Rural Perspectives Evidence, Theory and Action Cameron Stark Stonefield Castle Wednesday 10 th September, 2008

Outline Cry of pain model Mental Illness Geographical patterns of suicide Occupation Farming Conclusion

Model of Suicide

Modified Cry of Pain Model Judgement by person Escape Potential Stress Helplessness Self-Harm Social Support Illness Biological Genetics, Childhood Trauma, Brain Injury Social Norms Method Availability Method Choice Poverty

Mental Illness in Rural Areas

Mental Ill-Health National Morbidity Survey –largest UK psychiatric morbidity survey –Higher rates of alcohol and drug dependence, and some illnesses in urban areas –differences disappeared for alcohol and drugs, and attenuated for others, when adjusted for social variables

Experiencing Mental Health Problems in a Rural Area Work by Philo, Parr and Burns Some people find rural living helpful, but: –others report decreased anonymity –greater concern about contacting services –social isolation resulting from knowledge of their mental health problems

Suicide in Rural Areas

Background Reasonable international evidence of higher rates of suicide in some rural areas No single rural pattern across the world Often attributed to changing nature of rural areas Some evidence in Australia of lower uptake of mental health services Some occupations higher than expected rates, may be linked to method

Area Differences

Standardised Mortality Ratios Suicide and Undetermined Deaths Scotland

Influence of Rurality: Method Examined suicide and undetermined deaths in men and women, Deaths assigned to area of residence Population density used as rurality proxy Loglinear model fitted to deaths in each sex and age group Adjusted rate ratios produced for models including only significant factors and interactions

Significant Effects Deprivation independently significant in both genders and all age groups Population density significant in all groups other than young women Protective effect of lower population density in year and 45 and over age groups in women

Male Suicide and Undetermined Deaths, Scotland By Population Density years Source: Stark et al 2007

Male Suicide and Undetermined Deaths, Scotland By Population Density 45 years and over Source: Stark et al 2007

Suicide and Undetermined Death Men Aged years By Settlement Type

Suicide and Undetermined Death Men Aged 45 years and over, By Settlement Type

Occupation and Suicide

Selected Higher Risk Male Occupations Men aged years, Source: Stark et al 2006a

Selected Higher Risk Male Occupations: Men aged years, Source: Stark et al 2006a

Farming Suicide

Methods of Suicide Male Farmers and Foresters Source: Stark et al 2006b

Regression Model Potential overlap between factors Need to account for independent influence Stepwise backward elimination regression model 85% of variance described by farmers as percentage of general population Further 7.5% described by proportion of cattle and sheep LFA

Conclusions

Conclusions - I Reasonable evidence of higher than expected rates of male suicide in rural areas of Scotland – speed of change argues against biological mechanisms Probably more pronounced in older men, may be a protective effect in women Separate mechanism for farming deaths

Conclusions - II Separate mechanism for farming deaths Some occupations more deaths by suicide than would be expected – method availability, including firearms, may be important International work suggests that rural change and social networks may be important

Modified Cry of Pain Model Judgement by person Escape Potential Stress Helplessness Self-Harm Social Support Illness Biological Genetics, Childhood Trauma, Brain Injury Social Norms Method Availability Method Choice Poverty

Interventions Many global interventions – poverty, coping skills, problem solving, reduction in childhood trauma, levels of alcohol abuse, treatment of mental illness Rural: –Stressors –Social norms – modelling of other behaviours –Social support – appropriateness and acceptability of support –Restriction of methods

Rural Areas

The Rural Idyll “Happy, healthy, relatively problem-free and self-helping” (Cloke 1993) Powerful idea May conceal problems and poverty Often conflict between view of idealised conditions, and response to problems –safe area for children but concerns about strangers, accidents –all accounts in one English study were of local problems, rather than strangers

Rural Restructuring Contested concept –diversification of rural activity –diversification of farming income - ‘pluriactivity’ –changes to population structure –middle class inflow in England (‘counterurbanisation’) –increased environmental limits on land use –changes to public services

Falling Population Density Problems –increased ageing relative to national trends –deterioration of social networks –changes in demand for services –marginalised viability of service suppliers –decay of physical infrastructure Aasbrenn 1998

Rural Challenges ‘The traditionally identified problems affecting rural areas are well known. They centre on problems of accessibility, and on less-developed infrastructure and public services. They are often associated with low income levels, lack of job opportunities and emigration of population to urban areas. All of these problems still exist in parts of the United Kingdom...’ House of Lords Select Committee on the European Community (1991)

Source: Dept. of Social Policy and Social Work University of Oxford

Rural Deprivation Housing Household Deprivation Low incomes Opportunity Deprivation Jobs Education Health Recreation Mobility Deprivation Transport costs and inaccessibility Shaw 1979