The Care Situation, Stigmatization and Requirements of People with Mental Health Problems in Rural Areas

doi:10.4236/aasoci.2012.24035

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Advances in Applied Sociology

2012. Vol.2, No.4, 268-273

Published Online December 2012 in SciRes (http://www.SciRP.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2012.24035

268

The Care Situation, Stigmatization and Requirements of People

with Mental Health Problems in Rural Areas

Brigitte Jenull1, Ingrid Salem1, Eva Mir2

1Department of Psychology, Alpen-Adria-Universität, Klagenfurt, Austria

2Carinthia University of Applied Sciences, Feldkirchen, Austria

Email: [email protected]

Received September 11th, 2012; revised October 15th, 2012; accepted October 27th, 2012

With a lifetime prevalence of about 27% mental disorders are amongst the most common diseases. They

typically are of chronic course, thus affecting not only the respective people, but also the social surround-

ings. In order to provide mental health care in best possible proximity to their homes, transparency of the

services offered and a rapid access are needed. The present study aims at defining the problems and re-

quirements of rural mental health in a Carinthian region (Austria). The users (n = 46) and the family

members (n = 37) were surveyed regarding their individual situation, the current strains and the level of

social support. Additionally, expert interviews (n = 44) were conducted and analysed by using qualitative

content analysis. Findings revealed that much of mental health care is delivered by primary care physi-

cians and is too often limited to medication. As far as mobile psychosocial offers and expert staff are

concerned, all of our interviewed people locate serious flaws and need for action. The present study con-

cludes that there is urgent need to improve the care situation in rural areas. Case and care management

and initiatives to reduce stigmatization are of paramount importance.

Keywords: Mental Illness; Community-Based Mental Health Services; Unmet Medical Need;

Stigmatization

Introduction

Epidemiological studies show that mental disorders are

amongst the most common diseases within the population

(Knapp, McDaid, Mossialos, & Thornicroft, 2007; Wittchen &

Jacobi, 2005). Although every fourth person in the European

Union is concerned by mental health problems, 80% do not

receive appropriate treatment even yet the standard of knowl-

edge in prevention and therapy is high (Demyttenaere et al.,

2008; Siddiqi & Siddiqi, 2007; WHO, 2006). Medical needs in

rural areas are unmet due to shortage of qualified staff. Fur-

thermore there are often barriers by the geographical location,

socio-cultural events and economic conditions to access ser-

vices (Zanjani & Rowles, 2012). Low income and insufficient

education hamper early intervention and treatment of mental

health problems (Kumar, 2011; McElmurry, Marks, Cianelli, &

Mamede, 2002; Merkel, 2004). Gaps in patient-centered care

are caused by inadequate strategies and financing as most re-

sources are still directed towards hospital treatment (WHO,

2006).

Most people with mental health problems consult primary

care physicians but studies demonstrate that a substantial part

of the mental diseases presented, are not accurately diagnosed

(Gamm, Tai-Seale, & Stone, 2002; Siddiqi, & Siddiq, 2007;

Walters & Tylee, 2006). This is explained by insufficient train-

ing of primary care physicians and other variables like triviali-

zation of mental health problems by the patients. Many people

with mental diseases have doubts about effective treatment

possibilities or hope, they can handle the problem without see-

ing a health professional (Verhaak, Schellevis, Nuijen, & Volk-

ers, 2006). In addition mental diseases are often not diagnosed

at the initial contact with the physician and further consulta-

tions are mostly too brief for in-depth conversation since the

average time spent with the physician does not exceed 13 to 16

minutes (Bazelon Center for Mental Health Law, 2006).

Apart from unavailable or inadequate care, stigmatisation is

the most severe problem of patients with mental health prob-

lems (Corrigan, Kerr, & Knudsen, 2005; Health Scotland, 2008;

Kelly, 2006; Mueller et al., 2006). This assumed stigma pre-

vents patient contact with psychosocial services, thus causing

delay or inhibition of early diagnosis and intervention (Rüsch et

al., 2009; Schomerus & Angermeyer, 2008). Persons living in

rural areas feel even more stigmatized (Gamm et al., 2002).

