural regions along with higher rates of chronic disease and obesity and lower levels of socioeconomic status. However, there are variations across rural Australia and limited local data on mental health prevalence, risk, service use and protective factors. This study describes the prevalence of self-reported mental health problems of psychological distress and depression, in a rural region in Australia and aims to identify the factors associated with these problems.

METHODS

The Crossroads II study was a large-scale cross-sectional study undertaken in the Goulburn Valley region of Victoria, Australia in 2016-18. Data were collected from randomly selected households across four rural and regional towns and then screening clinics from individuals from these households. The main outcome measures were self-reported mental health problems of psychological distress assessed by the Kessler 10 and depression assessed by Patient Health Questionnaire-9. Unadjusted odd ratios and 95% confidence intervals of factors associated with the two mental health problems were calculated using simple logistic regression with multiple logistic regression using hierarchical modelling to adjust for the potential confounders.

RESULTS

Of the 741 adult participants (55.6% females), 67.4% were aged ≥ 55 years. Based on the questionnaires, 16.2% and 13.6% had threshold-level psychological distress and depression, respectively. Of those with threshold-level K-10 scores, 19.0% and 10.5% had seen a psychologist or a psychiatrist respectively while 24.2% and 9.5% of those experiencing depression had seen a psychologist or a psychiatrist, respectively in the past year. Factors such as being unmarried, current smoker, obesity, were significantly associated with a higher prevalence of mental health problems whereas physical activity, and community participation reduced the risk of mental health problems. Compared to rural towns, the regional town had higher risk of depression which was non-significant after adjusting for community participation and health conditions.

CONCLUSIONS

The high prevalence of psychological distress and depression in this rural population was consistent with other rural studies. Personal and lifestyle factors were more relevant to mental health problems than degree of rurality in Victoria. Targeted lifestyle interventions could assist in reducing mental illness risk and preventing further distress.

Developing fit-for-purpose funding models for rural settings: Lessons from the evaluation of a step-up/step-down service in regional Australia

INTRODUCTION

Sub-acute mental health community services provide a bridging service between hospital and community care. There is limited understanding of the local factors that influence success, and of the funding implications of delivering services in rural areas.

METHODS

This paper draws from quantitative and qualitative evaluation data from a regional Western Australian service to explore these issues.

RESULTS

Consumers satisfaction with the service was high and, overall, admission to the service resulted in positive outcomes. High re-admission rates may be linked to limited community support services following discharge.

DISCUSSION

Our results suggest that outcomes may be enhanced by implementing flexible approaches that address the resource limitations of the rural context, and that the current funding model for sub-acute mental health services in rural Australian may not be fit for purpose. More needs to be understood about how these services can be better integrated with existing support services, and how they can be better funded.

Higher hospitalization and mortality rates among SARS-CoV-2-infected persons in rural America

PURPOSE

Rural communities are among the most underserved and resource-scarce populations in the United States. However, there are limited data on COVID-19 outcomes in rural America. This study aims to compare hospitalization rates and inpatient mortality among SARS-CoV-2-infected persons stratified by residential rurality.

METHODS

This retrospective cohort study from the National COVID Cohort Collaborative (N3C) assesses 1,033,229 patients from 44 US hospital systems diagnosed with SARS-CoV-2 infection between January 2020 and June 2021. Primary outcomes were hospitalization and all-cause inpatient mortality. Secondary outcomes were utilization of supplemental oxygen, invasive mechanical ventilation, vasopressor support, extracorporeal membrane oxygenation, and incidence of major adverse cardiovascular events or hospital readmission. The analytic approach estimates 90-day survival in hospitalized patients and associations between rurality, hospitalization, and inpatient adverse events while controlling for major risk factors using Kaplan-Meier survival estimates and mixed-effects logistic regression.

