Advances in Applied Sociology
2012. Vol.2, No.4, 268-273
Published Online December 2012 in SciRes (
Copyright © 2012 SciRes.
The Care Situation, Stigmatization and Requirements of People
with Mental Health Problems in Rural Areas
Brigitte Jenull1, Ingrid Salem1, Eva Mir2
1Department of Psychology, Alpen-Adria-Universität, Klagenfurt, Austria
2Carinthia University of Applied Sciences, Feldkirchen, Austria
Received September 11th, 2012; revised October 15th, 2012; accepted October 27th, 2012
With a lifetime prevalence of about 27% mental disorders are amongst the most common diseases. They
typically are of chronic course, thus affecting not only the respective people, but also the social surround-
ings. In order to provide mental health care in best possible proximity to their homes, transparency of the
services offered and a rapid access are needed. The present study aims at defining the problems and re-
quirements of rural mental health in a Carinthian region (Austria). The users (n = 46) and the family
members (n = 37) were surveyed regarding their individual situation, the current strains and the level of
social support. Additionally, expert interviews (n = 44) were conducted and analysed by using qualitative
content analysis. Findings revealed that much of mental health care is delivered by primary care physi-
cians and is too often limited to medication. As far as mobile psychosocial offers and expert staff are
concerned, all of our interviewed people locate serious flaws and need for action. The present study con-
cludes that there is urgent need to improve the care situation in rural areas. Case and care management
and initiatives to reduce stigmatization are of paramount importance.
Keywords: Mental Illness; Community-Based Mental Health Services; Unmet Medical Need;
Epidemiological studies show that mental disorders are
amongst the most common diseases within the population
(Knapp, McDaid, Mossialos, & Thornicroft, 2007; Wittchen &
Jacobi, 2005). Although every fourth person in the European
Union is concerned by mental health problems, 80% do not
receive appropriate treatment even yet the standard of knowl-
edge in prevention and therapy is high (Demyttenaere et al.,
2008; Siddiqi & Siddiqi, 2007; WHO, 2006). Medical needs in
rural areas are unmet due to shortage of qualified staff. Fur-
thermore there are often barriers by the geographical location,
socio-cultural events and economic conditions to access ser-
vices (Zanjani & Rowles, 2012). Low income and insufficient
education hamper early intervention and treatment of mental
health problems (Kumar, 2011; McElmurry, Marks, Cianelli, &
Mamede, 2002; Merkel, 2004). Gaps in patient-centered care
are caused by inadequate strategies and financing as most re-
sources are still directed towards hospital treatment (WHO,
Most people with mental health problems consult primary
care physicians but studies demonstrate that a substantial part
of the mental diseases presented, are not accurately diagnosed
(Gamm, Tai-Seale, & Stone, 2002; Siddiqi, & Siddiq, 2007;
Walters & Tylee, 2006). This is explained by insufficient train-
ing of primary care physicians and other variables like triviali-
zation of mental health problems by the patients. Many people
with mental diseases have doubts about effective treatment
possibilities or hope, they can handle the problem without see-
ing a health professional (Verhaak, Schellevis, Nuijen, & Volk-
ers, 2006). In addition mental diseases are often not diagnosed
at the initial contact with the physician and further consulta-
tions are mostly too brief for in-depth conversation since the
average time spent with the physician does not exceed 13 to 16
minutes (Bazelon Center for Mental Health Law, 2006).
Apart from unavailable or inadequate care, stigmatisation is
the most severe problem of patients with mental health prob-
lems (Corrigan, Kerr, & Knudsen, 2005; Health Scotland, 2008;
Kelly, 2006; Mueller et al., 2006). This assumed stigma pre-
vents patient contact with psychosocial services, thus causing
delay or inhibition of early diagnosis and intervention (Rüsch et
al., 2009; Schomerus & Angermeyer, 2008). Persons living in
rural areas feel even more stigmatized (Gamm et al., 2002).
