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Small business and mental health: a rural NSW perspective

By Dr Kristina Gottschall and Dr Hazel Dalton, Centre for Rural and Remote Mental Health

Small businesses account for almost 98% of all actively trading NSW businesses, with 30% of those being located in regional NSW.1 72% of small businesses owners are aged over 40 years.2 67% of small business owners are male.3 What this might mean for mental health and wellbeing within small business is largely an unknown factor given that research and programs specifically targeted towards small business mental health are limited. There is even less research and programs looking specifically to rural, regional and remote contexts.4

There are a range of mental health risk factors that may be unique to those who own or work in small business including (but not limited to): financial pressures, high work demands, long work hours, market variability, and a lack of focus on self-care and work-life boundaries.5 In rural settings, these stressors can be compounded by issues of drought, bush fire, floods, and other adversities, in addition to everyday rural realities that may include economic downturn, corporatisation, 'boom and bust' variables, small town decline, aging populations, wealth disparities within a given community, climate change and dependence on local natural and social environments.6,7

Being a small business owner or working for a small business in rural locations can promote great satisfaction with quality of life, connection to the local community and a strong sense of identity. However, rural communities are each subject to a number of unique environmental, climatic, economic and social determinants, which may impact on rural people’s sense of wellbeing and also on their mental health.8 The COVID-19 pandemic has further amplified the challenges for small businesses in rural, regional and remote contexts. More than 30% of people surveyed in a recent Monash University study are recording high levels of distress, a rate almost four times that usually observed in employed Australian adults.9

Why the impact of mental illness on rural residents is greater

One in five Australians will experience mental illness in any given year, no matter where in Australia they live, and over a lifetime, almost half of all Australians will experience a mental illness.10 According to the National Rural Health Alliance, data indicates that the prevalence of common mental illnesses is similar across the country (around 20%).11 However, the ‘impact of mental illness on the lives of rural residents is greater due to differences in access to, and uptake of, effective treatments and services’.12 The Commonwealth Government’s Accessibility and quality of mental health services in rural and remote Australia report stated that although Australians living in rural areas are impacted by mental disorders at the same rate as people living in major cities, they are less likely to seek mental health treatment than their city dwelling counterparts.13 ,14 For instance, in 2016/2017, people living in remote areas accessed Medicare-subsidised mental health services at a rate of three times less than people living in major cities.15 Using data from the Australian Rural Mental Health Study (ARMHS), Handley and colleagues (2014) note that even when services are available, attitudinal barriers and poor mental health literacy prevents rural people from accessing mental health services.16 A second study showed that one-third of respondents who scored ‘high distress’ reported no problem with their mental health.17

There is also a high rate of suicide in rural communities (twice that of capital cities), which increases with remoteness.18 Data published by the Australian Bureau of Statistics shows that the rate of suicide has been rising more sharply outside of the Greater Capital Cities since 2012, compared to the rates for the Greater Capital Cities.19 From 2012 to 2016 the rate of suicide for the Indigenous population was 23.7 per 100,000. This was more than twice the rate as for non-Indigenous Australians over the same period 11.6 per 100,000.20 In 2016, 47 per cent of all suicides occurred outside capital cities, even though these areas account for only 32 per cent of Australia's total population.21

A unique combination of factors are believed to contribute to rural residents’ low rates of access to mental health services and the high rate of suicide. Broadly, rural communities perceive barriers in accessing mental health services and these can be categorised as structural (e.g., costs, distance), attitudinal (e.g., stigma concerns, confidentiality), and time commitments.22 Services are frequently limited or non-existent in a given local rural vicinity, and overall rural people experience:

…poor access to primary and acute health care, social and geographical isolation,

limited mental health services, funding restrictions, ongoing stigma surrounding mental illness

and the cost of travelling to and accessing mental health services

Royal Flying Doctor Service23

In addition, rural and remote communities with significant numbers of Aboriginal and Torres Strait Islander people are struggling with the effects of intergenerational trauma, poverty, and relative isolation. Remote Aboriginal and Torres Strait Islander people in particular face a lack of mental health services in their area, and many existing services lack appropriate levels of cultural competency.24