FINDINGS

Of 1,033,229 diagnosed COVID-19 patients included, 186,882 required hospitalization. After adjusting for demographic differences and comorbidities, urban-adjacent and nonurban-adjacent rural dwellers with COVID-19 were more likely to be hospitalized (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI], 1.16-1.21 and aOR 1.29, CI 1.24-1.1.34) and to die or be transferred to hospice (aOR 1.36, CI 1.29-1.43 and 1.37, CI 1.26-1.50), respectively. All secondary outcomes were more likely among rural patients.

CONCLUSIONS

Hospitalization, inpatient mortality, and other adverse outcomes are higher among rural persons with COVID-19, even after adjusting for demographic differences and comorbidities. Further research is needed to understand the factors that drive health disparities in rural populations.

Producer practices and attitudes: Non-replacement male calf management in the Australian dairy industry

Currently, there is no standardized rearing method or production guidelines for non-replacement male dairy calves that maximizes their economic viability. Producers have highlighted the need to match consumer expectations, but even with broadscale welfare improvement across the dairy industry, challenges remain at providing reliable and valuable pathways for non-replacement male dairy calves for beef production. A key consumer concern has been the use of on-farm euthanasia. Euthanasia has been a catalyst for change in the industry from a human and animal welfare perspective. The practice of euthanasia can lead to a decline in personnel wellbeing. To investigate the relationship between on-farm management practices of non-replacement male dairy calves and producer perceptions of their value proposition, an online questionnaire was provided to Australian dairy producers between June and October 2021. The aim was to identify supply-chain profitability of non-replacement male calves and investigate the attitudes and effects of euthanasia on producer wellbeing as part of managing these calves. A total of 127 useable responses were obtained, and a Bayesian network (BN) was utilized to model the interdependencies between management practices and wellbeing among participants. The results indicated that in general, dairy producers desired high welfare standards in their enterprises with regard to non-replacement male calves as well as expressed a desire to meet industry and consumers' expectations. In line with anecdotal reports of a reduction in practice, euthanasia was not identified as common practice in this group; however, producers were still accessing early-life markets for non-replacement male calves with operational requirements and environmental factors influencing their decisions. Producers expressed dissatisfaction with market access for their calves, as well as the lack of suitability of Australian beef grading standards for dairy-bred carcasses. Australian dairy managers and owners identified that euthanasia influenced employee wellbeing; however, they did not acknowledge euthanasia had an effect on their own wellbeing. Overall, the findings of this study indicate that all non-replacement male calf breeds had the potential to access profitable markets, and avoidance of euthanasia is a strong driver of change among dairy beef production systems in Australia.

A systematic review of geographical inequities for accessing clinical genomic and genetic services for non-cancer related rare disease

Place plays a significant role in our health. As genetic/genomic services evolve and are increasingly seen as mainstream, especially within the field of rare disease, it is important to ensure that where one lives does not impede access to genetic/genomic services. Our aim was to identify barriers and enablers of geographical equity in accessing clinical genomic or genetic services. We undertook a systematic review searching for articles relating to geographical access to genetic/genomic services for rare disease. Searching the databases Medline, EMBASE and PubMed returned 1803 papers. Screening led to the inclusion of 20 articles for data extraction. Using inductive thematic analysis, we identified four themes (i) Current service model design, (ii) Logistical issues facing clinicians and communities, (iii) Workforce capacity and capability and iv) Rural culture and consumer beliefs. Several themes were common to both rural and urban communities. However, many themes were exacerbated for rural populations due to a lack of clinician access to/relationships with genetic specialist staff, the need to provide more generalist services and a lack of genetic/genomic knowledge and skill. Additional barriers included long standing systemic service designs that are not fit for purpose due to historically ad hoc approaches to delivery of care. There were calls for needs assessments to clarify community needs. Enablers of geographically equitable care included the uptake of new innovative models of care and a call to raise both community and clinician knowledge and awareness to demystify the clinical offer from genetics/genomics services.