There is a difference between societal stigma and personal atti-
tude towards being affected by mental illness. Persons con-
cerned boost stigmatization by internalizing discrimination and
prejudice in the society. This leads to a loss in self-belief and
self-confidence resulting in an unfavorable prognosis (Corrigan
et al., 2005). In order to avoid exclusion from society of per-
sons living in rural areas and suffering from mental diseases,
the phenomenon of stigmatization needs consideration.
The study presented informs about patient-centered care of-
fers for mentally ill people living in a rural area in Carinthia
(Austria). Austria with a total area of 83,879 km² and 8,420,900
inhabitants consists of 9 provinces; Carinthia as one of those
has 558.056 inhabitants. 18,766 persons live in the study area,
this Carinthian district has with 23 persons per km² one of the
lowest population density in Austria. It is a rural region, and
more traditionally oriented. The inhabitants live mainly from
tourism. The net annual income of Carinthia salaried employed
persons in 2010 was about 23,500 Euro for men and 15,200
Euro for women. It is slightly below the average Austrian (Sta-
tistik Austria, 2012). Undisputed is the strain such patients
endure—thus the aim of the study is to show requirement of
patient-centered care offers as seen by health care providers,
patients and relatives. In a second step the experienced burden
of disease as well as perceived assistance was examined. These
results lead to recommendations for coordinated area-wide and
demand-oriented care.
Study Design
The present study is a cross-sectional evaluation and was de-
signed as census. Data were collected over an 8-month-period.
A mixed-method approach was chosen to answer the research
question. This approach integrates subjective views of experts,
of users as well as members to obtain comprehensive and rele-
vant results about the district (Creswell & Plano Clark, 2007).
Qualitative and quantitative methods were used within the
meaning of triangulation-designs.
Three target groups were examined to ensure a multi-per-
spective data base. For each target group an own methodology-
cal approach was chosen. Three project employees were re-
sponsible for the procedure of the study. These project em-
ployees got explanations and were given a coaching during the
whole study.
Interviews with Expert s
Experts were asked about the psychosocial overall situation
of the district. The interviews lasted about 20 minutes and were
conducted in the respective facilities. Physicians, psychothera-
pists, social workers, psychologists as well as caregiver in psy-
chosocial institutions of the district were interviewed. In this
context, guided interview is a suitable form of elevation. The
interview, based on the theoretical background presented earlier,
(e.g., Gamm et al., 2002; Merkel, 2004) outlined three central
1) Percentage of mentally ill people in the district;
2) Basis information of diagnosis;
3) Main focuses and problems of supply.
Questionnaire-Based Survey with User s
Users were interviewed with a predominant quantitative
questionnaire: socio-demographic data, one item to capture
stigmatization, a care-burden-scale (Salewski & Ostendorf,
2003) as well as a shortform of the questionnaire about social
assistance (F-SozU K-22) (Fydrich, Sommer, & Brähler, 2007)
were used.
The adapted care-burden-scale includes 26 items and is di-
vided into five subscales: social burden, sanitary stress, tempo-
ral stress, financial stress, demands of the family member and
relationship with family member. The responses to items were
rated on a 5-point-scale (never, rarely, sometimes, often and
always). Scales follow a theoretical methodology and dispose
of interne consistencies between α = .71 and α = .91 (Salewski
& Ostendorf, 2003). The questionnaire about social assistance
(F-SOZU K22) includes 22 items and it is possible to calculate
a total value. The sub-scales “emotional support”, “practical
support”, “social integration”, “availability of a person of trust”
and “satisfaction with social support” are documented fac-
tor-analytically and have a good reliability (α = .91) and posi-
tive results of validity (Fydrich et al., 2007). The questions are
answered on a 5-point scale rated from “not true” to “true”.
Questionnaire-Based Survey with Family Members
The questionnaire for family members bases on the same
questions as the questionnaire for users, because so compari-
sons are possible. Thus the instrument for users and for family
members was the same.
The experts gave both survey methods to the clients as well
as to their family members.
