Farming and mental health problems and mental illness.

BACKGROUND: Farmers experience one of the highest rates of suicide of any industry and there is growing evidence that those involved in farming are at higher risk of developing mental health problems. This article provides an overview of the literature examining mental health issues experienced by farming populations in the United Kingdom, Europe, Australia, Canada and the United States and identifies areas for further research. METHOD: A literature review (Medline, Science Direct, Ingenta, Proquest and PsychINFO) was carried out using the words 'farmers', 'agriculture', 'depression', 'mental health', 'mental illness', 'stress', and 'suicide', as well as a review of relevant papers and publications known to the authors. (Papers not written in English and those published prior to 1985 were excluded.) RESULTS: Fifty-two papers were identified with the majority focusing on stress and coping styles in farmers (24). A number of studies also focused on neuropsychological functioning and agricultural chemical use (7), depression (7), suicide (9), general mental health (4) and injury and mental health (1). This body of research studied male farmers, female farmers, farm workers, farming families, and young people living on farms. Research to date indicates that farmers, farm workers and their respective families face an array of stressors related to the physical environment, structure of farming families and the economic difficulties and uncertainties associated with farming which may be detrimental to their mental health. CONCLUSION: Whilst suicide rates in some groups of farmers are higher than the general population, conclusive data do not exist to indicate whether farmers and farming families experience higher rates of mental health problems compared with the non-farming community. It is clear, however, that farming is associated with a unique set of characteristics that is potentially hazardous to mental health and requires further research.

Doctors' perspectives on the viability of rural practice.

INTRODUCTION: Private practitioners play a vital role in meeting the health needs of rural communities. However, the prospect of operating a private practice business in rural Australia seems to be increasingly unattractive, because many communities are forced to recruit salaried or overseas-trained doctors. This study focuses on rural practices as businesses whose viability influences their attractiveness for the recruitment and retention of practitioners. The specific objectives are to ascertain which factors contribute to or threaten practice viability in rural areas, and whether they vary according to the degree of rurality or geographical remoteness. METHODS: This study is based on data collected from a national study into the viability of rural general practice undertaken jointly by the Rural Doctors Association of Australia and Monash University School of Rural Health Bendigo. The Rural Remote and Metropolitan Area (RRMA) classification was used as the indicator of rurality. The study surveyed all general practitioners practising in rural or remote regions of Australia (RRMAs 3 to 7). Only practitioners with some financial interest in the practice were selected for this analysis. Free-text responses to the two questions 'What are the key factors contributing to the viability of your practice?' and 'What factors would put the viability of your practice at risk?' were analysed using qualitative content analysis. Factors were derived iteratively through higher-level aggregation of responses. Chi-square tests were used to make comparisons across the RRMA categories. RESULTS: The national survey achieved a response rate of 35% of the entire population of GPs practising in RRMA 3 to 7 regions. Of these, 1050 respondents were relevant to this analysis. Seven major factors were identified by practitioners as the main contributors to practice viability. 'Practice characteristics' was nominated by 59% of respondents, followed by 'Income' (31%), 'Personal circumstances', 'Workforce' and 'Community characteristics' (all approximately 23%), 'GP activities and workload' (16%) and 'Professional support' (12%). Eight main factors were identified by practitioners as threats to viability. 'Workforce' was nominated by 57% of respondents, followed by 'Financial' (44%), 'Medico-legal' (33%), 'Administration-political' (16%), 'Community characteristics' (15%), 'GP-practice characteristics' and 'Personal circumstances' (10%) and 'Family circumstances' (3%). Across RRMA 3 to 5 the order of the percentage of respondents identifying each factor was generally consistent, with significant differences in the magnitude of the percentages for three contributing factors and four risk factors. While respondent numbers in RRMA 6 and 7 communities were low, significance testing did reveal differences between them and the rural communities on two contributing and one risk factor. CONCLUSIONS: Practice viability is a major factor affecting the attractiveness of rural and remote practice for intending and existing GPs. Initiatives designed to contribute to viability will not be successful unless measures are also adopted to address perceived threats. This study highlights the systemic nature of the factors which contribute to and threaten practice viability. Although a primary component of practice viability is economic, with income from consultations being critical, the importance of the interrelationships between the main viability factors should not be underestimated. Clearly a multifaceted systemic response is required to overcome problems associated with rural workforce recruitment of future and burnout of current rural GPs.