Improvement in Quality of Life through Self-Management of Mild Symptoms during the COVID-19 Pandemic: A Prospective Cohort Study

The COVID-19 pandemic has inhibited people's help-seeking behaviors (HSBs). In particular, older people in rural communities experienced limited access to medical care, which negatively affected their quality of life (QOL). Within HSB, self-management of mild symptoms may mitigate the difficulties experienced by older people in rural communities. However, few studies have examined the relationship between self-management and QOL. Therefore, we conducted a prospective cohort study to clarify this relationship. Our participants were over 65 years of age and lived in rural communities. QOL was measured with the EuroQol 5-Dimension 5-Level (EQ-5D-5L). Demographic data and QOL were collected from participants via questionnaires in 2021 and 2022. The exposure group showed a significantly greater change in EQ-5D-5L health status index scores than the control group (p = 0.002). In addition, the exposure group scored significantly lower than the control group on the EQ-5D-5L dimension "usual activities" in 2021 and on all dimensions in 2022. Thus, self-management of mild symptoms may improve QOL among older people in rural communities during the COVID-19 pandemic. Educational interventions for this population regarding self-management could improve QOL for entire communities.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

A Solution for Loneliness in Rural Populations: The Effects of Osekkai Conferences during the COVID-19 Pandemic

Social prescribing is an essential solution to the lack of social connection and interaction and provides a key approach to problems faced by communities during the COVID-19 pandemic. One social prescription used in Japan is the Osekkai conference, which has the potential to increase social participation in rural communities. The revitalization of Osekkai can improve social interactions among people involved in the conference, thereby reducing loneliness. This interventional study was conducted with people who participated in the Osekkai conference. The primary outcomes of the degree of loneliness were compared between 2021 and 2022 using the Japanese version of the three-item UCLA Loneliness Scale. The demographic data and process outcomes of participants were measured using a questionnaire. The participants’ roles in the Osekkai conference increased between the two periods. Loneliness scores tended to decrease during the study period (4.25 to 4.05, p = 0.099). In the questionnaire on loneliness, the scores for item 2 decreased significantly during the study period (1.36 to 1.25, p = 0.038). In conclusion, this study shows that the continual provision of Osekkai conferences as a social prescription may reduce the degree of loneliness among participants with improved social participation in rural communities. Future studies should investigate comparative interventions to show the effectiveness of social prescription on loneliness in communities.

Responding to rural adversity: a qualitative study of alcohol and other drug service users' experiences of service response to COVID-19 in Western Australia's Southwest

OBJECTIVE

This study reports on the impact of the COVID-19 pandemic on the lived experiences of people with substance use problems in accessing services in the Southwest region of Western Australia, and its implications for preparedness in a context of rural adversity.

METHOD

This was a qualitative study informed by the principles of phenomenology. Data were collected through semi-structured interviews and subjected to thematic analysis.

RESULTS

Twenty-two participants were interviewed. Two main themes were identified: disruption to supportive connections; and bridging the connection gap: local service response to the COVID-19 pandemic.

CONCLUSIONS

The COVID-19 pandemic restrictions exacerbated social isolation and mental health issues, and disrupted services and treatment in the Southwest. Our results demonstrate that local alcohol and other drug services in rural areas can successfully respond to crises by assertively and flexibly adapting their service provision.

Rethinking Accessibility in Light of the Orange Declaration: Applying a Socio-Ecological Lens to Rural Mental Health Commissioning

The prevalence of mental illness is a critical public health issue. In Australia, the prevalence of mental illness is similar across all settings, however, people living in rural and remote areas experience worse outcomes than their urban counterparts. Access to mental health services is critical, however, the notion of accessibility needs to be understood in the context of the uniqueness and variability of the rural experience. The Orange Declaration on Rural and Remote Mental Health recognized that rural areas face a series of interconnected challenges and called for place-specific responses and new funding models that reward collaboration and local partnerships. In this paper, we argue that recent mental health planning, policy and service development uses a narrow interpretation of the notion of accessibility that is out of step with current thinking on the heterogeneity of the rural experience. We use some examples of our own research and experience in rural Western Australia to argue that the current commissioning model is not aligned with the Orange Declaration, and remains largely metro-centric and reliant on a narrow conceptualization of service accessibility. We argue that what is needed is a dynamic, responsive, context-sensitive understanding of accessibility that is informed by the distinctiveness of rural adversity, and recognizes the heterogeneity and variability of the rural experience whilst acknowledging rural agency and social capital, and we suggest that applying a socio-ecological approach to the development of new commissioning models provides a way forward.

