Social Determinants of Psychological Wellbeing for Children and Adolescents in Rural NSW


 Background

The mental wellbeing of children and adolescents in rural Australia is under researched and imperative to understanding the long-term mental health outcomes for rural communities. This study used data from the Australian Rural Mental Health Study (ARMHS), particularly the parent report SDQ measure for children under 18 years old and their reporting parent’s demographic information in order to compare this sample’s mental wellbeing scores to the Australian norms and to identify what personal, family, community and rurality factors contribute to child mental wellbeing as pertaining to the SDQ total and subdomain scores.

Method

539 children from 294 families from rural NSW were included. SDQ scores for each child as well as personal factors (sex and age), family factors (employment status, household income and sense of community of responding parent), community SES (IRSAD) and rurality (ASCG) were examined.

Results

Children and adolescents from rural areas had poorer mental wellbeing when compared to a normative Australian sample. Further, personal predispositional and family factors were significant predictors of the psychological wellbeing of children and adolescents, while after controlling for other factors, community SES and level of rurality did not contribute significantly.

Conclusions

Early intervention for children and families living in rural and remote communities is warranted particularly for low income families. There is a growing need for affordable, universal and accessible services provided in a timely way to balance the discrepancy of mental wellbeing scores between rural and urban communities.


Background
Mental illness is a significant burden on the Australian health system (1). It has been more than a decade since rates of mental illness in rural and remote communities were reported as being similar to urban populations and up to five times higher (2,3). More recent Australian research has shown that rural adult populations have higher rates of suicide (4) and higher rates of psychological distress than their urban counterparts (2,3). Given that the onset of 50% of mental illness is before the age of 14, it is imperative to consider the factors that may contribute to psychological wellness in children (5). The rates of child psychological distress in rural Australian communities have not been adequately researched. In one study child and adolescent population mental illness rates were higher in non-metropolitan areas (6), while in 2014 suicide was the principal cause of death for children [5][6][7][8][9][10][11][12][13][14][15][16][17] years of age (4). Research needs to look beyond confirming differences in mental wellbeing and health status by place alone and disentangle the factors contributing to this difference (7). This 4 indicates the need to understand what factors contribute to mental wellbeing within rural child and youth populations and to enable the development of appropriate early intervention strategies (8,9).
According to the Australian Bureau of Statistics (2015b) an imbalance found in service provision and difficulties in accessing services, such as a doctor, may contribute to differences in mental wellbeing between urban and rural populations. Child service needs in rural Australia are understudied. For adults surveyed in rural areas with an estimated high mental health service need, 47% were not connected with a service (10). Within the limited Australian studies for children, the level of remoteness alone did not account for the emotional and behavioural problems of children under nine years old (11) or the mental health levels for adolescents 12-16 years old (12). However a national study of 6,310 families found that children and young people in non-metropolitan areas had higher rates of mental disorders (6). Thus, the level of rurality needs further exploration for its relationship with child and youth mental wellbeing.
However, dividing investigation only by geographic similarities alone assumes homogeneity of communities and in turn commonalities of experience (13,14). Thus, a broader exploration of possible contributing factors for child mental wellbeing is required. The bioecological model postulates that there are multiple factors that impact upon a child including their community, their family and individual factors (15)(16)(17). Further, this model stipulates that variables that impact upon a parent will inadvertently impact upon the child. This is a useful model to explore the determinants of psychological wellbeing within rural children and adolescents in Australia.
Studies suggest that level or degree of remoteness is not the key variable to account for the difference between mental health levels in urban versus rural communities rather that the key differentiating factor is the level of community disadvantage (18). Many international studies exploring the socio-economic status (SES) of communities have linked low community SES to poorer mental wellbeing of children (19,20). In the Australian context it has also been found that community SES rather than rurality predicts mental wellbeing in children under nine years old (11,21,22).
However, there is a paucity of childhood research in Australia across the age span and so it remains unclear if this finding is true for children over nine years old.