Rural GPs' ratings of initiatives designed to improve rural medical workforce recruitment and retention.

INTRODUCTION: Since the early 1990s, Australian governments have recognised the problems of rural medical workforce recruitment and retention and have implemented a range of programs and incentives designed to improve the supply of, and access to, doctors in rural and remote areas. Some incentives involve differential payments according to degree of rurality or remoteness. Since these programs involve considerable costs to governments, some assessment of their impact on recruitment or retention is warranted. The objective of this study is to examine the effectiveness of different recruitment and retention incentives from the perspective of the rural GP. Doctors practising in rural and remote communities were, therefore, asked to rank the relative importance of different interventions in terms of their impact on recruitment to and retention of GPs in their communities. METHODS: Six possible interventions were selected to cover the major objectives underpinning rural workforce programs most relevant to doctors currently in rural practice. Respondents assigned a rank to indicate the relative importance of each item with respect to each of the two questions: "What would help most to attract more GPs to this community?" and "What would help most to retain GPs in this community?" The data were collected as part of a national study into the viability of rural general practice undertaken jointly by the Rural Doctors Association of Australia and Monash University School of Rural Health Bendigo. The Rural, Remote and Metropolitan Areas (RRMA) classification was used as the rurality indicator. Analysis involved the calculation of mean ranks for each item. Item means were then ranked to indicate most to least important items in total, and within each RRMA category. RESULTS: Thirty-five percent of all GPs practising in rural and remote Australia responded to the national survey, representing 53% of all practices in those areas. Of these, 1050 doctors who nominated themselves as a principal, partner or associate in their practice were eligible for inclusion in this analysis. The results showed a high degree of agreement in the responses to both questions, with the possible interventions being ranked in the same overall order. 'Better remuneration for Medicare consultations' and 'Improved after-hours and on-call arrangements' were ranked as the most important interventions for both attracting and retaining GPs, whereas 'Better education and professional support activity' and 'Improved availability of allied health professional services' were ranked as least important of the options presented. 'Better locum availability' and 'Capital funding to improve practice infrastructure/enable GPs to set up practice' ranked in between. Results within each RRMA category were very similar to the overall rankings, confirming the significance of the improved remuneration and workload arrangements, regardless of geographical location. CONCLUSIONS: Ensuring professional support, workforce supply, income and infrastructure support are all relevant to the recruitment and retention of GPs in rural and remote areas. However, from the perspective of GPs practising in such areas, specific initiatives that increase the core income of rural practices, and which address those medical workforce supply issues which impact most on workload, are considered those which are most likely to assist in the recruitment and retention of GPs to Australia's rural and remote communities.

Mental health issues for rural and remote Australia.

The burden of mental health problems and disorders is high and rising both in Australia and globally. In response, the Commonwealth Government has moved to implement a national mental health strategy as the basis for a coordinated national approach to underpin initiatives designed to promote mental wellbeing and address mental ill health. This article outlines the nature and extent of mental health problems, provides an overview of changes in mental health policy and service delivery in Australia over the past decade, highlights issues in these areas of particular relevance for rural and remote Australia and calls for the development of a National Rural Mental Health Strategy.

Roles and activities of the Commonwealth Government University Departments of Rural Health.

