A scoping review of the barriers and facilitators to accessing and utilising mental health services across regional, rural, and remote Australia

The mental health of Australians who live in regional, rural, and remote Australia is an ongoing concern [1]. Poor healthcare access is one of the key determinants of adverse mental health outcomes, with access issues being more pronounced in regional, rural, and remote Australia (hereafter referred to as rural, in line with the Australian Government’s definition under the Rural Health Multidisciplinary Training [RHMT] Program [2]), compared to metropolitan Australia [3]. People living in rural Australia often face difficulties in obtaining healthcare, and this care is often delayed and more expensive for the patient [4]. These difficulties in accessing and utilising healthcare are implicated in the higher mental disorder burden experienced by those living in rural Australia, shown by the higher rates of suicide, compared with major cities [5]. Moreover, this group is less likely than those living in major cities to take-up and complete mental health treatment [6]. Workforce maldistribution plays a role in these health inequalities [7‐10], with more clinical full time equivalent (FTE) mental health professionals working in major cities, compared with rural areas (i.e., 92 vs. 30–80 mental health nurses, 15 vs. 2–6 psychiatrists, and 90 vs. 15–55 psychologists per 100,000/population) [3]. Other areas of the health workforce are similarly maldistributed across the country (i.e., 403 vs. 223–309 clinical FTE medical practitioners and 531 vs. 382–469 clinical FTE allied health professionals per 100,000/population in major cities versus rural areas) [11].

There are a number of factors that are implicated — both directly and indirectly — in the access and utilisation of mental health services, and these factors may be pertinent to the level of remoteness experienced. This includes particular aspatial (i.e., social) and spatial (i.e., geographical) dimensions [12, 13]. Aspatial dimensions consist of the factors that affect the affordability, acceptability, accommodation, and awareness of healthcare access. In the rural context of Australia, this tends to relate to social matters [14, 15] including stoicism, low help-seeking behaviours, and confidentiality concerns [16]. Spatial dimensions are concerned with the availability and accessibility of service access, including geographical isolation [14], service delivery capacity [17] [18], and dual-roles [14] (i.e., the intersection of professional and personal relationships) in rural areas. While here we define access as factors that pertain to the attributes/expectations of the individual and their alignment with the provider/services [12], other models conceptualise access as the opportunity to identify healthcare needs, seek services, reach resources, obtain or use services, and have the need for services fulfilled [19]. Utilisation refers to the generation of a healthcare plan throughout a healthcare encounter, as well as its implementation and follow-through [20].

Conceivably, mitigating the barriers and augmenting the facilitators to the utilisation of mental health services may be particularly important when considering the obstacles that people from rural areas face when accessing services. One previous study on rurally-based Australian adolescents suggested that barriers to accessing services, such as social exclusion and ostracism by members of their community, also likely prevented the continued utilisation of services and negatively affected treatment outcomes [21]. Cheesmond et al. [22], in a review of residents in rural Australia, Canada, and the United States of America, highlighted a link between sociocultural rurality, rural identity, and help-seeking behaviour. Cheesmond et al. [22] suggested that specific place-sensitive approaches are needed to overcome barriers to help-seeking, and that a greater understanding of help-seeking in the rural context is required. This includes further exploration of rurality as a concept, conducting research within diverse environments, allowing participants to contextualise barriers to help-seeking, and exploring the co-existence of multiple help-seeking barriers. Parallel to this, a paucity of research has focussed on the facilitators to accessing and utilising mental health services in rural Australia.

To the authors’ knowledge, no previous reviews have specifically focussed on understanding the barriers and facilitators to accessing and utilising mental health services within the rural Australian context. A scoping review was chosen as the preferred approach to this work because of the emerging and cross-disciplined nature of the research. The aim of this scoping review is to: (1) explore the barriers and facilitators to accessing and utilising mental health services for Australians living in rural areas; and (2) better understand the relationship between barriers and facilitators and their geographical context.

This scoping review conforms to the guidelines put forward by Arksey and O’Malley [23], follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) [24], and a published protocol [25].

The database search yielded 1,278 articles, of which 555 articles were removed due to duplication. Subsequently, 723 titles and abstracts were screened, and 441 were excluded due to ineligibility. At the full text stage, 282 articles were screened, with 181 studies being excluded, resulting in 47 articles meeting the eligibility criteria. The grey literature search yielded 128 potentially relevant sources, of which six were eligible after removing three for duplication. In total, 53 articles were included in this scoping review. A snowball search of the references of included records was also conducted and two additional records were identified but were deemed ineligible as they reported on studies/samples that were already included in the review. Figure 1 displays the PRISMA flow throughout each screening stage.