Community co-produced mental health initiatives in rural Australia: A scoping review

INTRODUCTION

Inaccessibility of mental health services in rural Australia is widely reported. Community co-produced mental health and well-being initiatives could fill gaps and complement other services.

OBJECTIVE

This scoping review summarises findings from peer-reviewed articles to identify the key features of co-produced Australian rural mental health initiatives that engage communities in their design, delivery or evaluation processes.

DESIGN

Between 2009 and 2019 inclusive, 14 articles met inclusion criteria and were reviewed using Arksey and O'Malley's review methodology.

FINDINGS

Communities co-produced initiatives through informing, collaborating and instigating them. Some initiatives operated in specific places, for example an art gallery, while others operated across regions. Only two initiatives involved community members in multiple activities targeting prevention, early intervention, education and service accessibility; other initiatives were more focused, for example designing a new service. Over half of initiatives found were targeted at Aboriginal and Torres Strait Islander Peoples. Most articles discussed evaluation approaches, though methods were diverse.

DISCUSSION

Published peer-reviewed evidence about Australian rural community co-produced mental health initiatives appears scant. Evidence found suggests they generate a range of supports that could complement or mitigate for lack of, public health services. The overall lack of evidence, diversity of initiatives and inconsistent evaluation makes it difficult to assess effectiveness and which activities might be scaled-up for wider benefit.

CONCLUSION

Rural communities have limited resources, and evidence of what constitutes best practice in co-producing mental health services would help to avoid 'reinventing the wheel.' Greater efforts in evaluating and publishing about initiatives would be helpful.

Responding to rural allied health workforce challenges in the public health system: Evaluation of the Allied Health Rural Generalist Pathway pilot in western New South Wales

OBJECTIVE

The Allied Health Rural Generalist Pathway pilot aimed to improve consistent access to physiotherapy services in rural communities using the "grow own" workforce strategy and existing resources.

DESIGN

A summative evaluation of the quality improvement project used to implement the Allied Health Rural Generalist Pathway was completed. A mixed method design was used and included focus groups and a framework analysis.

PARTICIPANTS

The temporary redesign of specific workforce resources created "development" positions. A shared same-discipline supervisor resource supported five early-career physiotherapists, the participants.

SETTING

The project was undertaken in rural New South Wales in the public health system.

MAIN OUTCOME MEASURES

The main outcome measures included a number of chronically vacant physiotherapy positions and stakeholder satisfaction.

RESULTS

Targeted vacancies were filled, services sustained with minimal service gaps and mean retention rate of 2.9 years. A statistically significant increase in service activity to patients in rural locations occurred as a result of the intervention (R-squared 29%, P < .05). Four out of five early career physiotherapists fulfilled terms of their contract and secured senior positions within the region. Whilst participants developed professionally, they did not complete the tertiary education component.

CONCLUSIONS

The Allied Health Rural Generalist multi-factorial approach supported recruitment, retention and capacity building within the targeted discipline of the allied health workforce. Patient need was met. The rural pipeline capacity was developed. The pathway was complementary of existing NSW Health systems. Systemic change is needed to overcome inefficiencies experienced during implementation and to ensure sustainability. Further research to develop discipline-specific clinical training guidance through the stages of a rural allied health professionals' career may be helpful.