Since 1996, University Departments of Rural Health (UDRH) have been established at Broken Hill, Mount Isa, Shepparton, Launceston, Whyalla, Alice Springs and Geraldton. Each UDRH is underpinned by Commonwealth funding for an initial period of 5 years. The role of the UDRHs is to contribute to an increase in the rural and remote health workforce through education and training programs, as well as a reduction in the health differentials between rural and urban people and between indigenous and non-indigenous peoples. A strong population health focus involving partnerships between existing health providers in a targeted region and the university sector underpins their operation. While UDRHs have been established as a means of addressing a national workforce problem, their organisational arrangements with universities and local service providers vary widely, as does the program mix of activities in education, research service development, facilitation and advocacy. This article outlines some of the activities and progress of the UDRHs to date.

Health and the 1999 Regional Australia Summit.

The Regional Australia Summit brought together 282 invited delegates from all parts of Australia. The aim of the Summit was to develop partnerships between the government, business and community sectors to deliver a better future for regional, rural and remote areas facing significant change. Health was one of 12 themes discussed at the Summit. Five key health priorities were identified; the need to change the dominant metropolitan mind-set, improve access to health-care services, improve service provision and workforce training, ensure equitable resource allocation, and adopt a population health approach. The ultimate success of the Regional Australia Summit will be gauged over time by the extent to which the health, wellbeing and prosperity of rural, remote and regional Australians has been improved, and existing problems and issues addressed. Nonetheless, the Summit is a significant event because it addresses issues at the highest level of government, emphasises coordination and the adoption of an intersectoral approach, and recognises the need to empower local communities and build partnerships between the government, corporate and community sectors.

A modified framework for rural general practice: the importance of recruitment and retention.

Whilst definitions of what constitutes general practice vary according to purpose, the pivotal role of general practitioners as key providers of health and medical services is acknowledged. Recent concerns to address both what general practitioners and their patients want and get from general practice stem from a recognized need to include stakeholder concerns about the adequacy of general practice alongside workforce issues such as recruitment and retention. Nowhere is this need so crucial as in rural areas where the range of health services is limited and major inequities exist in the availability of general practitioners. An extended framework for evaluating what general practitioners and their patients expect and receive from general practice, with particular reference to rural general practice in Australia is presented. Three inter-related dimensions of recruitment, retention and a whole patient/whole family approach to health care are suggested as underpinning this framework. The significance of each dimension to ensuring the provision of quality general practice care in rural communities, and the links between them, are outlined in the proposed framework.

Delimiting 'rural': implications of an agreed 'rurality' index for healthcare planning and resource allocation.

Rural and remote Australia is characterised by considerable geographical and social diversity. There is no 'natural' classification of what constitutes 'rural' or 'remote', and precise definition of what is meant by the term 'rural' has proved to be an elusive goal. Nonetheless, it is recognised that the differentiation of rural areas has important implications for healthcare planning and the research that underpins it. Whether it be the development of resource allocation formulae that determine the provision, location and type of rural health services, measuring service utilisation rates as an indicator of need for services or health outcome measures, the way in which populations and communities are delimited as urban, rural and remote will always influence and sometimes may even determine the assessment. The time is ripe for the development of an agreed classification for the investigation of rural health issues.

Factors in accessibility of general practice in rural Australia.

OBJECTIVE: To ascertain the importance rural Australians attribute to different factors of accessibility in their decision to consult a general practitioner. DESIGN: Survey by interview or delivery-and-collection questionnaire (participant's choice) based on the method of paired comparisons. SETTING AND PARTICIPANTS: All residents of 10 small rural communities in north-west New South Wales aged over 16 years in July and August 1996. MAIN OUTCOME MEASURES: Rank order and relative importance of residents' preferences for choosing to consult a particular doctor. RESULTS: Social accessibility or acceptability considerations were more important than geographical proximity in the choices of rural residents to consult a particular doctor. Elderly people, in particular, attributed most significance to acceptability and continuity of care. Geographical proximity ranked most highly for young and middle-aged people and men living in isolated communities. CONCLUSIONS: For rural inhabitants, geographical distance is not the sole or even the most important determinant in their choice of general practice care; rather, they will seek the services of a GP with whom they feel comfortable. Incentives programs designed to recruit and retain more GPs in rural practice must acknowledge the importance of attracting acceptable doctors. This requires that rural doctors acquire suitable clinical and communication skills to meet the diverse needs of their patients, as well as an understanding of rural culture.