This scoping review identified the barriers and facilitators experienced by healthcare providers delivering mental health services and individuals accessing, or attempting to access mental health services in rural Australia. Prominent barriers included: limited resources; system complexity and navigation; attitudinal and social matters; technological limitations; distance to services; insufficient culturally-sensitive practice; and lack of awareness. Facilitators included person-centred and collaborative care; technological facilitation; environment and ease of access; community supports; mental health literacy and culturally-sensitive practice. We also aimed to understand these barriers and facilitators in relation to their geographical context; however, the variability in the data precluded the geographical analysis from being completed.

This study revealed a paucity of research conducted in MM6 remote and MM7 very remote communities in Australia when specific spatial data are considered, as well as in the ACT — however, it is noted that the majority of the ACT is classified as metropolitan, with 99.83% (387,887 residents) of the population residing in MM1 at the time of the 2016 census [2]. Moreover, when proxy study locations are used, many studies are conducted by researchers located in metropolitan areas. Only three studies specifically included service users who were under the age of 18 years old, representing a significant gap in understanding the mental health service needs of the younger population. Although it is acknowledged that there are considerable research ethics restrictions in place to protect children and young people, the onset of many mental health issues tends to occur between 14.5 and 18 years of age [85], highlighting the importance of understanding barriers and facilitators to accessing mental health services amongst the younger cohort. Due to the heterogeneity of the findings, the following discussion considers the most prominent barriers and facilitator concepts identified across the studies.

Review findings support limited resources as being one of the biggest restrictors of mental health service access and utilisation within rural Australia. Thes findings echo reports at the national scale, which show the mental health workforce is heavily concentrated in metropolitan areas compared to other remoteness areas, relative to the population [86]. Considerable efforts need to be made to reduce the resource inequalities, including the dearth of mental health professionals practicing outside of metropolitan cities. Recently, the National Mental Health Workforce Strategy Taskforce (the Strategy) was established to deliberate the quality, supply, distribution, structure, and methods to improve attracting, training, and retaining Australia’s mental health workforce [87]. The Consultation Draft of the Strategy highlights six objectives, including (1) careers in mental health are recognised as, attractive; (2) data underpins workforce planning; (3) the entire mental health workforce is utilised; (4) the mental health workforce is appropriately skilled; (5) the mental health workforce is retained in the sector; and (6) the mental health workforce is distributed to deliver support and treatment when and where consumers need it [88]. These objectives reflect the systemic resource issues cited in the current scoping review and emphasise the importance of a contemporary approach to increasing resources for mental health services in rural Australia. This contemporary approach is important, as it has previously been acknowledged that increasing graduates has not resolved workforce maldistribution in other areas of healthcare (i.e., medical physicians), but rather, an improved distribution of both human and other resources is needed [89, 90].

For the service user, resource issues spanned both aspatial and spatial dimensions and include the affordability (i.e., perceived worth relative to cost) and accessibility of the service (i.e., the location of the service and ease of getting to that location) [12, 13]. Transport issues were commonly reported to be a resource issue within the current review and the wider literature. Limited transport compounds access issues for specific subpopulations, such the elderly, particularly when they do not have personal transport and when there is no public transport available [50]. This issue is likely compounded by resource limitations, including the cost of travel, and is specifically related to spatial distance to services. Distance to services is a significant barrier to accessing healthcare. Wood et al. [91] in a systematic review, identified that there is a lack of research which measures spatial access specific to mental health services in Australia, and highlighted a need for consensus on what is reasonable access to healthcare services. Further, reports have noted that while distance alone is a significant barrier to accessing healthcare, accommodation may sometimes need to be sought depending on the time of the appointment, adding to the cost of attending the appointment [92] and further perpetuating the resource issues experienced by those living in rural areas of Australia. In addition, although not specifically reported in the current review, it is likely that the time required for traveling to and attending such appointments may require the individual to choose between tending to work or family needs or receiving the help needed.