Data analysis and representation of results, with which it is
possible to find something out about institutions or persons,
were not used. This was important to guarantee study partici-
pants anonymity. The completed questionnaires were collected
in the facility and then given to the project management.
Data Collection and Analysis
The transcripts of all expert-interviews were used for fol-
lowing qualitative content analysis. Structured, deductive and
inductive techniques were used (Mayring, 2007).
The questionnaires for users and their family members were
analysed with classical statistical analysis methods (arithmetic
mean comparisons by t-test and univariate variance analysis).
SPSS 20.0 (Bühl, 2011) was used for these statistical analysis
Experts were recruited about all local mental health facilities
in the investigated area. A total of 44 experts took part in the
study. 12 of the interviewees were physicians and the other 32
people are in leading positions in psychosocial facilities and
belong to different occupational groups (social work, psychol-
ogy, psychotherapy ···). The participation rate of experts was
84 %.
Users and Family Members
In the course of interviews a possible distribution of ques-
tionnaires to family members and persons concerned was dis-
cussed with experts. For reasons of anonymity no sampling was
conducted and the questionnaires were distributed by the ex-
perts. 83 of 300 questionnaires were returned. This correspond
a participation rate of 31% of users and 25% of family mem-
bers. 26 female clients and 19 male clients (n = 46, n = 1 with-
out description) of psychosocial facilities in the explored dis-
trict were on average 58 (±20) years (range: 6 - 93 years) old.
16 persons were married, 12 people were single and 18 lived
separate respectively were divorced or widowed at time of the
study. 18 clients lived alone and 16 in a partnership or with
parents together and 12 lived together with other family mem-
bers. For 25 persons family members took care (14 from part-
ners, 11 from other family members) and 19 persons were
looked after institutional, for example by mobile services. Two
persons did not provide information.
37 family members (25 women, 12 men) took part in the
study. The family members were on average 53 (±13) years
(range: 27 - 82 years) old. At time of the study 17 persons were
employed. Bulk of family members were married (n = 30),
Copyright © 2012 SciRes. 269
Copyright © 2012 SciRes.
three were single and one person lived separately and three
persons did not provide information. The male family members
are significantly older than the female (t = 2.738, df = 31, p
= .010).
Assessment of Patient-Centered Care (Expert
Experts from a wide range of professions were questioned in
order to get an extensive view of the available logistics. Due to
the varied approaches by the different professions, results were
analyzed separately (medical doctors (n = 12) and psychosocial
health professionals (n = 32)).
Primary care physicians reported that 20% to 50% of their
patients had mental health problems. Three doctors made most
diagnoses during the conversations held with their patients, also
because they had known them for a long time. Two thirds of the
physicians referred their patients to specialists or to psychiatric
departments in the nearest hospital whenever they suspected
mental health problems. Ten of the twelve doctors emphasized
antipsychotic medication and seven led an educational and
counseling conversation, advising the patients on helpful and
supportive steps to take.
The main focus in patient-centered care for mental diseases
can be pin-pointed to a very basic provisioning.
We now present the results by defining the main categories
within each domain giving some typical examples.
As can be seen in Table 1 perceived problems or shortcom-
ings in Medicare are of ultimate concern. Living far from
medical and psychosocial services is also mentioned. Most
relevant seems the problem of stigmatization, which might
jeopardize the utilization of offered services. Professionals also
allude to the patients’ fear regarding anonymity.
From their respective perspectives, clients, relatives and ex-
perts likewise ask for an improvement in patient-centered care
(see Table 2). Experts in this field add the request for special-
ized staff, networking and publicly visible awareness training.
Table 1.
General problems of the existing supply system (N = 44).
Category Definition Statements n1 = 12 n2 = 32
Society Stigmatization tabooization
There are big social fears of comi ng-out.
There is especially in rural areas a lack of acceptance and
··· is ashamed ···
4 15
Inadequate supply Limited to medications lack of
Medications are the standard.