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The SES level within the family has also been widely studied and is considered one of the most robust factors in predicting child and adolescent mental wellbeing globally (19,23) and for Australian children (6,11,21,22,24). There is emerging evidence that the impact of family SES increases with the child's age (24). SES is particularly important to consider in Australian rural and remote communities as some are disproportionally affected with variable incomes dependent on cyclic factors and higher rates of unemployment and lower family household incomes than urban communities (14). There are many ways to measure family SES including parental employment and its correlate, level of household income. The literature is robust in showing that unemployment can cause psychological distress in adults (25,26) and there are mixed results for the role parental unemployment plays in child psychological distress (22,27). Exploration of the role of family SES through measures of income and parental employment needs to be undertaken to understand its impact on wellbeing for children in rural Australia.
Using the same sample data from this study, Kelly,Lewin (28) found that for adults, mental wellbeing, as measured by K10 scores, was moderated by personal factors including marital status, trait neuroticism, education level and individual level contextual factors such as sense of community.
Other factors that influenced adult wellbeing were recent adverse events, worry about drought and exposure to rural adversity.
Other mediating factors for mental health can be seen in disadvantaged communities, such as sense of community connectedness. Globally it is accepted that an adult's own sense of connectedness to their community is linked to their mental wellbeing (29)(30)(31)(32)(33). Australian rural populations show a higher sense of connection to community that acts as a protective factor for adult mental wellbeing even when the community is experiencing adverse drought conditions (32,34), with emerging evidence for adolescent populations (35,36). As there is a relationship between various parental factors that impact upon child mental wellbeing, and a high sense of community is a strong protective factor for adults in rural areas, it is prudent to consider if parental sense of community influences child mental wellbeing. There is little research exploring the relationship between parental sense of community and child mental wellbeing.
6 Individual child factors such as age and sex have been shown to have a complex interaction with mental wellbeing throughout child development (11,24,37). Due to limited longitudinal studies of child development exploring mental wellbeing factors, comparisons across cross-sectional studies are difficult to make due to the use of different measures of mental wellbeing and different age groupings in each study. Some Australian studies place age and sex as more predictive of mental wellbeing scores than rurality or community and family SES levels (12). However, the mechanisms that underlie the reasons for these individual level differences are unclear.

Hypothesis
The aim of this study is to explore the relationship between social determinants of health, and on the mental wellbeing of children from rural and remote communities in NSW. This study will; 1) compare child mental wellbeing across urban and rural Australia; 2) compare rural child mental wellbeing across categories of remoteness; and 3) explore determinants and moderators of child mental wellbeing. It is hypothesised that the relationship between child mental wellbeing and rurality will be All invited participants were over 18 years old and randomly selected from the Australian Electoral Roll. People living in special dwellings such as hospitals and prisons, those without an identifiable telephone number, non-English speaking members of a household, and those with hearing impairments that made attaining phone consent difficult were excluded. Participants over 65 years were briefly screened over the phone for cognitive status using the Telephone Interview for Cognitive Status (TICS-M) and those with a total score of <17 were excluded.
Information about the study and surveys were mailed, with up to five follow up telephone contacts.
The data was collected at baseline with follow up at 3 years for children and the parent who completed the child measures. Participant numbers included in the current study are provided in The Strengths and Difficulties Questionnaire -Parent Report (SDQ, 38) is a 25-item questionnaire for parents or carers to report on how they perceive their child's level of functioning as a mechanism to assess psychological wellbeing and distress in children. There are versions for children aged 4-10 years old and 11-17 years old. The SDQ has five subscales: emotional symptoms, conduct problems, hyperactivity-inattention, peer problems and prosocial behaviour. Each item is scored 0, 1 or 2, with somewhat true always scoring 1 and not true and certainly true scoring 0 or 2 depending if the item is a strength or difficulty. The absence of prosocial behaviour is indicated by lower scores whereas higher scores on the other domains indicate increased problems. The SDQ also calculates a Total Problem score which includes four of the domains above, excluding prosocial behaviour. The maximum Total Problem score is 40, with a higher score indicating increased problems. The SDQ is psychometrically sound with good internal consistency (Cronbach α: 0.73) and re-test reliability (0.62) (39)and widely used as a screening tool for psychological wellbeing in children (40). Further, SDQ scores in the 90 th percentile have predictive validity for independent psychiatric disorders for the SDQ parent, teacher and youth scales (39).