The government response to access barriers in rural and remote Australia

It appears that the mental health needs of rural Australians are not currently being addressed adequately.25 The 2018 Commonwealth Government Senate inquiry, ‘Accessibility and quality of mental health services in rural and remote Australia’, took 138 submissions from a wide variety of rural and remote stakeholders – from those with lived experience, community, Indigenous people, through to service providers.26 The Commonwealth Government’s response to the inquiry acknowledged the barriers around access in rural and remote Australia, accepting the inquiry’s recommendation around the development of a national rural and remote mental health strategy that seeks ‘to address the low rates of access to services, workforce shortage, the high rate of suicide, cultural realities, language barriers and the social determinants of mental health in rural and remote communities’.27 The government also supports other recommendations from the inquiry including a monitoring framework, place-based/local approach to mental health, improvements to the National Disability Insurance Scheme (NDIS), longer term investments for rural and remote mental health services, fly-in-fly-out staff, peer support workers and Aboriginal and Torres Strait mental health services, and the design of educational and online materials to reduce stigma and increase mental health literacy. What ultimately results from the inquiry and government response is a situation that is still unfolding.

Nevertheless, despite these challenging and diverse contexts, there is more to be learned from rural small business people and rural communities’ resilience and social connections.28 A recent study argued that by comparison to urban businesses, regional small businesses are on average more durable, and contribute to their region’s socio-economic viability to a greater extent.29 An understanding of mental health in this sector might be thus enhanced by analysing compositional, contextual, and collective community factors.30

Resiliency and complex community contexts and networks are key areas of interest in our research around mental health in small rural business with Everymind in the Ahead for Business project. More research needs to occur in these areas, and importantly, input sought from rural people themselves. To develop and adapt programs to best meet the needs of those who work in rural small business, it is important to better understand sector-specific mental health and wellbeing needs, and to use this information to guide development of a tailored sector specific response that is effective, accessible and equitable.31

To find out more about Dr. Hazel Dalton click here, and to find out more about Dr. Kristina Gottschall click here.

References

1. NSW Government (2019). NSW Small Business Strategy 2020 Discussion Paper, NSW Government, https://www.bellingenchamber.com/nsw-small-business-strategy-2020-discussion-paper-for-public-comment/ : 2.Defined as outside the Sydney Greater Metropolitan Region, Newcastle and Wollongong.

2. Ibid.

3. Ibid.

4. The Australian Bureau of Statistics (ABS) uses the Accessibility and Remoteness Index of Australia (ARIA+) which classifies geographical locations according to road distance from a point to the nearest Urban Centre. To avoid confusion, this paper will use the “rural” inclusive of all the following ARIA+ categories: Inner Regionals, Outer Regional, Remote, Very Remote. In addition, “rural” will be the preferred term as it denotes a culture, an identity, and a social construct that participants may resonate with.

5. Black Dog Institute & Everymind (2019). Mental health and wellbeing in Australian small business, https://preventhub.org.au/priorities/priority-1/project-2

6. Austin, E., Handley, T., Kiem,A., Rich, J., Lewin, T., Askland, H., Askarimarnani, S., Perkins, D. & Kelly, B. (2018). Drought-related stress among farmers: Findings from the Australian Rural Mental Health Survey, Med J Aust. 209 (4): 159-165.

7. Irwin, P.M. The Impact of Changing Demography and Socioeconomic Environments, and Ageing in a Small, Rural Town in Australia. Population Ageing 12, 247–269.

8. Commonwealth of Australia (2018). Accessibility and quality of mental health services in rural and remote Australia, Commonwealth of Australia, The Senate – Community Affairs References Committee. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MentalHealthServices/Report

9. Collie, A., (2020). 90% out of work with one week’s notice. These 8 charts show the unemployment impacts of coronavirus in Australia. The Conversation, April 28, 2020.

10. Commonwealth of Australia (2018). Accessibility and quality of mental health services in rural and remote Australia, Commonwealth of Australia, The Senate – Community Affairs References Committee. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MentalHealthServices/Report

11. National Rural Health Alliance, (2017), Mental Health in Rural and Remote Australia. https://www.ruralhealth.org.au/sites/default/files/publications/nrha-mental-health-factsheet-dec-2017.pdf

12. Hazell, T., Dalton, H., Caton, T. & Perkins, D. (2017). Rural Suicide and its Prevention: a CRRMH position paper. University of Newcastle, Australia. p.6

13. Also see: Handley, T., Kay-Lambkin, F., Inder, K., Lewin, T., Attia, J., Fuller, J., Perkins, D., Coleman, C, Weaver, N. & Kelly, B. (2014). Self-reported contacts for mental health problems by rural residents: Predicted service needs, facilitators and barriers, BMC Psychiatry, 6:14, 249.