Transport and other resource issues, as well as distance to services, may be mitigated through telehealth appointments, which have been central to the provision of healthcare since the beginning of the COVID-19 pandemic. However, the utilisation of telehealth requires many patients to have had a face-to-face consultation with their GP in the previous 12 months [93], which may preclude some Australians from rural areas from its use, considering the significant workforce maldistribution previously discussed. Moreover, rural areas of Australia also experience digital disadvantage as a result of lower internet connectivity — brought about by the high costs of installing internet infrastructure in rural and remote areas — and the socio-economic disadvantage experienced by those who live outside of metropolitan areas [94]. These issues are compounded by an ageing population, lower educational levels, a larger primary industry sector, a higher unemployment rate, and a higher Indigenous population in rural and remote Australia [94]. High cost, connectivity issues, and suitability for specific client groups should be key considerations in the delivery of technology-based mental health services. Notwithstanding these issues, the current review identified that technology-based services may be a useful adjunct to physical services, particularly in relation to reducing the need to travel, consultation immediacy, and clinician upskilling. This finding partially supports a recent systematic review, which found that youth located in rural and remote areas of Australia and Canada prefer to see mental health professionals in person, with telehealth provided as an additional option [95]. As such, the benefits and limitations to technology-based mental health services needs to be carefully considered by those designing services.

A key barrier to both access and utilisation in the current review was the complexity of using and navigating the mental health system. These issues typically occur at the system and organisation level and affect the way a service operates and its culture, making it challenging for service users to receive effective care. A complex mental health system and service fragmentation has been previously reported to lead to confusion and a lengthy amount time spent trying to navigate the system, with these issues being even greater amongst those who are younger, less autonomous, or who have less experience navigating the system [96]. System navigation initiatives may address this gap and have previously been implemented via the Partners in Recovery (PIR) program — established to facilitate care coordination for people with severe and persistent mental illness — with positive impacts for those who used the program [97]. However, the introduction of the National Disability Insurance Scheme has superseded the PIR program, and has rendered many former PIR program participants ineligible for support [98, 99], representing a significant gap in mental health service navigation and care coordination support. Isaacs et al. [100], identified that it is more cost effective to support people with severe and persistent mental illness to access PIR supports than to not provide this support, due to the potential increased need for other services (e.g., hospital admissions, homelessness supports, residential supports). Indeed, the Australian Government’s Productivity Commission (Productivity Commission) recommended that life insurers should have greater flexibility to fund approved mental health services to reduce the likelihood of hospitalisation for mental health issues [101]. In addition, Isaacs et al. [100] reported that co-located services — which were reported as a facilitator in the current review — and the increased need of non-clinical support through mental health community support services, offered via non-governmental and not-for-profit organisations, were demonstrated to be important considerations for cost effective mental health care.

Attitudinal or social matters are frequently reported to be key barriers for rural Australians to accessing care and are considered to be an aspatial dimension [12, 13]. These matters which include stigma, fear of judgement, stoicism, lack of trust, preference for keeping to oneself, and reluctance to seek help have been reported on the global scale as impacting upon help-seeking in rural areas in relation to rural identity [22]. Stoicism, in particular, is ordinarily viewed as a positive trait, with rural participants of a global review contextualising stoicism as an inflexible element to their core identity, however, this trait has repeatedly been reported as a barrier to the uptake of mental health services in this review [45, 50, 67, 70] and in the wider literature [22]. In terms of addressing attitudinal and social matters, previous Australian research [16] has identified that intentions to seek help for a mental or emotional issue decreased with a higher classification of remoteness. Moreover, stoicism and attitudes towards seeking professional help were predictive of help-seeking intentions for participants from both rural and metropolitan areas, but sex, suicidality, and previous engagement with a mental health professional were additionally predictive of help-seeking intentions for rural Australians [16]. The current scoping review identified few studies that specifically reported on these issues in relation to barriers to accessing services [37, 55, 68, 70], suggesting a need to increase research focus on these issues. Interestingly, Kaukiainen and Kõlves [16] study, found that attitudes towards seeking professional help mediated the relationship between stoicism and help-seeking intentions for participants from both rural and metropolitan locations, suggesting that attitudes towards seeking professional help may be a fruitful avenue to target to increase help-seeking intentions for all Australians [16]. Education programs delivered in secondary school or tertiary settings have been suggested as a way to improve attitudes towards help-seeking and stigma [102]. These avenues may also be useful to increase mental health literacy (i.e., the public knowledge and recognition of mental disorders and knowing where and how to seek help) [84] in the community, given that lack of awareness was a barrier and mental health literacy was a facilitator in the current review.

