National Rural Mental Health Survey Scotland:
Report Executive Summary
Professor Sarah Skerratt
With Dr Elliot Meador and Dr Michael Spencer
13th April 2017
Understanding of rural people’s experiences of mental ill health in rural Scotland is largely anecdotal. A more systematic analysis was needed, in order to (i) identify whether rural-specific issues exist, and (ii) inform policy and practice.
To enable this sensitive topic to be approached appropriately, a partnership was formed between SRUC’s Rural Policy Centre and Support in Mind Scotland (SiMS), bringing together complementary skills and knowledge of rural Scotland and mental ill health respectively.
The research was carried out when the national Mental Health Strategy was being refreshed, and while preparations are in progress for a Suicide and Self-Harm Strategy/Plan, a Dementia Strategy and a national Strategy to tackle Social Isolation.
In March 2017, the Scottish Government published its new, ten-year Mental Health Strategy, recognising rural issues of isolation and service provision, and the central role of the new National Rural Mental Health Forum in creating connections between communities to address isolation and improve mental wellbeing.
Scoping phase: two service-user-focused workshops were co-hosted by SRUC/SiMS in June 2016 (Inverness and Dumfries) to form the basis for the survey questions.
Online (Survey Monkey) and offline (paper) survey: targeted at those experiencing mental ill health within rural Scotland, publicised through SiMS database, professional networks of SRUC and SiMS and via social media (Twitter and Facebook).
Questions: open and closed, covering personal characteristics, self-reported mental health issues, Warwick-Edinburgh categories of mental wellbeing, public transport and mental health services, geographical remoteness, importance of community, desired changes to mental health services and key messages to policy makers.
Analysis: mixed methods, using quantitative (SPSS, R, ArcGIS, Descriptive analysis, T-tests and chi squared tests) and qualitative (Thematic Analysis) approaches.
Survey sample: 343 responses were received from those experiencing mental ill health across rural Scotland, covering 94 postcode areas from Remote through to Accessible rural. The highest number of responses came from the Dumfries and Galloway postcode area. Respondents were 273 female, 70 male, the majority in the 45-54 age cohort, with almost 50 aged 16-24. The majority were in paid employment, self-employed or on government training, with less than 50 unable to work – generating new evidence from those employed who also experience mental ill health. Occupations were spread across business, finance and the public sector.
Respondents’ self-reported mental health issues: 197 people reported depression (67% of the sample), 87 people reported generalised anxiety disorder (29%), 64 people reported suicidal thoughts and feelings (22%), 53 people reported social anxiety disorder (18%) with 35 reporting self-harming behaviour (12%). This was during the four-week period of August-September 2016. Percentages of those self-reporting were similar for males and females, and were also spread across ages, both patterns running counter to some stereotypical expectations.
Geographical location and distance to mental health facilities: respondents’ partial postcodes (e.g. KW14 or TD11) enabled the comparison of actual geographical location against perceived geographical remoteness. There was no clear link between the two, except for those living in “Remote rural”, with 80% of those living in Remote small towns and 50% of those living in Accessible rural Scotland considering themselves to be geographically remote. The majority of respondents stated that public transport acts as a barrier to them receiving proper care needed to manage their mental health, a situation which worsened for those self-reporting suicidal thoughts and feelings, and self-harming behaviour. This can lead to a “layering” of isolation factors.
Community support and connections: community is experienced in many different ways by survey respondents, with local connections being close and strong for some, while being judgemental and parochial for others. Responses are mixed with respect to the extent to which respondents feel supported by their community or can rely on community members when an urgent but non-life-threatening mental wellbeing issue arises. The majority of respondents do not feel they can be open about their mental health problems in their community. Similarly, respondents express a variety of advantages and disadvantages about where they live, in relation to their local community.
Key question 1: If you could change one thing about mental health services in rural Scotland, what would it be and why?