There is a difference between societal stigma and personal atti-

tude towards being affected by mental illness. Persons con-

cerned boost stigmatization by internalizing discrimination and

prejudice in the society. This leads to a loss in self-belief and

self-confidence resulting in an unfavorable prognosis (Corrigan

et al., 2005). In order to avoid exclusion from society of per-

sons living in rural areas and suffering from mental diseases,

the phenomenon of stigmatization needs consideration.

The study presented informs about patient-centered care of-

fers for mentally ill people living in a rural area in Carinthia

(Austria). Austria with a total area of 83,879 km² and 8,420,900

inhabitants consists of 9 provinces; Carinthia as one of those

has 558.056 inhabitants. 18,766 persons live in the study area,

this Carinthian district has with 23 persons per km² one of the

lowest population density in Austria. It is a rural region, and

more traditionally oriented. The inhabitants live mainly from

tourism. The net annual income of Carinthia salaried employed

persons in 2010 was about 23,500 Euro for men and 15,200

Euro for women. It is slightly below the average Austrian (Sta-

tistik Austria, 2012). Undisputed is the strain such patients

B. JENULL ET AL.

endure—thus the aim of the study is to show requirement of

patient-centered care offers as seen by health care providers,

patients and relatives. In a second step the experienced burden

of disease as well as perceived assistance was examined. These

results lead to recommendations for coordinated area-wide and

demand-oriented care.

Methodology

Study Design

The present study is a cross-sectional evaluation and was de-

signed as census. Data were collected over an 8-month-period.

A mixed-method approach was chosen to answer the research

question. This approach integrates subjective views of experts,

of users as well as members to obtain comprehensive and rele-

vant results about the district (Creswell & Plano Clark, 2007).

Qualitative and quantitative methods were used within the

meaning of triangulation-designs.

Measures

Three target groups were examined to ensure a multi-per-

spective data base. For each target group an own methodology-

cal approach was chosen. Three project employees were re-

sponsible for the procedure of the study. These project em-

ployees got explanations and were given a coaching during the

whole study.

Interviews with Expert s

Experts were asked about the psychosocial overall situation

of the district. The interviews lasted about 20 minutes and were

conducted in the respective facilities. Physicians, psychothera-

pists, social workers, psychologists as well as caregiver in psy-

chosocial institutions of the district were interviewed. In this

context, guided interview is a suitable form of elevation. The

interview, based on the theoretical background presented earlier,

(e.g., Gamm et al., 2002; Merkel, 2004) outlined three central

questions:

1) Percentage of mentally ill people in the district;

2) Basis information of diagnosis;

3) Main focuses and problems of supply.

Questionnaire-Based Survey with User s

Users were interviewed with a predominant quantitative

questionnaire: socio-demographic data, one item to capture

stigmatization, a care-burden-scale (Salewski & Ostendorf,

2003) as well as a shortform of the questionnaire about social

assistance (F-SozU K-22) (Fydrich, Sommer, & Brähler, 2007)

were used.

The adapted care-burden-scale includes 26 items and is di-

vided into five subscales: social burden, sanitary stress, tempo-

ral stress, financial stress, demands of the family member and

relationship with family member. The responses to items were

rated on a 5-point-scale (never, rarely, sometimes, often and

always). Scales follow a theoretical methodology and dispose

of interne consistencies between α = .71 and α = .91 (Salewski

& Ostendorf, 2003). The questionnaire about social assistance

(F-SOZU K22) includes 22 items and it is possible to calculate

a total value. The sub-scales “emotional support”, “practical

support”, “social integration”, “availability of a person of trust”

and “satisfaction with social support” are documented fac-

tor-analytically and have a good reliability (α = .91) and posi-

tive results of validity (Fydrich et al., 2007). The questions are

answered on a 5-point scale rated from “not true” to “true”.

Questionnaire-Based Survey with Family Members

The questionnaire for family members bases on the same

questions as the questionnaire for users, because so compari-

sons are possible. Thus the instrument for users and for family

members was the same.

