Bridging the divide: exploring the relationship between mental and physical health in rural areas.

Those living in rural settings may experience particular challenges to their mental as well as physical health, which together with issues relating to healthcare access can lead to disparities in outcomes. This commentary looks at the relationship between mental and physical health in rural areas and highlight the urgent need for a holistic approach to healthcare in these regions.

Brief Digital Interventions to Support the Psychological Well-being of NHS Staff During the COVID-19 Pandemic: 3-Arm Pilot Randomized Controlled Trial.

BACKGROUND: Health and social care staff are at high risk of experiencing adverse mental health (MH) outcomes during the COVID-19 pandemic. Hence, there is a need to prioritize and identify ways to effectively support their psychological well-being (PWB). Compared to traditional psychological interventions, digital psychological interventions are cost-effective treatment options that allow for large-scale dissemination and transcend social distancing, overcome rurality, and minimize clinician time. OBJECTIVE: This study reports MH outcomes of a Consolidated Standards of Reporting Trials (CONSORT)-compliant parallel-arm pilot randomized controlled trial (RCT) examining the potential usefulness of an existing and a novel digital psychological intervention aimed at supporting psychological health among National Health Service (NHS) staff working through the COVID-19 pandemic. METHODS: NHS Highland (NHSH) frontline staff volunteers (N=169) were randomly assigned to the newly developed NHSH Staff Wellbeing Project (NHSWBP), an established digital intervention (My Possible Self [MPS]), or a waitlist (WL) group for 4 weeks. Attempts were made to blind participants to which digital intervention they were allocated. The interventions were fully automated, without any human input or guidance. We measured 5 self-reported psychological outcomes over 3 time points: before (baseline), in the middle of (after 2 weeks), and after treatment (4 weeks). The primary outcomes were anxiety (7-item General Anxiety Disorder), depression (Patient Health Questionnaire), and mental well-being (Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes included mental toughness (Mental Toughness Index) and gratitude (Gratitude Questionnaire-6). RESULTS: Retention rates mid- and postintervention were 77% (n=130) and 63.3% (n=107), respectively. Postintervention, small differences were noted between the WL and the 2 treatment groups on anxiety (vs MPS: Cohen d=0.07, 95% CI -0.20 to 0.33; vs NHSWBP: Cohen d=0.06, 95% CI -0.19 to 0.31), depression (vs MPS: Cohen d=0.37, 95% CI 0.07-0.66; vs NHSWBP: Cohen d=0.18, 95% CI -0.11 to 0.46), and mental well-being (vs MPS: Cohen d=-0.04, 95% CI -0.62 to -0.08; vs NHSWBP: Cohen d=-0.15, 95% CI -0.41 to 0.10). A similar pattern of between-group differences was found for the secondary outcomes. The NHSWBP group generally had larger within-group effects than the other groups and displayed a greater rate of change compared to the other groups on all outcomes, except for gratitude, where the rate of change was greatest for the MPS group. CONCLUSIONS: Our analyses provided encouraging results for the use of brief digital psychological interventions in improving PWB among health and social care workers. Future multisite RCTs, with power to reliably detect differences, are needed to determine the efficacy of contextualized interventions relative to existing digital treatments. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN) ISRCTN18107122; https://www.isrctn.com/ISRCTN18107122.

The mental health of NHS staff during the COVID-19 pandemic: two-wave Scottish cohort study.

BACKGROUND: Health and social care workers (HSCWs) are at risk of experiencing adverse mental health outcomes (e.g. higher levels of anxiety and depression) because of the COVID-19 pandemic. This can have a detrimental effect on quality of care, the national response to the pandemic and its aftermath. AIMS: A longitudinal design provided follow-up evidence on the mental health (changes in prevalence of disease over time) of NHS staff working at a remote health board in Scotland during the COVID-19 pandemic, and investigated the determinants of mental health outcomes over time. METHOD: A two-wave longitudinal study was conducted from July to September 2020. Participants self-reported levels of depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7) and mental well-being (Warwick-Edinburgh Mental Well-being Scale) at baseline and 1.5 months later. RESULTS: The analytic sample of 169 participants, working in community (43%) and hospital (44%) settings, reported substantial levels of depression and anxiety, and low mental well-being at baseline (depression, 30.8%; anxiety, 20.1%; well-being, 31.9%). Although mental health remained mostly constant over time, the proportion of participants meeting the threshold for anxiety increased to 27.2% at follow-up. Multivariable modelling indicated that working with, and disruption because of, COVID-19 were associated with adverse mental health changes over time. CONCLUSIONS: HSCWs working in a remote area with low COVID-19 prevalence reported substantial levels of anxiety and depression, similar to those working in areas with high COVID-19 prevalence. Efforts to support HSCW mental health must remain a priority, and should minimise the adverse effects of working with, and disruption caused by, the COVID-19 pandemic.