Reflections on national rural health policy: the 'big picture' framework.

A major concern of many rural and remote communities, as they struggle to cope with the impacts of social, economic and demographic changes, is the effect of government policies on health services. The National Rural Health Strategy has evolved as the key framework guiding action for improving health services for people in rural and remote Australia. The importance of maintaining an awareness of the 'big picture' of rural health remains paramount if interventions designed to bring about improved health status are to tackle the underlying causes of the problems, minimise problems associated with lack of co-ordination between health authorities, and avoid duplication of activity. Given the communality of rural health problems across Australia, close co-operation and collaboration among rural health groups is vital in developing appropriate national rural health policy. At the same time rural communities must continue to participate actively in the policy formulation and implementation process.

Fostering multidisciplinary research and approaches to rural health issues: the concept of an International Summer Institute.

The challenge of how best to provide equitable, accessible and affordable health care in rural and remote settings is an international concern. It has been acknowledged that a multidisciplinary approach to current rural health issues involving social scientists and health practitioners may be crucial in developing appropriate responses. One initiative designed to facilitate multidisciplinary research and greater collaboration between researchers and practitioners was an International Summer Institute sponsored by the Social Science and Humanities Research Council of Canada. This article outlines an Australian perspective on the rationale for, background to, and structure of this initiative, and evaluates it as one option for promoting multidisciplinary approaches to rural health research.

Evaluating the importance of information sources for preventive health care in rural Australia.

Health promotion and prevention are critical elements of public health programs designed to improve health status and extend life chances. The pattern of mortality and morbidity in rural Australia suggests a particularly important role for health promotion and preventive measures in country areas. However, the importance of preventive health measures and how people access health-related information is not well understood. This study examines which sources of health-related information are most valued by rural residents and whether the importance attributed to different sources varies according to age, sex and geographic location. The results demonstrate the overwhelming importance of the general practitioner and pharmacist in provision of preventive health information for all rural people. There is a need to ensure that the work carried out by all those involved with health promotion is closely integrated with that of rural general practitioners.

Health care preferences in a country town.

OBJECTIVES: To identify the preferences of rural Australians for health care services and to relate their attitudes towards health care services in general and preventive health care services in particular to their sociodemographic characteristics and their degree of geographic access to available services. DESIGN: Both an interview and a delivery-and-collection questionnaire survey were conducted. The method of paired comparisons was used to determine the structure of preferences for a set of health care services. SETTING: The study area comprised the small rural settlement of Nyngan, and the surrounding farming lands in the Bogan Shire, New South Wales. PARTICIPANTS: A random sample of 20% of residents was surveyed in October 1989. MAIN OUTCOME MEASURES: In the absence of any studies on the attitudes of rural Australians towards health care services, no a priori hypotheses were formulated. Both the rank order of preferences and a preference interval showing the "distance" between the preferences were calculated. RESULTS: The results show the overwhelming importance attributed to curative medical services compared to those oriented to preventive health care. In particular, the services provided by the doctor are indisputably the most highly valued of all health care services. The attitudes of rural residents to particular preventive services varied, with those services most relevant to immediate needs being the ones most highly valued. CONCLUSIONS: The felt need for health care among country people centres on the adequate provision of doctors and hospitals; preventive services which address the longer-term health care needs of country people may best be provided by closely integrating them with curative medical services.

Health status and health care in rural Australia: a case study.

