School of Nursing
Online Journal

Promoting Rural Health and Reducing Rural Suicide

Lana Ennis

Introduction

In this literature review I will investigate what contributing factors affect the prevalence of male suicide rates in rural communities of New Zealand. I have refined my search question using the PECOT (Whitehead, 2013) model to find specific, more accurate and useful information that I will critically discuss. I also state why I chose this topic, the implications it has within the rural setting, and how evidence gained from reviewing literature has lead me to formulate recommendations including important factors that will reduce the rate of rural males suicides. The increase in rural male suicide rates over the last 25 years and the emerging research on this issue has made it a significant topic in New Zealand. In recent years a number of organisations have collaborated in order to combat this issue; but there has been insignificant change with a real urgency for it. Rural nurses are vital for the mediation of those depressed or suicidal farmers and navigation into mental health services. As nurses, it is our role to engage and communicate as we are the catalyst for change in public health (Castledine, 2002), we are trained to use evidence based practice and we can help to design and implement specific interventions to target this issue. 

Clinical issue

Suicide Statistics (2012) New Zealand’s supports suicide rates have historically always been high, with a spike in the mid 1980s. Suicide is not new in farming culture, but is becoming more recognised by society. Suicide rates are higher in rural areas at 16 per 100,000 people compared to urban being 11.2 (Ministry of Health, 2011). According to Walker (2012) on average 24 rural males complete suicide each year. Additionally, male suicide rates are higher than women at a ratio of 26:5 (Karlin, 2014). Males are staunch, thus tend not to seek help or sign up for counseling and treatment and in turn suffer from undiagnosed depression. Rural suicide is not freely spoken about among New Zealand public as there are negative attitudes and stigma associated with mental illness. 

PECOT

Through use of the PECOT model (Whitehead., 2013) I have developed my search question on New Zealand’s current rural suicide issue. Given the high rate of suicide among New Zealand rural men, I want to understand the barriers that prevent these men from seeking help and why they are not being diagnosed. In turn, I hope to identify effective ways in which mental health services can work to reduce this occurring. The literature review will be based on the question: Why is there a continued high prevalence of suicide in rural male farmers in New Zealand?  

Evidence and findings

Farming life is a full time, live in commitment, characterised by taxing circumstances such as financial distress, long work hours and severe isolation, which may exacerbate anxiety and stress levels (Stark, Riordan, & O’Connor, 2011). Farmers draw on their determination and strength of character during these challenging times. Farmers’ strengths and qualities, such as resilience, being capable of coping and self-reliance can be both beneficial and detrimental. Those traits affect why men fail to seek mental health support and on the contrary, why they have promising recovery rates when they do commence treatment and/or therapies (Hughes & Keady, 1996). Farmers can cope when they are mentally well, however, when stress levels are increased significantly this can be detrimental to their mental state, resulting in undiagnosed depression (Botha & White, 2000).

Symptoms and causes

Depression is a mental illness that is characterised by the inability to concentrate, insomnia, loss of appetite, feelings of extreme sadness, helplessness and hopelessness and thoughts of death (Smith, Segal, & Robinson, 2014). Suicide is a desperate attempt to escape the unbearable feelings of specifically “hopelessness”, where no other option is perceived (Federated Farmers of New Zealand, 2014). Suicidal farmers are desperate for an alternative, but suffer from tunnel vision. The majority give warning signs such as negative feelings, dramatic mood swings, social withdrawal, neglect of farm maintenance and negative attitudes towards ones future (Oliffe, Orrodniczuk, Bottorff, Johnson, & Hoyak, 2012). The common risks appear to be social isolation, geographic isolation and rural men’s conceptualisation of depression – the trait of stoic self-reliance (Karlin, 2014).  

The downstream effects of anxiety and depression are substantial. For example, poorer decision making on the farm, affecting animals and the whole farm system has a cumulative negative affect on farm productivity and profitability (Judd, Jackson, Fraser, Murray, Robins, & Komiti, 2006). The most significant effect of course, is on the family and those closest to the person affected (O’Hara, 2010). Depressed rural men adopted more risky behaviours including alcohol and tobacco use, and had more injuries and motor vehicle accidents, which may also attribute to depressive symptoms (Roy, Tremblay, Oliffe, Jbilou, & Robertson, 2013).  