We've got what the NHS ultimately intended for us: Experiences of community engagement in rural primary care services change.

Policy promotes service user engagement in health services design and delivery. Various tools exist to support the engagement of citizens within health services design. We consider community engagement within the context of primary care delivery in remote and rural areas of Scotland. We present findings from three years of qualitative work with community members and healthcare professionals within five different remote and rural areas, undergoing primary care service changes. 364 interviews were carried out with community members and healthcare professionals on their experiences of, and feelings towards, the services changes. A key theme to emerge from our thematic analysis of the qualitative data is experiences of community engagement. In this paper we present our analysis of this theme. We identify different types of community engagement discourse within community and healthcare professional interviews. We illustrate these themes and, through consideration of five case study areas, demonstrate how these discourses can co-exist within the same service change process. The paper presents our sub-themes on community engagement relating to discourses of inclusion and exclusion; the role of the General Practitioner (GP); conceptualisations of the organisational role of the NHS; discourses of fear and, finally, community members understandings of what it means to be active "agents of change" (or not) within health services redesign. We argue that context is as important as method when it comes to facilitating a positive community engagement experience for citizens. Our findings have relevance to the emerging social science literature on citizen experience of public sector community engagement activities.

A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being.

BACKGROUND: Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis. METHODS: We undertook a rapid review of the literature following guidelines by the WHO and the Cochrane Collaboration's recommendations. We searched across 14 databases, executing the search at two different time points. We included published, observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic. RESULTS: The 24 studies included in this review reported data predominantly from China (18 out of 24 included studies) and most sampled urban hospital staff. Our study indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes. CONCLUSIONS: The evidence to date suggests that female nurses with close contact with COVID-19 patients may have the most to gain from efforts aimed at supporting psychological well-being. However, inconsistencies in findings and a lack of data collected outside of hospital settings, suggest that we should not exclude any groups when addressing psychological well-being in health and social care workers. Whilst psychological interventions aimed at enhancing resilience in the individual may be of benefit, it is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Further research including social care workers and analysis of wider societal structural factors is recommended.

Barriers and facilitators to participating in cardiac rehabilitation and physical activity in a remote and rural population: A cross-sectional survey.

BACKGROUND: Cardiac disease requires ongoing active management which may include attendance at formal cardiac rehabilitation (CR) and increased physical activity (PA). However, uptake rates are sub-optimal. This study aimed to identify factors associated with attendance at CR and PA in a rural Scottish population. METHODS: A cross-sectional postal survey assessing factors potentially associated with attending CR and participating in PA. Data were also collected from hospital electronic medical records. Binary logistic and ordinal regressions were used to identify barriers and facilitators to participation. RESULTS: The cohort consisted of 840 participants referred to the CR department of a regional Scottish hospital. After applying the inclusion/exclusion criteria, 567 patients were sent a questionnaire. The number of returned questionnaires was 295 (52.0%). Responders were predominantly male (75.9%), with a mean age of 68.7 years. At the multivariate level, the only factor associated with CR attendance was a lack of perceived need (odds ratio [OR] 0.02, 95% confidence interval [CI] 0.01-0.06). Analyses of PA associations identified self-efficacy as the only significant facilitator (OR 1.29, 95% CI 1.05-1.59), and a lack of willpower as the only barrier (OR 0.42, 95% CI 0.18-0.97). Other factors were linked to CR attendance and PA at a univariate level only. CONCLUSIONS: This study characterised CR and PA participation, and explored demographic, medical, and psychological factors associated with both activities - with the most important being perceived need, self-efficacy and willpower. These findings may be beneficial in clinical practice by targeting these factors to increase CR attendance and PA levels.

Using micro-geography to understand the realisation of wellbeing: A qualitative GIS study of three social enterprises.

Social enterprises are promoted as a method of welfare reform, to transition people out of disadvantage by addressing poverty, unfulfilled capabilities and social exclusion. This study explores how three Work Integration Social Enterprises (WISEs) in Australia help to realise wellbeing for their employees by mapping their micro-geographical experience of wellbeing. By mapping the sites within a social enterprise where wellbeing is realised, we provide a practical, empirical and replicable methodology that is useful for gaining insights into where and how wellbeing realisation occurs. This situates wellbeing as an upstream place-based resource likely to influence downstream health outcomes.