The experts gave both survey methods to the clients as well

as to their family members.

Data analysis and representation of results, with which it is

possible to find something out about institutions or persons,

were not used. This was important to guarantee study partici-

pants anonymity. The completed questionnaires were collected

in the facility and then given to the project management.

Data Collection and Analysis

The transcripts of all expert-interviews were used for fol-

lowing qualitative content analysis. Structured, deductive and

inductive techniques were used (Mayring, 2007).

The questionnaires for users and their family members were

analysed with classical statistical analysis methods (arithmetic

mean comparisons by t-test and univariate variance analysis).

SPSS 20.0 (Bühl, 2011) was used for these statistical analysis

methods.

Sample

Experts

Experts were recruited about all local mental health facilities

in the investigated area. A total of 44 experts took part in the

study. 12 of the interviewees were physicians and the other 32

people are in leading positions in psychosocial facilities and

belong to different occupational groups (social work, psychol-

ogy, psychotherapy ···). The participation rate of experts was

84 %.

Users and Family Members

In the course of interviews a possible distribution of ques-

tionnaires to family members and persons concerned was dis-

cussed with experts. For reasons of anonymity no sampling was

conducted and the questionnaires were distributed by the ex-

perts. 83 of 300 questionnaires were returned. This correspond

a participation rate of 31% of users and 25% of family mem-

bers. 26 female clients and 19 male clients (n = 46, n = 1 with-

out description) of psychosocial facilities in the explored dis-

trict were on average 58 (±20) years (range: 6 - 93 years) old.

16 persons were married, 12 people were single and 18 lived

separate respectively were divorced or widowed at time of the

study. 18 clients lived alone and 16 in a partnership or with

parents together and 12 lived together with other family mem-

bers. For 25 persons family members took care (14 from part-

ners, 11 from other family members) and 19 persons were

looked after institutional, for example by mobile services. Two

persons did not provide information.

37 family members (25 women, 12 men) took part in the

study. The family members were on average 53 (±13) years

(range: 27 - 82 years) old. At time of the study 17 persons were

employed. Bulk of family members were married (n = 30),

B. JENULL ET AL.

270

three were single and one person lived separately and three

persons did not provide information. The male family members

are significantly older than the female (t = −2.738, df = 31, p

= .010).

Results

Assessment of Patient-Centered Care (Expert

Interviews)

Experts from a wide range of professions were questioned in

order to get an extensive view of the available logistics. Due to

the varied approaches by the different professions, results were

analyzed separately (medical doctors (n = 12) and psychosocial

health professionals (n = 32)).

Primary care physicians reported that 20% to 50% of their

patients had mental health problems. Three doctors made most

diagnoses during the conversations held with their patients, also

because they had known them for a long time. Two thirds of the

physicians referred their patients to specialists or to psychiatric

departments in the nearest hospital whenever they suspected

mental health problems. Ten of the twelve doctors emphasized

antipsychotic medication and seven led an educational and

counseling conversation, advising the patients on helpful and

supportive steps to take.

The main focus in patient-centered care for mental diseases

can be pin-pointed to a very basic provisioning.

We now present the results by defining the main categories

within each domain giving some typical examples.

As can be seen in Table 1 perceived problems or shortcom-

ings in Medicare are of ultimate concern. Living far from

medical and psychosocial services is also mentioned. Most

relevant seems the problem of stigmatization, which might

jeopardize the utilization of offered services. Professionals also

allude to the patients’ fear regarding anonymity.

From their respective perspectives, clients, relatives and ex-

perts likewise ask for an improvement in patient-centered care

(see Table 2). Experts in this field add the request for special-

ized staff, networking and publicly visible awareness training.

Table 1.

General problems of the existing supply system (N = 44).

Category Definition Statements n1 = 12 n2 = 32

Society Stigmatization tabooization

“There are big social fears of comi ng-out.”

“There is especially in rural areas a lack of acceptance and

tolerance.”

“··· is ashamed ···”

4 15

Inadequate supply Limited to medications lack of

alternatives

“Medications are the standard.”