Changes in the Comprehensiveness of Rural Medical Care for Older Japanese Patients during the COVID-19 Pandemic

Help-seeking behaviors (HSBs) refer to how people use lay and medical care to address their symptoms and diseases. The COVID-19 pandemic may have changed older, rural patients’ preferences and experiences regarding HSBs, thereby, affecting the comprehensiveness of medical support for communities. This study identified changes in the comprehensiveness of medical care for older, rural patients, who are often dependent on others for accessing medical services. This observational study was performed with patients who lived in Unnan City. Patients’ dependency and changes in comprehensiveness of medical services were assessed and calculated. The total usage of medical care decreased from 2018 to 2020 at all medical care levels. The proportion of patients who received comprehensive care was higher in 2020 than in 2018, at all care levels. At care dependent levels 3 to 5, the differences in the proportions were statistically significant. This study illustrates an association between the COVID-19 pandemic and the proportion of comprehensiveness of medical care among older rural patients with a decrease in medical care usage. Moreover, an improved proportion of comprehensiveness of medical care leads to appropriate HSBs. Going forward, HSBs and patient-centered care should be promoted by policy makers.

Fears Related to COVID-19 among Rural Older People in Japan

Coronavirus disease 2019 (COVID-19) has affected people’s social lives by inhibiting their movement; this seriously impacts the lives of older people in particular. Rural older people may have been particularly affected because they live dispersedly and in isolation. This study explored rural older people’s perceptions of how COVID-19 has impacted their social lives. This qualitative study assessed participants who were 65 years and older and residing in rural Japanese communities. Five focus group discussions were conducted with 53 participants to explore their perceptions and challenges during COVID-19. Data were analyzed using thematic analysis, and four themes were developed: the beginning of suffering, social cognitive suppression, reflection on rural contexts, and critical approaches to the pandemic based on rural standards. The daily activities of rural older people were suppressed due to social norms and pandemic-related standard precautionary measures based on urban areas. Specific infection control standards for rural areas and the provision of direct information to individuals in the community to sustain social support are needed. To effectively maintain rural social support, as well as the trust and accountability of rural citizens, constant dialog among local governments and rural citizens is required.

Editors' Comments on the Special Issue "Social Determinants of Mental Health"

Mental disorders are one of the greatest public health concerns of our time, and they are affected by social factors. To reduce the considerable burden of mental disorders, more global and systematic knowledge of the social determinants of mental health is necessary. This paper presents the results of the 27 studies included in the International Journal of Environmental Research and Public Health Special Issue, “Social Determinants of Mental Health”. The studies are grouped into four broad categories: social inclusion and mental health, young people’s mental health, mental health at work, and mental health service users. The results cover different countries, age populations, settings, and methodologies. Finally, the main findings on the relationship between social determinants and mental health are presented and summarized.

Characteristics of Confidence and Preparedness in Paramedics in Metropolitan, Regional, and Rural Australia to Manage Mental-Health-Related Presentations: A Cross-Sectional Study

Mental-health-related presentations account for a considerable proportion of the paramedic's workload in prehospital care. This cross-sectional study aimed to examine the perceived confidence and preparedness of paramedics in Australian metropolitan and rural areas to manage mental-health-related presentations. Overall, 1140 paramedics were surveyed. Pearson chi-square and Fisher exact tests were used to compare categorical variables by sex and location of practice; continuous variables were compared using the non-parametric Mann-Whitney and Kruskal-Wallis tests. Perceived confidence and preparedness were each modelled in multivariable ordinal regressions. Female paramedics were younger with higher qualifications but were less experienced than their male counterparts. Compared to paramedics working in metropolitan regions, those working in rural and regional areas were generally older with fewer qualifications and were significantly less confident and less prepared to manage mental health presentations (p = 0.001). Compared to male paramedics, females were less confident (p = 0.003), although equally prepared (p = 0.1) to manage mental health presentations. These results suggest that higher qualifications from the tertiary sector may not be adequately preparing paramedics to manage mental health presentations, which signifies a disparity between education provided and workforce preparedness. Further work is required to address the education and training requirements of paramedics in regional and rural areas to increase confidence and preparedness in managing mental health presentations.