Financial problems are one of the biggest issues in the farming sector. Farmers have been left in devastation and despair from recent droughts and earthquakes.  In addition, the removal of the subsidies, uncertain returns, and fluctuation in strength of the New Zealand dollar, increasing interest rates, huge debts and operational compliances from government legislation may induce stress and thus, depressive symptoms (O’Hara, 2010).  Farmers work long hours 24/7, lack sleep and take few holidays. In a survey by Botha (2013) dairy farmers reported working more than 70 hours per week and during on ‘on-farm’ breaks, they can not stop worrying and thinking about jobs they need to achieve (Roy et al. 2013).  

Farmers become more isolated as there is less opportunity for social contact regarding work discussions, as more impersonal communication increases with emails and cellphone use (Roy et al., 2013). There has been a decline in church attendances, and in traditional meeting places such as salesyards (O’Hara, 2010). Rural settings have become decimated in recent years with educational, commercial and social service closures. Traditional family dynamics have changed with more mobility; seeing family networks spread far and wide (Kutek, Turnbull, & Fairweather-Schmidt, 2011). The latter all correlate with increasing rates of depression amongst rural males. 

Stigma and lack of awareness

Research undertaken by Nicholson (2008) clearly identifies stigma and negative community attitudes towards mental health as a serious issue, hence why males find it difficult to seek help. A Taranaki survey suggests 89% of people who suffered mental illness experienced some sort of discrimination (Ministry of Health, 2011). The stoic image is a barrier that needs to be broken down, as farmers are normal human beings who feel the ups and downs of wins and losses as everybody else (Fuller, Edwards, Procter, & Moss, 2000). There is a perceived culture of silence in rural communities of New Zealand, as many will not discuss emotional issues. Two thirds of sufferers do not seek help for mental health issues and are more likely to seek help for physical symptoms (Botha et al., 2013). 

Tens of thousands of 2010s issue of “Down On The Farm” representing Otago/Southland/Canterbury (O’Hara, 2010) and the 2012s Taranaki issue (Evans, 2012) was distributed to promote awareness. These documents are for farmers by farmers with a core message that seeking help for mental distress is a strength and not a weakness. 

The Ministry of Health launched National Depression Initiative (NDI) in 2006. Sir John Kirwan a well-known ex-All Black fronts the NDI, his masculine identity is relative to many ‘kiwi blokes’. Kirwan, has experienced depression and is an advocate towards re-imaging masculine ideologies, instead of reinforcing hegemonic gender norms, which may obstruct men from expressing and identifying their mental illness (Alston & Kent, 2008). Kirwan’s identity incorporates a modern New Zealand mans characteristics as more open about their emotional needs (Levant & Habben, 2003). In 2014 Federated Farmers and NDI have combined to tackle the societal attitudes. Farmer’s subjective experience are documented on the NDI website which reinforces the change in image.

Action

There is a need to educate rural communities to detect depression, as some farmers cannot recognise it themselves (Houle, Mishara, & Chagnon, 2008). In a systematic review Gulliver et al.,(2012) concluded people often seek help from informal sources, such as friends or family. Suicide prevention begins with being able to recognise the warning signs and taking action as early as possible (Stark et al., 2011). Services need to ensure relevant education and training is available in these communities. Strong, cohesive and self-determining communities are a real protective factor against suicide prevention activities, as suicide is something that affects us all (Alston et al., 2008).  

“Like Minds” have held workshops for rural men and women. One and two-day courses were held, and were both fully enrolled, this is sufficient proof enough that there is a huge interest and high demand for information (personal communication, 2014). MH101 courses have seen a promising trend with wives attending the first few classes alone, then are joined by their husbands for the duration of the course (personal communication, 2014). This indicates that rural men can be targeted via rural women. Husband’s do not necesarrily have to attend, as women’s ability to recognise when their children, partners, friends, have symptoms. Therefore they are better equipped to manage the situations and can commence to process of figuring out what is the issue. New Zealand’s efforts have seen a 50 percent increase in accessed mental health services from 2001-2011 (Walker, 2012). 