14. Also see: Handley T., Lewin, T., Perkins, D. & Kelly B. (2018). Self-recognition of mental health problems in a rural Australian sample. Aust J Rural Health. 26(3): 173-180.

15. Commonwealth of Australia (2018). Accessibility and quality of mental health services in rural and remote Australia, Commonwealth of Australia, The Senate – Community Affairs References Committee.

16. Handley, T., Kay-Lambkin, F., Inder, K., Lewin, T., Attia, J., Fuller, J., Perkins, D., Coleman, C, Weaver, N. & Kelly, B. (2014). Self-reported contacts for mental health problems by rural residents: Predicted service needs, facilitators and barriers, BMC Psychiatry, 6: 14, 249.

17. Handley T., Lewin, T., Perkins, D. & Kelly B. (2018). Self-recognition of mental health problems in a rural Australian sample. Aust J Rural Health. 26(3): 173-180.

18. Hazell, T., Dalton, H., Caton, T. & Perkins, D. (2017). Rural Suicide and its Prevention: a CRRMH position paper. University of Newcastle, Australia.

19. Australian Bureau of Statistics, (2017), 3303_0 Causes of Death, Australia, 2016.

20. Hazell, T., Dalton, H., Caton, T. & Perkins, D. (2017). Rural Suicide and its Prevention: a CRRMH position paper. University of Newcastle, Australia

21. Department of Health, Submission 30, p. 9, citing Australian Bureau of Statistics (ABS), National Survey of Mental Health and Wellbeing: Summary of Results, 23 October 2008, p. 7 and 27, https://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4326.0Main+Features32007?OpenDocument (accessed 11 November 2018).

22. Handley, T., Kay-Lambkin, F., Inder, K., Lewin, T., Attia, J., Fuller, J., Perkins, D., Coleman, C, Weaver, N. & Kelly , B. (2014). Self-reported contacts for mental health problems by rural residents: Predicted service needs, facilitators and barriers, BMC Psychiatry, 6:14, 249.

23. Royal Flying Doctor Service (RFDS), Mental Health in Remote and Rural Communities, March 2017. Received by the committee as: RFDS, Submission 22, Attachment 1.

24. Ibid.

25. Perkins, D., Farmer, J., Salvador-Carulla, L., Dalton, H. & Luscombe, G., (2019). The Orange Declaration on Rural and Remote Mental Health, The Australian Journal of Rural Health, 27: 374-379.

26. Commonwealth of Australia (2018). Accessibility and quality of mental health services in rural and remote Australia, Commonwealth of Australia, The Senate – Community Affairs References Committee. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MentalHealthServices/Report

27. Commonwealth of Australia (2019). Australian Government response to the Senate Community Affairs References Committee Inquiry report: Accessibility and quality of mental health services in rural and remote Australia. https://www.health.gov.au/sites/default/files/response-accessibility-and-quality-of-mental-health-services-in-rural-and-remote-australia.pdf p.5

28. See: McManus, P., Walmsley, J., Argent, N., Baum, S., Bourke, L., Martin, J., Pritchard, B., & Sorensen, T., (2012). Rural Community and Rural Resilience: What is important to farmers in keeping their country towns alive? Journal o Rural Studies, 28: 20-29. See: Singh-Peterson, L. & Underhill, S. (2017). A multi-scalar, mixed methods framework for assessing rural communities’ capacity for resilience, adaptation, and transformation, Community Development, 48:1, 124-140. See: Madsen, W. & O’Mullan, C., (2016). Perceptions of Community Resilience After Natural Disaster in a Rural Australian Town, Journal of Community Psychology, 44(3): 277-292.

29. Hettihew, S. & Wright, C. (2018). Nature and Importance of Small Business in Regional Australia, with a Contrast to Studies of Urban Small Business, Australasian Journal of Regional Studies, 24(1): 96 – 121.

30. Collins, J., Ward, B., Snow, P., Kippen, S. & Judd, F. (2017). Compositional, Contextual, and Collective Community Factors in Mental Health and Well-Being in Australian Rural Communities, Qualitative Health Research, 27(5): 677-687.

31. icare and Everymind (2017). White Paper: Can digital interventions help to improve mental health and reduce mental ill-health in small business? NSW, Australia.

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