Knowledge of the health status of, and patterns of health care service utilization by rural Australian communities, is scant. This deficiency limits attempts to formulate policies designed to bring about efficient, effective and equitable delivery of health care services. This article reports the results of a health interview survey conducted in the Wimmera region of Victoria during spring 1984. The results demonstrate not only that patterns of morbidity in rural areas differ from the Australian average, but also that the health status of rural dwellers is worse than that of most Australians. Evidence suggests that while accessibility is not the most significant determinant of utilization of health care services, distance from services does affect propensity to use them.

A potent, heat-stable protein inhibitor of [branched-chain alpha-keto acid dehydrogenase]-phosphatase from bovine kidney mitochondria.

A heat- and acid-stable protein inhibitor of the [branched-chain alpha-keto acid dehydrogenase]-phosphatase was purified over 100,000-fold from extracts of bovine kidney mitochondria. The nearly homogeneous protein was recovered with a yield of 4-8%. The apparent molecular weight of the inhibitor is about 36,000. This protein is a noncompetitive inhibitor of the phosphatase, and the inhibitor constant (Ki) is about 0.13 nM. The inhibition was reversed 50% by about 1.3 mM Mg2+ and about 0.1 mM spermine. This protein inhibitor is different from the cytosolic protein phosphatase inhibitors 1 and 2.

Stimulation of pyruvate dehydrogenase phosphatase activity by polyamines.

Pyruvate dehydrogenase phosphatase requires Mg2+ or Mn2+, and its activity in the presence of Mg2+ is markedly stimulated by Ca2+. At saturating Mg2+ and Ca2+ concentrations, the polyamines spermine, spermidine and putrescine stimulated the activity of pyruvate dehydrogenase phosphatase 1.5- to 3-fold. Spermine was the most active of the polyamines. At a physiological concentration of Mg2+ (1 mM) and saturating Ca2+ concentration, the stimulation by 0.5 mM spermine was 4- to 5-fold, and at 0.3 mM Mg2+, the stimulation was 20- to 30-fold. In the absence of Mg2+ or Ca2+, spermine had no effect. These results suggest that a polybasic factor may be involved in the regulation of pyruvate dehydrogenase phosphatase activity.

Purification and properties of branched-chain alpha-keto acid dehydrogenase phosphatase from bovine kidney.

Branched-chain alpha-keto acid dehydrogenase (BCKDH) phosphatase was purified about 8000-fold from extracts of bovine kidney mitochondria. The highly purified phosphatase exhibited a molecular weight of approximately 460,000, as estimated by gel-permeation chromatography. Another form of the phosphatase, with an apparent molecular weight of approximately 230,000, was also detected under conditions of high dilution. In contrast to pyruvate dehydrogenase phosphatase, BCKDH phosphatase was active in the absence of divalent cations. BCKDH phosphatase was inactive toward 32P-labeled phosphorylase a, but exhibited approximately 10% maximal activity with 32P-labeled pyruvate dehydrogenase complex. BCKDH phosphatase activity was inhibited by GTP, GDP, ATP, ADP, UTP, UDP, CTP, and CDP. Half-maximal inhibition occurred at about 60, 200, 200, 400, 100, 250, 250, and 400 microM, respectively. These inhibitions were reversed completely by 2 mM Mg2+. GTP was replaceable by guanosine 5'-(beta, gamma-imido)triphosphate. GMP, AMP, UMP, CMP, NAD, and NADH showed little effect, if any, on BCKDH phosphatase activity at concentrations up to 1 mM. Heparin showed half-maximal inhibition at 2 micrograms/ml. This inhibition was only partially (30%) reversed by 2 mM Mg2+. CoA and various acyl-CoA compounds exhibited half-maximal inhibition at 150-300 microM. These inhibitions were not reversed by 2 mM Mg2+. BCKDH phosphatase activity was stimulated 1.5- to 3-fold by protamine, poly(L-lysine), and poly(L-arginine) at 3.6 micrograms/ml.