In our district there is a lack of institutions, ··· a deficit in
psychiatric supply, psychotherapy ·· · 16 21
location Long avenues difficult to use
It is difficult because our rural situation ··· who drives every
week to a group therapy to city A or city B?”
··· it can take a long time that somebody comes truly ···
3 11
Savings Financial aspects
Medical care is on the back burner.
Everywhere is saved, ··· additional offers would be gut, but
not financed.
10 11
Note: n1 = physicians; n2 = experts of psychosocial institutions
Table 2.
Desires for a better supply (N = 155).
Category Definition Statements n1 n2 n3n4
Improving the supply
Location-based offers (learning
assistance, day-care centers, work
projects, youth centre, ···)
Housing units near community for
chronically ill people (psychiatric
A centre for emergency and crises
psychosocial care
self-help groups
A centre for emergency and crises, ··· Hermagor
as a central place, to get quickly in different valleys.”
··· a psychotherapeutic o
···a mobile psychosocial care would be
desirable ···
6 22 3121
Public relations Awareness training
Awareness raising
··· more awareness training...information, what
possibilities are there ···
more awareness training for family members who
care for somebody, ···adolescents, ···in schools ···
talk about topics without t aboo ···
18 1
Interdisciplinary work
Interface management
Health care system needs increased collaboration
with physicians ···
··· an intermediary between family doctor, hospital
and patient/family members, ··· trained people, who
network an d coordinate.”
Experts Staff increasing ··· workers with flexible applicability ···
··· take stock of clientele more intensively ··· 6 15 1
Note: n1 = physicians; n2 = experts of psychosocial institutions; n3 = clients; n4 = family members.
Experience of Str ain an d S upport
The investigation yielded interesting results: consumers of
patient-centered care or mobile care services showed signifi-
cantly lower signs of health stress than patients looked after by
relatives (F(2, 40) = 4.463, p = .018). These patients were also
burdened by their relationship towards the family member tak-
ing care of them (F(2, 40) = 3.464, p = .041) more than patients
who were cared for institutionally.
The form of housing—living alone, with a partner or other
family members—is associated with experience of burden and
support of the clients: The univariate analysis of variance
showed that affected people, who live alone have significantly
lower values on the scale of health burden compared to affected
people, who live together with a partner or family members
(F(2, 42) = 5.334, p = .009). Also in the subscale “make de-
mands” was a significant difference: affected people, who live
alone, judge their demands significantly lower than affected
people, who live with family members (F(2, 41) = 3.699, p
= .034). Persons concerned, who live together with other family
members have significantly less frequently a person of trust in
their social network (F(2, 39) = 3.939, p = .028) and they are
less socially integrated (F(2, 39) = 2.917, p = .046). Otherwise
there were no statistically noticeable differences between the
Gender differences were shown in the experience of burden
and support of the family members. Male family members
judge the temporal burden of care significantly higher than
women (t-test for independent samples, t = 2.413, p = .022).
Female family members judge emotional support higher (t =
1.956, p = .049). Three groups of age were formed to explore a
possible association of age and the experience of burden and
support: people under 45 years, 45 to 60, and people over 60.
Health of family members over 60 was significantly higher
burdened (F(2, 29) = 4.432, p = .021) and they reported more
financial problems than younger family members (F(2, 29) =
3.352, p = .049). Older family members reached significantly
lower total values in F-SozU K-22 than family members under
45 years (F(2, 29) = 3.373, p = .048). Over 60 years old get
significantly less support than younger family members.
Experience of Stigmatization
As can be seen in Figure 1, half of the persons concerned
often or even permanently feel excluded from society by their
impairment. Two thirds of the relatives did not (or seldom) feel
excluded due to the illness of their family member. For the
majority of patients (73%) stigmatization is part of their daily
The study presented provides insight into the outpatient care
reality of patients with mental health problems in a small
Carinthian district, thus meeting the demand of observational
research by including users and their relatives of patients-cen-
tered care (Riedel-Heller, Bramesfeld, Roick, Becker, & König,
2008). With respect to the variability and heterogeneity of rural
areas (Philo, Parr, & Burns, 2003) the results presented here
should be considered only valid for the studied area.
