The term ‘rural and remote’ in this section refers to all geographic areas outside major cities in Australia, which includes both inner and outer regional, as well as remote and very remote areas [1757]. People living in rural and remote communities experience a variety of social, attitudinal, economic, geographic, and community barriers which means that they are likely to have difficulties accessing treatments and specialist care [1758, 1759]. Youth in these communities are at particularly high-risk, and alcohol-related and rural stressors are likely to play a role in the high rates of suicide among males [1760–1763].
The lack of specialists in rural and remote regions tends to result in heavy reliance on primary and AOD health care providers. Compared to major cities, rural areas have significantly less access to specialised mental health care, with per-person supply of employed medical practitioners decreasing according to remoteness [1758]. Although there is a national focus across Australia to increase the supply of health workers to rural and remote areas, it is estimated that regional areas access 42% of psychiatrists, 89% of mental health nurses, and 59% of psychologists per 100,000 people compared to major cities, with even poorer access for remote areas [1764]. Moreover, Medicare expenditure on mental health services in inner regional and remote areas is considerably lower than that in major cities [1759, 1765], which suggests lower per-person access to, and receipt of, healthcare services.
People living in rural areas have indicated that addressing treatment barriers by investing in medical infrastructure and increasing the number of healthcare providers would improve their ability to receive adequate treatment for their co-occurring conditions [1766]. This evidence aligns with experiences of healthcare workers in rural areas, who have highlighted difficulties in providing adequate services due to personnel, resource and infrastructure shortages, such as lack of high-speed internet, or equipment for e-health/telehealth [1767, 1768]. Such disruptions impact on the continuity of care, and can result in rural patients being the least likely to receive follow-up monitoring for AOD use issues relative to people living in less remote locations [1769].
The health of rural and remote Australians is comparatively poorer than Australians living in major cities [1758], and the lack of resources and healthcare workers makes working in these settings particularly challenging. Self-harm, and suicide rates similarly increase with remoteness in Australia, and are almost three times higher in very remote areas (29.4 per 100,000 people) compared to major cities (10.9 per 100,000 people; [1759]).
Research has found that people living in remote areas are less likely than major city residents to endorse evidence-based interventions as useful for mental health treatment, and are less likely to perceive psychologists, psychiatrists, GPs, and social workers as helpful in the treatment of mental health conditions [1770, 1771]. There is also evidence that people living in remote areas are also more likely than those living in major cities to identify non-evidence-based treatments (e.g., alcohol and painkillers) as helpful interventions for mental health conditions, highlighting the need for effective communication and psychoeducation focused on best-practice treatment and management of mental health in rural and remote areas [1770, 1771].
Although accessing treatment has been identified as a particular challenge in this population group, self-guided approaches, such as bibliotherapy or e-health interventions have proven to be effective as have alternatives to face-to-face methods (e.g., telephone, email, internet) where geographical isolation and lack of specialist services are obstacles [1772]. For example, moodgym is a free online CBT self-help program for anxiety and depression (http://www.moodgym.com.au) that has been shown to be effective in treating symptoms of anxiety and depression [1131, 1773], MindSpot provides therapist-guided online psychological treatment for anxiety, depression, stress and low-mood (http://www.mindspot.org.au), and Mental Health Online (formerly Anxiety Online) comprises five e-therapy programs for GAD, SAD, panic disorder, PTSD, and OCD (http://www.mentalhealthonline.org.au/; [1195, 1196]). Although definitive evidence regarding the efficacy of Mental Health Online is lacking, two naturalistic studies found that participation in the program was associated with significant reductions in severity of all five disorders, and increased confidence in managing one’s own mental health care. Significant improvements in quality of life were also consistently observed for GAD, SAD, and PTSD e-therapy programs, but not the OCD or panic disorder programs [1195, 1196]. Furthermore, in an RCT conducted among participants with co-occurring depression and AOD use, the efficacy of computerised CBT/MI among both urban and rural participants was compared to face-to-face treatment [1774]. Similar improvements were observed in depression, alcohol, and cannabis use when compared with face-to-face treatment, and the computerised delivery was acceptable to people in both urban and rural locations, even among people who indicated a preference for face-to-face therapy [1774].
In terms of feasibility and acceptability of these approaches, while there is evidence that clinicians working in rural areas are optimistic about the use of e-health interventions, until recently there has been a preference for e-health approaches to be integrated alongside existing services, and used as an adjunct rather than alternative to more traditional face-to-face approaches [1775]. As described in Chapter B6 however, the COVID-19 pandemic has necessitated a rapid revolution to the way in which healthcare is delivered and accessed, with approximately 35% of mental health-related services delivered via telehealth between March and September 2020, following the introduction of telehealth items to the Medicare Benefits Schedule [1776]. While e-health interventions have the potential to address many limitations associated with service accessibility among people living in rural and remote areas, evidence suggests that resistance to e-health may be overcome by enhancing community education and program familiarity [1777, 1778].
A systematic review examining telehealth services in rural and remote Australia summarised six key factors associated with the successful integration of telehealth into practice [1779]:
- Vision: Clear, realistic, and feasible outline of the purpose of the service.
- Ownership: Inclusive and genuine consultative service development with stakeholders; supportive management; clinicians who are actively engaged and participating in service delivery (service champions).
- Adaptability: Recognition of the need to remain responsive to stakeholders; willingness to adapt the service model in response to clients, clinicians, and services.
- Economics: Deliver cost savings, prioritising required services for delivery of healthcare; provide value for money for clients; achieve comparable care with clinical benefits.
- Efficiency: Clearly defined, efficient processes for managing activity; recognition that quantity is not reflective of success; high levels of activity not necessary for sustainability.
- Equipment: Careful consideration of required, affordable infrastructure, with plans to manage technical support.
Patterns of AOD use and the types of stressors experienced are likely to vary across different rural and remote areas. For example, inhalants are a particular problem in some rural and remote areas, especially within Aboriginal and Torres Strait Islander populations [1650], whereas cocaine and hallucinogens are more likely to be used in major cities and inner regional areas [1780]. People living in remote and very remote areas are also more likely to use cannabis, non-prescription pharmaceuticals, and opioids compared to people living in major cities [1759, 1780]. The proportion of people drinking alcohol at risky levels increases with increasing remoteness, with certain occupational groups (in particular, farming communities) at particularly high risk, and hospitalisation and mortality associated with alcohol consumption is considerably higher for rural communities relative to urban communities [1780, 1781]. Significantly more people living in rural and remote areas smoke tobacco, although daily smoking rates have declined over the past 10 years in major cities, inner regional, remote, and very remote areas [1780]. People living in rural and remote areas may also experience unique stressors to those in urban areas. For instance, regional and remote incomes can be heavily reliant on industries affected by external factors, such as farming, forestry and mining, which can increase stress when conditions are unfavourable [1759].
AOD workers need to be aware of the particular issues related to AOD use in their communities. Professional networking with local health providers, and fostering trust, non-judgemental acceptance, and confidentiality with clients, may be particularly important in rural/remote communities. In small rural communities, anonymity is very difficult to maintain, presenting a range of additional challenges for the AOD workers. Therefore, issues of confidentiality are particularly crucial.