“In our district there is a lack of institutions, ··· a deficit in

psychiatric supply, psychotherapy ·· ·” 16 21

Geographical

location Long avenues difficult to use

“It is difficult because our rural situation ··· who drives every

week to a group therapy to city A or city B?”

“··· it can take a long time that somebody comes truly ··· ”

3 11

Savings Financial aspects

“Medical care is on the back burner.”

“Everywhere is saved, ··· additional offers would be gut, but

not financed.”

10 11

Note: n1 = physicians; n2 = experts of psychosocial institutions

Table 2.

Desires for a better supply (N = 155).

Category Definition Statements n1 n2 n3n4

Improving the supply

system

 Location-based offers (learning

assistance, day-care centers, work

projects, youth centre, ···)

 Housing units near community for

chronically ill people (psychiatric

care)

 A centre for emergency and crises

 psychosocial care

 self-help groups

“A centre for emergency and crises, ··· Hermagor

as a central place, to get quickly in different valleys.”

“··· a psychotherapeutic ambulance...free o

charge”

“···a mobile psychosocial care would be

desirable ···”

6 22 3121

Public relations  Awareness training

 Awareness raising

“··· more awareness training...information, what

possibilities are there ···”

“more awareness training for family members who

care for somebody, ···adolescents, ···in schools ···”

“talk about topics without t aboo ···”

18 1

Networking

 Interdisciplinary work

 Cooperation

 Interface management

“Health care system needs increased collaboration

with physicians ···”

“··· an intermediary between family doctor, hospital

and patient/family members, ··· trained people, who

network an d coordinate.”

Experts  Staff increasing “··· workers with flexible applicability ···”

“··· take stock of clientele more intensively ···” 6 15 1

Note: n1 = physicians; n2 = experts of psychosocial institutions; n3 = clients; n4 = family members.

B. JENULL ET AL.

Experience of Str ain an d S upport

The investigation yielded interesting results: consumers of

patient-centered care or mobile care services showed signifi-

cantly lower signs of health stress than patients looked after by

relatives (F(2, 40) = 4.463, p = .018). These patients were also

burdened by their relationship towards the family member tak-

ing care of them (F(2, 40) = 3.464, p = .041) more than patients

who were cared for institutionally.

The form of housing—living alone, with a partner or other

family members—is associated with experience of burden and

support of the clients: The univariate analysis of variance

showed that affected people, who live alone have significantly

lower values on the scale of health burden compared to affected

people, who live together with a partner or family members

(F(2, 42) = 5.334, p = .009). Also in the subscale “make de-

mands” was a significant difference: affected people, who live

alone, judge their demands significantly lower than affected

people, who live with family members (F(2, 41) = 3.699, p

= .034). Persons concerned, who live together with other family

members have significantly less frequently a person of trust in

their social network (F(2, 39) = 3.939, p = .028) and they are

less socially integrated (F(2, 39) = 2.917, p = .046). Otherwise

there were no statistically noticeable differences between the

groups.

Gender differences were shown in the experience of burden

and support of the family members. Male family members

judge the temporal burden of care significantly higher than

women (t-test for independent samples, t = −2.413, p = .022).

Female family members judge emotional support higher (t =

1.956, p = .049). Three groups of age were formed to explore a

possible association of age and the experience of burden and

support: people under 45 years, 45 to 60, and people over 60.

Health of family members over 60 was significantly higher

burdened (F(2, 29) = 4.432, p = .021) and they reported more

financial problems than younger family members (F(2, 29) =

3.352, p = .049). Older family members reached significantly

lower total values in F-SozU K-22 than family members under

45 years (F(2, 29) = 3.373, p = .048). Over 60 years old get

significantly less support than younger family members.

Experience of Stigmatization

As can be seen in Figure 1, half of the persons concerned

often or even permanently feel excluded from society by their

impairment. Two thirds of the relatives did not (or seldom) feel

excluded due to the illness of their family member. For the

majority of patients (73%) stigmatization is part of their daily

life.