Family SES
Family SES was measured through the employment status of the parent responding and the annual household income (41).

Parental Sense of Community
The Sense of Community Index, a 12-item true or false self-report measure that depicts a person's sense of connection to a place or community (42) was administered to the responding parent. This is 8 a psychometrically adequate tool with higher score indicating more attachment and connection to the community (43).

Community SES
The Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD, 44) was used to represent the level of advantage and disadvantage for an area through the families' reported postcode. The IRSAD encapsulates variables such as family income, mortgage levels, education levels, household overcrowding and vehicle access, and then assigns a decile based on these factors. A higher IRSAD score indicates relatively less disadvantage and more general advantage. A lower score indicates relatively more disadvantage and less general advantage. The IRSAD formula used for this study was based on Australian Bureau of Statistics 2006 Census of Population and Housing data to match when the participant data was collected.

Level of Rurality
The Australian Standard Geographic Classification (ASGC) categorises the level of remoteness based on the Accessibility/Remoteness Index of Australia Plus (ARIA+), a measure of the level of remoteness in road distance from required services within Australia (45). The ASGC groups the ARIA+ into five categories: major cities, inner regional, outer regional, remote, and very remote. This study uses the last four categories as major cities were not included in the sample.

Data Analysis
Data entry, cleaning and analysis was performed using Statistical Package for Social Sciences version 25 statistical software (46). Analysis primarily reported SDQ as a continuous variable as this gave clearer indications of changes.
When SDQ scores are grouped it was into clinical significance bands of normal, borderline and abnormal, based on the Australian norms by Mellor (47).
Due to non-normality of the data, the SDQ subscale and total scores, and parental Sense of Community scores were transformed to standardised scores for further analysis.
Household income was grouped into three categories based on exploratory analysis of grouping the participants into equal income thirds and based on appropriate statistical comparison of income groups on SDQ means. This matched with the Australian Taxation Office personal income tax brackets for 2010-2011 being split into thirds. Low income includes nil income to $37,000, medium income $37,001 to $80,000 and high income above $80,000.
Employment status of the parent completing the child measures was spilt into three groups based on appropriate statistical comparison of SDQ means across the original five employment categories.
There were no significant differences in SDQ scores across those who were not working (unemployed (n=19), not working due to illness/disability (n=13) and retired (n=1); this was therefore collapsed into one group. The remaining groups were employed and unemployed.
Demographic differences were examined using ASGC Chi square, Fisher's Exact test, independent sample t-tests, ANOVAs and Kruskall-Wallis statistics as appropriate.
Comparisons were conducted of the current rural SDQ sample with Australian norms (47) using independent sample t-tests.
The relationship between child psychological wellbeing (using the SDQ subscales and total score) and For all analyses, statistical significance was set at p ≤ 0.05.

Results
The SDQ parent report forms were completed by 294 separate families for 539 children. Within the sample 169 parents completed SDQ forms for more than one child in their family ( Table 1 in

SDQ sample scores compared to Australian normative data
Comparisons between the current non-urban sample and the Australian norms were made across ASGC and SDQ domains, showing higher problem scores for the current sample. There were significantly greater total problem scores, conduct problem scores, and peer problems within the current sample, however the current sample also had significantly better prosocial skills than the Australian normative data (47). Greater conduct problem scores than the normative data were also noted across all the ASGC regions (see Table 3). Children in Inner Regional areas and Remote regions also had greater total difficulties and peer problems. Those in very remote regions also had greater emotional symptoms and peer problems. Those in Inner Regional areas had greater social skills than the normative data.

SDQ scores and ASGC groups
There was a significant difference between the number of people within an SDQ domain or category across all ASGC areas in the Total Difficulties Score (Welch's F (3, 202.76) = 2.95, p = 0.034), Peer Problems Score (Welch's F (3, 535) = 3.029, p= 0.028) and SDQ Conduct Problem scores (F (3, 535) = 4.53, p= 0.004). Significant differences (see Table 3 in Supplementary Files) were found between Outer Regional and Remote communities, with those in Outer Regional areas scoring significantly lower than those in Remote areas for each of these outcomes (Total Difficulties Score Games-Howell p = .031; Peer Problems score Tukey HSD p = .025; Conduct Problems score Tukey HSD p = .002).