There is a strong need and desire to create ways for people to connect with one another before their personal crises occur;
These connections need to be “low-level”, in non-clinical and informal settings, through trusted people and networks;
Services need to be close to the place of need, designed to include mobile services and outreach, particularly on the islands; this “outreach” approach recognises the significant stress of travelling to appointments for those with mental ill health;
Mental health care must be mainstreamed within the NHS and not a “bolt-on”;
There must be parity between mental and physical health care;
There must be an increased focus on the needs of children and young people, reducing waiting times, particularly in relation to self-harming.
Key question 2: What key message do you want to tell policy makers to help you manage your mental ill health in a rural setting?
Mental ill health is an invisible illness – made more invisible by being rural and remote;
Users of mental health services must be listened to and respected;
Mental ill health does lead to death – it is a serious issue;
There must be shorter waiting times to see specialists;
There must be support for “low-level” contact outwith hospital environments, close to communities.
Implications of findings:
Legitimacy: this research has presented the voices of those experiencing mental ill health in rural Scotland. Those responding stated that they were experiencing a range of mental health issues; this makes their views no less valid, in fact it enhances their validity, given the focus is on their experiences and proposals for what needs to change to improve their mental wellbeing in a rural setting.
Communities: the research has uncovered significant complexities around the extent to which respondents feel that their communities are supportive of them. This is extremely important in and of itself, in terms of overcoming social isolation and addressing issues of stigma and prejudice. It is also important due to the direction-of-travel, in policy and practice, towards community-based health and social care. There is work to be done in understanding how to engender and support well connected communities so that they can provide the appropriate “low-level, non-clinical, local, trusted” approaches called for by respondents, and how the work of the National Rural Mental Health Forum can support this inclusive shift at national and regional levels.
Policy: there is a need to continue to feed evidence from the rural survey into the National Rural Mental Health Forum and the ten-year Mental Health Strategy, as well as the Suicide and Self-Harm Strategy/Action Plan and the National Strategy to tackle Social Isolation. The new survey evidence is also of relevance to: Community Empowerment (Scotland) Act 2015 (e.g. through Community Planning Partnerships and their Local Outcome Improvement Plans); the 2016/17 Enterprise and Skills Review; “Our Islands Our Future” and the Islands Bill; the Rural Economy and Connectivity portfolio of the Scottish Government; as well as to the specific Actions of the Mental Health Strategy around inclusive employment (Actions 36 and 37).
Evidence: The ultimate aim of this new rural evidence is to improve people’s mental wellbeing. Although the numbers of these rural voices will always remain small, due simply to being a part of only one fifth of Scotland’s population spread over 98% of its land mass, they nonetheless provide a compelling and authentic evidence base from which to build learning and tailored support.
Firstly, we would like to acknowledge the time taken by the survey respondents in filling in the survey, in being open in their responses, particularly in giving their thoughts and suggestions around rural mental health services and key messages to policy makers. Without their considered input, this report could not have been written.
Secondly, we are grateful for the feedback and input from the members of the National Rural Mental Health Forum, on the initial exploration of the survey findings in November 2016, and their subsequent comments at the second meeting of the Forum in March 2017. Their thoughts and reflections have helped guide elements of this report, with the usual disclaimer applying - that any errors and omissions remain those of the authors.
Thirdly, we appreciate the publicising of the online and offline survey by colleagues in SiMS, SRUC and more widely through mental health charity networks, and colleagues throughout the “rural world” who shared and re-Tweeted the postings on Facebook and Twitter, to enable people in as many parts of rural Scotland as possible to know about the survey, and to have the opportunity to respond.
Fourthly, I would like to acknowledge the quantitative data analytics of Dr Elliot Meador and Dr Michael Spencer (SRUC) whose work has been presented at the two meetings of the Forum, the Cross Party Group in the Scottish Parliament on Rural Policy and in this Report, alongside the qualitative findings from the survey. Their insights have contributed to the rich narrative from across Scotland’s rural communities.
Finally, we would like to thank the Scottish Government’s Rural Communities Policy Team for their engagement and commitment as we have delivered the first and second stages of the analysis with stakeholders. We have greatly valued their consistent encouragement and support throughout. We are also grateful for RESAS Underpinning funds which contributed towards analysis of the data and report-writing.