Co-production of "nature walks for wellbeing" public health intervention for people with severe mental illness: use of theory and practical know-how.

BACKGROUND: Interventions need to be developed in a timely and relatively low-cost manner in order to respond to, and quickly address, major public health concerns. We aimed to quickly develop an intervention to support people with severe mental ill-health, that is systematic, well founded both in theory and evidence, without the support of significant funding or resource. In this article we aim to open and elucidate the contents of the 'black box' of intervention development. METHODS: A multidisciplinary team of seven academics and health practitioners, together with service user input, developed an intervention in 2018 by scoping the literature, face-to-face meetings, email and telephone. Researcher fieldnotes were analysed to describe how the intervention was developed in four iterative steps. RESULTS: In step 1 and 2, scoping the literature showed that, a) people with severe mental illness have high mortality risk in part due to high levels of sedentary behaviour and low levels of exercise; b) barriers to being active include mood, stress, body weight, money, lack of programmes and facilities and stigma c) 'nature walks' has potential as an intervention to address the problem. In Step 3, the team agreed what needed to be included in the intervention so it addressed the "five ways to mental wellbeing" i.e., help people to connect, be active, take notice, keep learning and give. The intervention was mapped to key behavioural change concepts such as, personal relevance, relapse prevention, self-efficacy. In Step 4, the team worked out how best to implement the intervention. The intervention would be delivered over 12 weeks by members of the hospital team and community walk volunteers. Participants would receive a nature walks booklet and text messages. CONCLUSIONS: We developed a theoretically-informed, evidence-based nature walks programme in a timely and relatively low-cost manner relevant in an era of growing mental illness and funding austerity. Further research is required to test if the intervention is effective and if this approach to intervention development works.

Psychological effects of outdoor activity in type 2 diabetes: a review.

Previous research has shown individuals living with type 2 diabetes are more likely to experience depression, anxiety and reduced quality of life (QoL) in comparison to those without the disease. Physical activity has been highlighted as an important factor in improving physiological and psychological parameters in this population. Previous systematic reviews have found mixed results regarding the effects of exercise on psychological problems. Green exercise is an emerging research area with mounting evidence demonstrating positive effects on mental health. Objectives of the current review investigated whether conducting physical activity in outdoor environments had any effect on psychological problems in individuals with type 2 diabetes. Methods such as PubMed, Medline, PsycINFO, Scopus, Cochrane library, CINAHL, SPORTDiscus and Google Scholar databases were searched. The databases were searched for articles which used an outdoor exercise intervention and investigated psychological problems in individuals with type 2 diabetes. Results from the 1467 retrieved articles, 4 studies were included in the systematic review, consisting of 231 participants. All four studies investigated QoL, one study looked at depression and one investigated general wellbeing. Mixed results were found regarding QoL, no significant effect was found for depression. However, general wellbeing was improved. Due to the limited number of studies eligible for inclusion and the heterogeneity of outcome measures, it was difficult to draw firm conclusions. This systematic review acts as a starting point for future investigations into the use of green exercise in improving the mental health of individuals living with type 2 diabetes. Registration: PROSPERO: CRD42018088212.

Does the Mode of Exercise Influence the Benefits Obtained by Green Exercise?

Green exercise studies have tended to use walking as a modality of exercise to establish benefits to mental health. Whether green exercise benefits translate into different forms of green exercise has been deemed an important research gap. A mixed-methods study design was used to compare psychological responses between two forms of green exercise; golf and walking. A total of 20 participants (10 in each group), with a range of ages and experience were recruited to take part in the study. Participants in the walking condition exhibited significantly greater levels of dissociative cognitions than golf condition participants. Consequently, only the walking condition significantly improved in a directed attention test. Results from the Exercise-Induced Feeling Inventory questionnaire found the walking condition demonstrated increases in all four subscales, whereas the golf condition showed no significant improvements. Based on the findings from the qualitative analysis, distinct differences were seen with regards to the perception of the environment. Participants in the golf condition noted natural elements as obstacles to effective performance, whereas the walking group noted natural stimuli as evoking positive feelings. In agreement with the Attention Restoration Theory, the current study demonstrates that the benefits of green exercise are somewhat reduced when greater levels of directed attention towards the activity are exhibited during green exercise.

What Motivates Participants to Adhere to Green Exercise?