Variables that Contribute to SDQ Scores Differences
Analyses of the relationship between personal, family, community SES and rural factors are presented in Table 4 in the Supplementary Files.
Personal factors contributed significantly to the total SDQ score and all SDQ subscales, except emotional symptoms, indicating that there was generally poorer mental wellbeing for males and younger participants.
Family factors contributed significantly to total SDQ scores and all SDQ subscales except prosocial behaviour. Mental health was poorer for those in families with lower household incomes, lower parental sense of community scores, and with unemployed parents.
After controlling for personal and family factors, community SES did not significantly contribute to the variance for the SDQ scores. Furthermore, after controlling for personal, family, and community factors, the relationship between remoteness and SDQ scores was no longer significant.
Moderator analyses examining impact of the interaction between ASGC and Sense of Community on the SDQ measures revealed no effect. Similarly, there was no significant impact of the interaction between ASGC and age on SDQ scores.

Discussion
There is little evidence about the social determinants of psychological wellbeing for young people within rural and remote communities. This study aimed to identify the social determinants of health that impact on the psychological wellbeing of children in rural regions of NSW, Australia. This study established that children and adolescents in rural and remote communities of NSW have poorer psychological wellbeing than the general Australian population. Consistent with expectations we found that personal predispositional and family factors were significant predictors of the psychological wellbeing of children and adolescents, while after controlling for other factors, community SES and level of rurality were not significant contributors. This is the first study to show that children and adolescents in rural and remote NSW have poorer psychological wellbeing when compared to normative data from Mellor's (2005) general Australian population study. It also provides evidence of generally lower levels of psychological wellbeing in children and adolescents in regions that are rural, with remote regions having the worst overall outcomes. This concurs with research in adults showing poorer mental health in rural and remote communities of Australia (2).
The initial analysis confirmed broad differences in this rural population's psychological wellbeing, as well as poorer results for children within remote communities. Rurality was not significant in the hierarchical regression. Thus, whilst differences in psychological wellbeing are clear by rurality level, either it is not the rurality itself that impacts on psychological wellbeing or the ASGC is not sufficiently sensitive. This finding is similar to prior research with adults in rural communities (28) and suggests need for investigation of a wider scope of childhood psychological well-being influences at multiple levels of the Bronfrenbrenner's bioecological model.
Community SES did not impact on psychological wellbeing within this sample. Due to the uneven distribution of participants within the IRSAD categories, this should be considered cautiously and differs from national and international research which suggest community SES to be a significant factor contributing to child and adolescent mental wellbeing (19,20,23).
In this study child psychological wellbeing was not primarily related to rural contextual factors of community relative advantage and disadvantage and degree of rurality. Personal predisposition factors of age and gender, and familial factors including family SES as measured through parental employment and income, and parental sense of community had the greatest significant contribution to child and adolescent wellbeing.
The personal predisposition factors of age and gender have a significant and complex influence in child and adolescent psychological wellbeing in both rural and remote communities and more broadly.
This study highlighted that, similar to the general population (12,48) personal predisposition factors of younger age and male gender are significant factors in childhood wellbeing in rural regions of NSW.
Further, age and gender are more influential than factors of rurality and community SES. While this 13 does not give insight into the presence of greater degree of problems in rural and remote locations, it does indicate that the knowledge regarding the personal predisposition factors for child mental wellbeing apply to rural and remote locations, which will influence surveillance, prevention, early intervention and treatment policies and practices in these regions.
The impact of family factors such as household income level and factors of SES influencing child psychological wellbeing in Australia are consistent with the emerging Australian evidence for rural and remote children under nine years old (11) and the general Australian child population of four to seven years old (21,22).
Additionally, this study included parental sense of community in family factors and found this to be a strong contributing factor, with higher parental sense of community associated with higher levels of child mental wellbeing. This was evident across SDQ total scores as well as all subdomains bar prosocial behaviour. There is strong evidence nationally and internationally for the relationship between psychological wellbeing and connectedness to one's community for adult populations (29)(30)(31)(32) and evidence is emerging that this is consistent for rural adolescent populations where selfreported sense of community acts as a moderator of mental wellbeing (34,36). There is very little research on the role that parental sense of community plays directly in child psychological wellbeing and how to enhance parental sense of community to benefit children (49). In retrospective adult studies there is evidence that strong sense of community can act as a protective factor (50,51).
There is also evidence of connections with supportive and "healthy" adults and parents to increase resilience amongst children (52). Future studies could develop a child's sense of community measure.
Consideration should be given to understanding the connection between parental sense of community and the impact this has on children. Through understanding the impact of sense of community on both the child and parent individually and in connection with each other interventions can be designed to enhance community connectedness as a protective factor for families.
The three components explored in this study; personal, family and wider community; reflect the bioecological theory of Bronfenbrenner (15), (16) regarding the need to understand a person within their context. However, this study found the critical importance of personal and family factors, but not 14 community factors as they relate to relative disadvantage and degree of rurality. It is plausible that other community factors that were not examined such as environmental stressors, such as drought, flood or fires, may also influence child and adolescent wellbeing and these need further exploration.
The resultant findings of this study of lower psychological wellbeing in children and adolescents in rural and remote locations in Australia that personal and family factors are more influential than rural contextual factors, are consistent with the findings for adults involved in this same ARMHS study (28).
These consistent findings of personal and family factors influencing psychological wellbeing of both children and adults in rural and remote locations match what is known about the influences on psychological wellbeing in the general population (18,53). However, this research poses an interesting question regarding why there is disparity between urban and rural communities' mental wellbeing and warrants further investigation be undertaken into broader factors such as suggested by the bioecological model. One factor to consider is the poorer engagement with services in rural Australian communities, with one study finding that 47% of adults with estimated high service needs were not being connected to a service (10). This could also be true for children and adolescents, more so if they are seen as needing a specialised service. Further, the imbalance of service provision between major cities and very remote areas is likely to impact on child wellbeing (54).

