Agricultural populations have problems accessing health care services for a number of reasons: rural areas lack qualified health care professionals, and residents face financial constraints and even local stigmas that serve as barriers to getting treatment. These challenges are even more pronounced when residents need to access behavioral or mental health services, experts said here Monday during a conference on rural health care.
As a result, America’s rural populations have become more susceptible to depression, anxiety, substance abuse and suicide. In fact, rural men are not only much more likely to have suicidal thoughts, but also much more likely to act on such thoughts successfully. Just more than 40 percent of rural women in a University of Maryland study were depressed, compared to less than 20 percent of urban women. Child psychiatrists are only available in roughly 5 percent of the nation’s rural counties that have populations ranging from 2,500 to 20,000 — and general practice psychiatrists are only available in 25 percent of those same counties.
As a result, the precious few behavioral health professionals serving rural populations are testing and utilizing more technological tools for outreach. From peer-to-peer support groups to privacy-ensured educational seminars, rural residents with Internet access are being provided more opportunities to escape the isolation and unique cultural dogmas that often a part of rural living.
Most importantly, existing pilot programs are proving that support and reassurance need only be a click away.
Making a Difference Despite Distance
“It’s a group of extremely rural women in several different states who come together over the Internet to talk about life, shared experiences, challenges and simply support one another,” said Clarann Weinert, a professor at the Montana State University College of Nursing and a Sister of Charity of Cincinnati, while explaining the Women To Women program. “What we’ve learned is that by allowing these women, most of whom were suffering from severe depression, to come together in this way, we’ve been able to significantly reduce their depression. We know this because of the measures we are taking, and also because the women are telling us how much being a part of the group has helped them.”
The program, which began in the mid-1990s, is open to women between the ages of 35 and 65 who have a chronic illness. Those accepted into the program must either live in a town with a population under 12,500 or live further than 25 miles from a town with a population in excess of 12,500.
To date more than 700 women from Montana, North Dakota, South Dakota, Nebraska, Iowa, Wyoming, Idaho, Oregon and Washington have participated in the program, which includes a 22-month computer-based support group that is moderated by a health care professional. The computer-based support has been so successful that most women who participate form some sort of social network of their own once the 22-month program ends so that they can continue to be in contact with one another.
“One woman may be in Wyoming. Another may be in Washington. Still another might be in North Dakota. But where you are sitting doesn’t make any difference when you are on the computer,” Weinert said.
Although the women all face chronic illnesses, no attempt was made to segregate or group based on specific diseases such as cancer, lupus, spinal injuries or diabetes.
“They actually spend very little time talking about the specifics of their diseases,” she explained. “They talk about life, living life and what has to be done despite the fact that we have whatever it is that we have.”
Weinert said many of the women express themselves on the group through poetry or original drawings. By encouraging each other, she said, they renew their own strengths. And, because everyone in the group can relate to the over-riding issues surrounding chronic illness — fatigue, stress, sadness — there is no shortage of compassion for those who feel overwhelmed as well as no shortage of joy for moments of success.
“This has a lot of potential,” Weinert admitted, saying she’s contemplating adding new applications for computer-based support and health information groups. “It was expensive because we had all the research bells and whistles. Now that we have proven that it works, however, it could be pared down to a very simple option where groups of women come together with one moderating professional who only visits with them once a month. The rest of the time they are supporting each other.”
In the coming weeks, Minnesota rural health advocates will launch free web-based, stress-oriented seminars. Although the webinars have not yet been made available to the public, organizers from Minnesota’s Sowing the Seeds of Hope hotline provided an overview and live demonstration Monday to participants at the rural health care conference. The “webinars” are a pilot project of the Sowing the Seeds of Hope hotline, and are made possible by a grant by the Otto Bremer Foundation.
“We were really looking at the end users and their needs,” said Dr. Karen Shirer, an associate dean and capacity area leader for the Extension Center for Family Development at the University of Minnesota. “So, we were really looking at ag producers, workers and their family members. We wanted them to be able to access stress education from their own homes, where they would not experience the stigma and other embarrassment that can accompany taking that first step.”
Many rural people are concerned about perceived or real stigma that is associated with seeking behavioral health services. It was that concern that prompted the Minnesota group to partner with Minnesota State University Extension to distribute the webinars through their “Families in Tough Times” initiative.
In order to create a program that would be both helpful and used by rural people, developers first contacted and surveyed 130 health care professionals who had worked with nearly 25,000 rural Minnesotans during the previous year. When the results were tabulated, developers had a very good idea of what types of stresses rural residents were most reporting to health care professionals as well as a better picture of what percentage of that population would be most likely to utilize a webinar.
“Nineteen percent of these professionals through that agricultural people would view webinars. One in five. We thought that wasn’t too bad,” she said.
“We also thought — because of the way technology is changing and how more people are using those services — that it might be one-in-five today, but it could be three-in-five two years from now. What we also know is that ag producers use the Internet and technology.”
In Minnesota, SSoH partners with Crisis Connection in Richfield to provide hotline services. Each year the Minnesota group receives about 4,000 calls from rural areas. If the one-in-five estimate holds true, however, the organization will reach roughly 18,000 Minnesotans with the webinars.
Across the seven-state program, most callers report stress due to financial difficulties and daily living as the primary reason for their call. Others phone due to personal mental health issues, depressed family members, marital and family conflicts or addictions. In specific times of crisis, callers may seek help with particular farm-related problems, such as how to stop a livestock disease outbreak or how to access weather-related emergency services.
Although the services reported by the surveyed providers varied slightly from this list — for instance, family conflicts were the number one reason individuals sought help — there were many more similarities than differences.
Another Access Issue
One of the key challenges facing behavioral health professionals who wish to reach rural populations through technology is one that they can’t control: Rural Internet access. Broadband typically isn’t an option in more rural areas and, in the few areas in which it is available, high-speed access remains fairly cost-prohibitive.
“It was a real issue when we first began recruiting women for the Women To Women program,” Weinert said. “When women who were accepted to the program didn’t have equipment or access, we provided it to them. Now, however, we rarely encounter a woman who doesn’t already have what she needs to participate.”
Dial-up access, the rural standard for access, varies greatly by region and even by phone line. Some may be able to launch interactive scripts and programs, but others may have to wait several minutes for basic photograph to load.
“Honestly, we just don’t really know how accessible the webinars are going to be,” Shirer said. “There are no strong numbers to tell us what type of access rural families have to the Internet.”
Dr. Kay Slama, principal of Slama Consulting in Spicer, Minn., and a professional helping with the webinar project, knows all too well that, despite the fact that developers didn’t utilize all existing interative elements to create the webinars, there will still be some individuals who cannot access it due to their Internet connection.
“I have dial-up at home,” she said during the conference breakout session. “I am able to access and use the webinar. But, I have a friend who also has dial-up, and she can’t use it at all.”
Lynda Waddington is a reporter for the Iowa Independent.
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