There is a lack of research into green exercise which investigates and compares motivational drivers between the different types of outdoor activities. The current paper addressed this gap by classifying and comparing three types of green exercise: (i) Recreational physical activity, (ii) competitive sport, and (iii) outdoor adventure sport. Using a mixed methodological approach, the present study investigated the motivations for adhering to green exercise and directly compared the differences between these three forms of green exercise. Online questionnaires and face-to-face interviews were used to collect data. The results demonstrated that within all types of green exercise, enjoyment was the greatest motivator. Based on analysis of the qualitative materials, extrinsic motivators such as the environment, family, and friends were highlighted as key factors in beginning and continuing their activity. However, intrinsic motivators were also emphasised as more important in adherence to green exercise. Furthermore, as seen in other research, numerous psychological benefits were reported over time. The results of the study may act as a starting point in understanding how we may increase public engagement in green exercise by prompting participants to select a form of green exercise that best suits them based on their motivational profile.

The personal and community impact of a Scottish Men's Shed.

Social isolation and loneliness are known to be associated with increased morbidity and mortality. Therefore, reducing social isolation and loneliness may improve such outcomes. In relation to men's health, "Men's Sheds" have been shown as one mechanism to achieve this. Studies in Australia and England have shown social, health and personal benefits; however, this remains an area that has not yet been researched in Scotland. This study, therefore, aimed to assess the characteristics of attendees, self-reported motivations for and the values and benefits of attending the Shed from the views of the attendees themselves. The participants of the study were the members of a Men's Shed in the North of Scotland, which was initially set-up by a small number of core Shedders. A convenience sample was recruited by opportunistic interviewing of participants when they attended the Shed using a mixed methods approach from 1 to 15 November 2016. In the absence of a validated questionnaire, a bespoke questionnaire was developed in several iterative stages. The answers to the questionnaire were transferred to an electronic database and analysed by frequency and thematic analysis. The participants (n = 31) had a mean age (SD) of 69.7 ± 9.5 with 96.8% being retired, thus the majority of the Shed users were older and retired. The results suggest that there were several benefits from attending the Shed, with an overwhelming majority of the sample reporting personal, social and health benefits-however, more research is needed to determine the magnitude of these. This study has also shown that the men attending the Shed frequently discussed health, which could potentially have a beneficial effect. The Shed therefore, as a community project, has the potential to have a positive impact on health welfare by focusing on the social aspects of life.

Learning and unlearning dignity in care: Experiential and experimental educational approaches.

Guarding against loss of human dignity is fundamental to nursing practice. It is assumed in the existing literature that 'dignity' as a concept and 'dignity in care' as a practice is amenable to education. Building on this assumption, a range of experiential and experimental educational approaches have been used to enhance students' understanding of dignity. However, little is known about student nurses' views on whether dignity is amenable to education and, if so, which educational approaches would be welcomed. This mixed-methods study used an online questionnaire survey and focus groups to address these questions. Student nurses in Scotland completed online questionnaires (n = 111) and participated in focus groups (n = 35). Students concluded that education has transformative potential to encourage learning around the concept of dignity and practice of dignity in care but also believed that dignity could be unlearned through repeated negative practice exposures. Experiential and experimental educational approaches were welcomed by student nurses, including patient testimony, role-play, simulation, and empathy exercises to step into the lives of others. Nurse educators should further integrate experiential and experimental educational approaches into undergraduate and postgraduate nursing curricula to guard against the loss of learning around dignity students believed occurred over time.

Student nurses' perceptions of dignity in the care of older people.

AIM: The aim of this research was to investigate student nurses' perceptions of the concept of dignity in the care of older people. Student nurses regularly move between the classroom and the clinical setting and are thus ideally placed to cast light on the barriers that exist to providing dignity in care and the way in which their theoretical understanding of dignity is shaped by exposure to the practice setting. METHOD: All student nurses on a three-year undergraduate nursing programme at one university were invited to participate in an online questionnaire survey and focus groups. RESULTS: Students equated the practice of upholding dignity with listening to individuals, involving them in decision making and maintaining their privacy. Participants were mostly confident about what dignity meant in practice, but were unsure about the more theoretical aspects. Four major barriers to the promotion of dignity were highlighted-these were organisational, environmental, professional and personal in nature. CONCLUSION: Dignity education should occupy a more prominent position in pre-registration nursing programmes.

Revealing student nurses' perceptions of human dignity through curriculum co-design.