New Zealand is taking steps towards forming a strong force to decrease rural suicide rates by collaboration of services. For example, rural communities are meeting with District Health Boards, to discuss collaboration of services to meet local needs (Federated Farmers of New Zealand, 2014). This is a positive shift that hopefully other Primary Health Organisations will consider. It is expected that stronger connection and partnerships between the organisations will ensure better outcomes for those suffering from depression (Keyzer, 1997). 

Nurses play a key role

Pirret’s (2014) recent research in New Zealand has concluded that nurse practitioners and trainee medical specialists were significantly in-different in relation to diagnosis accurateness. From this study it was also found although nurse practitioners practised independently and autonomously they had built relationships with medical specialists and were significantly much more likely to consult rather than registrar’s (Pirret, 2014). According to international research, nurses spend more time than doctors educating patients and their families about their condition and how to manage it (Pirret, 2014). Evidence supports nurses can be confident in our knowledge to teach and clinical judgment; we are educated and, have the ability to detect depression. Earlier intervention is easier said than done, research suggests farmers must first view the nurse as valuable within the community or else the service may be ineffective (Hughes et al., 1996).

Rural nurses need to establish strong interlinks with colleagues as well as a demographic profile by immersing themselves in the culture and environment of farming (Banner, MacLeod, & Johnson, 2010). Every farmers’ experience is unique; nurses need to develop an understanding of this to provide optimal advocacy (Kutek et al., 2011). Showing respect, rights and equality for people with mental illness just as important as providing sufferers with best treatment and therapies (Castledine, 2002).

Recommendations and rational and implications

After undertaking this literature review themes emerged that there is a deficit in how to know when rural males need help, where to find help and how do family and friends support them to get help when they need to. New Zealand needs to focus on supporting the development of, and encouraging the use of farmer self-help strategies (Roy & Tremblay, 2012). Nurses need to monitor and evaluate the effectiveness of collaborative primary and secondary prevention activities. I believe New Zealand’s government needs to support research that enhances networks understanding of issues and solutions associated with stress and poor mental health seen in farmers. I would recommend surveys to all rural communities to establish their preference. Somehow, rural communities need to find the time and effort to start socialising more together; this may be another opportunity for an mental health awareness watch and support system. 

Australia is having success in their efforts in reducing their national suicide rate after allocating $440 million to suicide prevention two years ago whilst New Zealand spent 5.6% of this amount for 2013-2016. New Zealand has fewer resources than other countries, so we need to use these efficiently. I believe that networking and collaboration with governments, other health promotion organisations and initiatives to combat mental illness stigmas through advocacy and raising awareness is key. I recommend more education for rural communities with regard to mental health; workshops are already having a positive effect, this needs to be maintained if not improved. Geographic limitations is a very difficult to barrier overcome, however through survey and communication we can work to resolve this issue. I believe education should not only assist in management of stress, but how to cope better for when the next stressful situation occurs.

Conclusion

Mental health promotion and education in rural communities combined with stronger bonds between such organisations and rural communities may increase detection amongst farmers suffering from depression and thus, decrease rates of suicide. Based on current research, I believe that the key to decreasing such suicide rates is having a positive and willing attitude when it comes to making use of resources, such as support systems, which may help with depressive symptoms such as suicide. Current research indicates that those suffering will benefit from raised awareness about the prevalence of mental illness and in turn, attempt to avoid negative stigmas associated with mental illness amongst men. Rural communitities and the organisations serving them must continue to do so as farmers can not do it alone. 

References

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Banner, D., MacLeod, M., & Johnson, S. (2010). Role Transition in Rural and Remote Primary Health Care Nursing. McGill University School of Nursing, 42(4), 40-57.

Botha, N., & White, T. (2013). Distress and burnout among NZ dairy farmers: research findings and policy recommendations. Extensive Farming Systems,9(1), 160-170.

Castledine, G. (2002). The development of the role of the clinical nurse specialist in the UK. British Journal of Nursing,11(7), 506-508.

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Fuller, J., Edwards, J., Procter, N., & Moss. (2000). How definitions of mental health problems can influence help seeking in rural and remote communities. Australian Journal of Rural Health, 8, 148-153.

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