Literature maintains that primary care physicians are the first
point of contact regarding mental health problems (Gamm et al.,
2002; Walters & Tylee, 2006). Medical experts in the investi-
gated area had a substantive proportion of patients with mental
health diseases, reports ranging between 20 and 50 percent.
Manthorpe, Moriarty, Stevens, Hussein and Sharif (2012) noted
in their study that it is important to improve the situation of the
patient and their family members as well as to provide the prac-
titioners a forum to discuss relevant problems. For us it seems
to be a main point that practitioners get support in terms of
training and supervision in order to meet the varying needs of
their patients.
The major problem of these patients is the high level of
stigmatization noticeable within their surroundings (Health
Scotland, 2008). While struggling with symptoms of their
mental health problems, they have little chances of finding
employment and thus structuring their daily life (Rüsch, An-
germeyer, & Corrigan, 2005). This topic of taboo and exclusion,
relevant to society, leads to a social retreat of patients with
mental illness. They prefer to hide their problems, which ham-
pers treatment in an early stage of the disease. In order to keep
their problems under cover, people living in rural areas prefer
to seek advice or help from inconspicuous persons instead of
consulting specialists.
A possible proposal for helpful solutions might be the con-
struction of larger social networks (Burns, 2007; Lewis, Baeza,
& Alexander, 2008) where people struck by (mental) diseases
are taken care of by an interdisciplinary team. After a first di-
agnose, this center should provide a plan for crises and consecutive
Figure 1.
Stigmatization family members and clients.
Copyright © 2012 SciRes. 271
therapy and coordinate the whole process including contact
with relatives and family.
All interview partners emphasized the necessity of ameliora-
tion in patient-centered care, including psychoeducational ac-
tivities and work-related training. Counteraction is needed for
discrimatory comments and wrong accusations such as e.g.
spreading rumours about higher crime rates in persons with
mental diseases. Affected patients have to be supported by em-
powerment and dialogue or discourse with all parties concerned.
The dialogue of professional experts with concerned patients
gains an additional dimension by including relatives and keep-
ing the societal context in mind (Bombosch, Hansen, & Blume,
2004). This perspective creates equality between patient, rela-
tives and carers.
Relatives report an increase of strain by their own aging.
While their health problems increase, social support, integration
in civic life and life-satisfaction decrease.
Older community members of this rural area, who are bur-
dened by the care for a mentally ill relative, are a high priority
target group for intervention.
Regarding current care concepts, the control sample of pa-
tients cared for in an institutional setting, showed a lower level
of strain than persons cared for by their relatives. The support
of each individual in the areas of housing, work and recrea-
tional activities is a consequential necessity. In case of care
being provided by relatives or close family, they need to be
supported by offering them psychoeducation, encouragement
and work relief.
Since the seventies psychiatric patient-centerd care in Austria
has undergone quite a couple of renewing initiatives such as
reduction of inpatient bedding, an increase of community based
services and socio-professional reintegration of mentally ill
persons into daily community life (BMGFJ, 2005; Zechmeister,
A couple of urban regions in Austria (Schöny & Katschnig,
1991) have a well-developed extramural care system whereas
rural areas lack of expert staff as well as specific day-structur-
ing facilities.
More than a decade later Merkel (2004) as well as Black-
stock, Innes, Cox, Smith and Mason (2006) arrive at similar
results and claim that in general, more attention should be paid
to the rural mental health, because the shortage in rural com-
munities is dramatic due to cultural economic and geographical
reasons. Our study confirms these findings: Treatment of pa-
tients with mental health problems in the examined community
is reduced to minimal interventions without including further
parties involved. There is a lack of qualified staff necessary to
provide affordable and comprehensive treatment and care.
In general, more attention should be paid to the rural mental
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