Dignity is a slippery concept to define - yet it has been at the heart of media and policy debates around the provision of health and social care in recent years; particularly in the United Kingdom following the Mid-Staffordshire scandal and subsequent Francis Inquiry. This paper considers the concept of dignity in care from the perspective of student nurses. Thus, it allows us to discuss how professional nurses-to-be conceptualise dignity and also how they consider it should/could be taught at undergraduate and postgraduate levels of training, and as part of their Continuing Professional Development. It is only through understanding how student nurses conceptualise and experience human dignity, and the giving and receiving of dignity in care, that it will be possible to support its facilitation in the preparation of practitioners. This paper reports on findings from a series of participatory research workshops held with undergraduate nursing students in Scotland in 2013-14 that were designed to engage the students in the development of educational resources to support the teaching of dignity in care within the nursing curriculum. The outputs from each workshop, along with analysis of transcripts of the workshop discussions, demonstrate the value of co-design as a methodology for involving students in the development of interdisciplinary resources. We observed a desire from students to actively enhance their understandings of dignity - to be able to recognise it; to see dignity in care being practiced; to experience providing such care and to have the appropriate tools to reflect on their own experience. Overall, the research revealed a rich understanding of the ways in which human dignity is conceptualised by nursing students as an embodied practice, associated with memory and personal to an individual. It was understood by the students as shifting, experiential and fragile.

Community participation for rural healthcare design: description and critique of a method.

This paper outlines a community participation process that was developed to engage rural community stakeholders in designing new health services. The paper explains what led up to the process and provides critique around applying the process for other health services and in other communities. Internationally, community participation is widely invoked, but it is only broadly explained in the literature, other than reviews of outcomes or descriptions of problems. This paper provides an actual process, derived from iterative research, that others could use, but explains caveats in the method and its application. From developing this method of community participation for service design, we conclude that rather than being a benign and inherently 'good thing', community participation is a process into which health services managers and communities should enter cautiously. Stronger parameters around desirable outcomes and awareness of potential pitfalls in the process are important to address.

An exploration of the longer-term impacts of community participation in rural health services design.

This article explores what happened, over the longer term, after a community participation exercise to design future rural service delivery models, and considers perceptions of why more follow-up actions did or did not happen. The study, which took place in 2014, revisits three Scottish communities that engaged in a community participation research method (2008-2010) intended to design rural health services. Interviews were conducted with 22 citizens, healthcare practitioners, managers and policymakers all of whom were involved in, or knew about, the original project. Only one direct sustained service change was found - introduction of a volunteer first responder scheme in one community. Sustained changes in knowledge were found. The Health Authority that part-funded development of the community participation method, through the original project, had not adopted the new method. Community members tended to attribute lack of further impact to low participation and methods insufficiently attuned to the social nuances of very small rural communities. Managers tended to blame insufficient embedding in the healthcare system and issues around power over service change and budgets. In the absence of convincing formal community governance mechanisms for health issues, rural health practitioners tended to act as conduits between citizens and the Health Authority. The study provides new knowledge about what happens after community participation and highlights a need for more exploration.

Theory in rural health.

OBJECTIVE: This paper offers theories to explain persistent rural health challenges and describes their application to rural health and research. METHODS: Review of theories from several disciplines. FINDINGS: Key issues in rural health are poorer health status and access to health care, staff shortages, relationship-based health provision and the role of health services in community sustainability. These could be fruitfully addressed by applying theory and findings around social determinants of health, economic sociology, the role of culture and capitals approaches to measuring assets. In particular, the concept of rural health might be a barrier to progressing knowledge; and relational approaches, common in geography, offer a more useful conceptual framework for studying health and place. CONCLUSIONS: To move beyond its current stage, rural health needs to look to other disciplines' theories and ideas; particularly, it needs a more contemporary understanding of what place means so that health status and service provision can be improved by more thoughtful research.

Being rural in rural health research.

This paper explores ways that being from a rural background might influence the health research process and why this might occur. It draws on the research experiences of three 'generations' of rural health researchers to suggest rural background affects how researchers approach and conduct study, and how they interpret findings. Concepts of positionality, habitus, performance and 'othering' are explored to suggest how existing sociological and philosophical ideas can explain why rural researchers possess a particular worldview that may influence their research outputs.

Is a global rural and remote health research agenda desirable or is context supreme?

OBJECTIVE: This paper proposes that there is value in international comparison of rural and remote health-care service delivery models because of practical reasons - to find ideas, models and lessons to address 'local' delivery challenges; and for theoretical reasons - to derive a conceptual framework for international comparison. METHODS: Literature review and commentary. FINDINGS: There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care. CONCLUSIONS: The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.