Providing person-centred and collaborative care was reported as a key facilitator in the current review. Person-centred care is generally defined as care that is holistic and incorporates the person’s context, individual expression, beliefs, and preferences, and includes families and caregivers, as well as prevention and promotion activities [103]. Indeed, person-centred care is a prominent practice model in mental health care, and this model of care may be particularly beneficial in rural Australia, given that it aims to decrease barriers between health service providers via shared knowledge. This model of care is collaborative by nature, although it should be noted that collaborative care is a distinct, though related model of care. Collaborative care refers to health professionals and patients working together to overcome a mental health problem [104]. This model of care has been shown to improve depression and anxiety outcomes across the short to long term (i.e., 0–24 months), and has benefits on medication use, patient satisfaction, and mental health quality of life [104]. The Productivity Commission recommended the trial of innovation funds to diffuse best practice in mental health service delivery and to eliminate practices that are no longer supported by evidence [101]. Such innovation funds may allow healthcare providers to maintain currency on practices such as person-centred and collaborative care. Importantly, the Royal Commission into Victoria’s Mental Health System (the Royal Commission) [90] identified person-centred care as a way to promote inclusion and prevent inequalities, and was specifically linked to providing culturally safe mental health care — which was noted as a facilitator to access and utilisation in the current review and has been highlighted as an important approach to eliminate health inequalities [105]. Moreover, the Royal Commission recommended the use of an integrated service approach — where service providers can work together to provide care [90]. This approach to care may mitigate service fragmentation and system complexity and navigation barriers, and also permit environments that are comfortable and allow ease of use — as identified as facilitators in the current review.

Community support, both in the sense of individuals feeling connected to the community and healthcare providers being seen within the community, was a key concept in the current review. For the service user, Johnson et al. [39] reported that accessing services under the scrutiny of the community was seen as a challenge, but that the community was also seen a source of strength. Crotty et al. [56] noted the duality for healthcare providers being involved with the community in both a social and professional sense, leading to both challenges and a feeling of togetherness. This sense of togetherness reflects the historical view that rural and remote communities have been connected over several generations [106]. Notably, in the current review, one study on healthcare provider perspectives on workforce retention reported that personal connections and a ‘natural’ connection to the community were key factors in the decision for staff working in remote areas to stay [33], suggesting the importance of embedded relationships in this setting. Preferences to stay in rural and remote towns have been associated with a sense of belonging and the quality of diverse and interesting activities, particularly for younger people [107], and these factors should be strengthened to permit the retention of the rural mental health workforce.

It is noteworthy that many of the studies were undertaken at metropolitan locations, suggesting that much of the research completed on rural locations was not necessarily conducted within this setting. However, it is acknowledged that many university locations are affiliated with major campuses, which are often located in metropolitan areas. Simultaneously, many rurally-based health and community services do not have the resources to undertake locally-generated research, and this consequently limits the evidence available for policymakers to make informed decisions regarding the health of the rural population — noting that place-based approaches are gaining traction [108‐110]. This area is a key focus of the RHMT program [111]. The RHMT program aims to maximise investment in of Australia via academic networks, developing an evidence-base, and providing training in rural areas for health professionals. To date the RHMT program has seen that health graduates who undertook clinical placements in the most rural settings are working more in rural locations [112], and this is likely to have flow-on effects for healthcare providers to build connections to these areas, retain the workforce, and increase health outcomes for the community.

This review highlights the need for a contemporary approach to mental health services in rural Australia. This includes encouraging and educating the public about mental health issues and how to seek and engage in timely mental health care that is appropriate to one’s needs. Simultaneously, this review suggests a need to reconsider how the public navigates mental health services, and to redesign services that are easy to engage with, culturally safe, comfortable to use, and have technological capabilities. This may be more accurately achieved when services are designed with local issues and the community in mind via the integration of bottom-up place-based strategies and top-down place-sensitive approaches, particularly given that a one-size-fits-all approach to policy — and thus mental health service design — does not favour regions and localities [113]. It is critical that rural mental health services are invested in to remove barriers and improve health equity. The fiscal implications of such investment may be offset using this integrated approach, which leverages local and external assets, encourages workforce retention, and may reduce costs in other areas healthcare service delivery.