Discussion

The study presented provides insight into the outpatient care

reality of patients with mental health problems in a small

Carinthian district, thus meeting the demand of observational

research by including users and their relatives of patients-cen-

tered care (Riedel-Heller, Bramesfeld, Roick, Becker, & König,

2008). With respect to the variability and heterogeneity of rural

areas (Philo, Parr, & Burns, 2003) the results presented here

should be considered only valid for the studied area.

Literature maintains that primary care physicians are the first

point of contact regarding mental health problems (Gamm et al.,

2002; Walters & Tylee, 2006). Medical experts in the investi-

gated area had a substantive proportion of patients with mental

health diseases, reports ranging between 20 and 50 percent.

Manthorpe, Moriarty, Stevens, Hussein and Sharif (2012) noted

in their study that it is important to improve the situation of the

patient and their family members as well as to provide the prac-

titioners a forum to discuss relevant problems. For us it seems

to be a main point that practitioners get support in terms of

training and supervision in order to meet the varying needs of

their patients.

The major problem of these patients is the high level of

stigmatization noticeable within their surroundings (Health

Scotland, 2008). While struggling with symptoms of their

mental health problems, they have little chances of finding

employment and thus structuring their daily life (Rüsch, An-

germeyer, & Corrigan, 2005). This topic of taboo and exclusion,

relevant to society, leads to a social retreat of patients with

mental illness. They prefer to hide their problems, which ham-

pers treatment in an early stage of the disease. In order to keep

their problems under cover, people living in rural areas prefer

to seek advice or help from inconspicuous persons instead of

consulting specialists.

A possible proposal for helpful solutions might be the con-

struction of larger social networks (Burns, 2007; Lewis, Baeza,

& Alexander, 2008) where people struck by (mental) diseases

are taken care of by an interdisciplinary team. After a first di-

agnose, this center should provide a plan for crises and consecutive

Figure 1.

Stigmatization family members and clients.

B. JENULL ET AL.

therapy and coordinate the whole process including contact

with relatives and family.

All interview partners emphasized the necessity of ameliora-

tion in patient-centered care, including psychoeducational ac-

tivities and work-related training. Counteraction is needed for

discrimatory comments and wrong accusations such as e.g.

spreading rumours about higher crime rates in persons with

mental diseases. Affected patients have to be supported by em-

powerment and dialogue or discourse with all parties concerned.

The dialogue of professional experts with concerned patients

gains an additional dimension by including relatives and keep-

ing the societal context in mind (Bombosch, Hansen, & Blume,

2004). This perspective creates equality between patient, rela-

tives and carers.

Relatives report an increase of strain by their own aging.

While their health problems increase, social support, integration

in civic life and life-satisfaction decrease.

Older community members of this rural area, who are bur-

dened by the care for a mentally ill relative, are a high priority

target group for intervention.

Regarding current care concepts, the control sample of pa-

tients cared for in an institutional setting, showed a lower level

of strain than persons cared for by their relatives. The support

of each individual in the areas of housing, work and recrea-

tional activities is a consequential necessity. In case of care

being provided by relatives or close family, they need to be

supported by offering them psychoeducation, encouragement

and work relief.

Since the seventies psychiatric patient-centerd care in Austria

has undergone quite a couple of renewing initiatives such as

reduction of inpatient bedding, an increase of community based

services and socio-professional reintegration of mentally ill

persons into daily community life (BMGFJ, 2005; Zechmeister,

2004).

A couple of urban regions in Austria (Schöny & Katschnig,

1991) have a well-developed extramural care system whereas

rural areas lack of expert staff as well as specific day-structur-

ing facilities.

More than a decade later Merkel (2004) as well as Black-

stock, Innes, Cox, Smith and Mason (2006) arrive at similar

results and claim that in general, more attention should be paid

to the rural mental health, because the shortage in rural com-

munities is dramatic due to cultural economic and geographical

reasons. Our study confirms these findings: Treatment of pa-

tients with mental health problems in the examined community

is reduced to minimal interventions without including further

parties involved. There is a lack of qualified staff necessary to

provide affordable and comprehensive treatment and care.

In general, more attention should be paid to the rural mental

health.

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