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

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

3. Model of Suicide

4. 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

5. Mental Illness in Rural Areas

6. 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

7. 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

8. Suicide in Rural Areas

9. 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

10. Area Differences

11. Standardised Mortality Ratios Suicide and Undetermined Deaths Scotland 1981 - 1999

12. Influence of Rurality: Method Examined suicide and undetermined deaths in men and women, 1981- 1999 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

13. 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 25 - 44 year and 45 and over age groups in women

14. Male Suicide and Undetermined Deaths, Scotland 1981 - 1999 By Population Density 15 - 24 years Source: Stark et al 2007

15. Male Suicide and Undetermined Deaths, Scotland 1981 - 1999 By Population Density 45 years and over Source: Stark et al 2007

16. Suicide and Undetermined Death Men Aged 25 - 44 years 1981 - 1999 By Settlement Type

17. Suicide and Undetermined Death Men Aged 45 years and over, 1981 - 1999 By Settlement Type

18. Occupation and Suicide

19. Selected Higher Risk Male Occupations Men aged 16 - 45 years, 1981 - 99 Source: Stark et al 2006a

20. Selected Higher Risk Male Occupations: Men aged 45 - 64 years, 1981 - 99 Source: Stark et al 2006a

21. Farming Suicide

22. Methods of Suicide Male Farmers and Foresters 1981 - 1999 Source: Stark et al 2006b

23. 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

24. Conclusions

25. 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

26. 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

27. 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

28. 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

30. Rural Areas

31. 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

32. 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

33. 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

34. 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)

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

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