Limitations
This study is the first to explore child and adolescent wellbeing throughout rural and remote regions of one Australian state and included only children who reside at home rather than those boarding away for educational purposes. Therefore, whether these findings extend to wider rural and remote population needs to be established. While the results are limited to this population, the importance of these findings cannot be underestimated. One limitation of this study was that no comparison urban sample was collected in parallel with regional and remote data. Therefore, comparisons of findings in this study were compared to a published Australian normative sample. While methodological differences between samples may account for some of the differences in wellbeing scores, it is notable that much research in psychology similarly compares their findings to those of published norms.

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Other study limitations include a low response rate, however this is congruent with other rural based population-based surveys (55). The current study used parent observational reports for child wellbeing and future research may be able to have a more nuanced understanding of social determinants of health on psychological wellbeing by including child and teacher report measures for both wellbeing (SDQ) and social support (36,56,57). Further inclusion of personal demographic information such as if the family identifies as Aboriginal and Torres Strait Islander or from a Culturally and Linguistically Diverse community may be beneficial in future research to further assess differences in mental wellbeing levels and differences in responses to social determinants of health (12,58). Further, some parents responded for multiple children within their family which might have weighted some family variables in the analysis.

Future research
As there is such limited Australian specific research regarding children from regional and remote communities, further research is vital to deepen the understanding of the social determinants of mental wellbeing for children. Boosting the psychological wellbeing of rural children and teens may be an early intervention strategy to assist with managing the findings of disproportionate adult rural versus urban mental wellbeing.
Multiple other family factors should be included in future studies including parental mental illness and the impact this has on child psychological wellbeing within a rural context (59), and other broader family stressors (60).
As SDQ is a broad measure of wellbeing (39), to understand about more specific aspects of childhood psychological wellbeing more extensive questionnaires such as the Child Behaviour Checklist and Behaviour Assessment System for Children would be useful to map wellbeing concerns to DSM criteria and to more specifically understand the make-up of the lower psychological wellbeing scores in rural communities.

Conclusion
This is the first time that poorer psychological wellbeing in children and adolescents from rural and remote communities has been demonstrated in Australia and has implications for understanding 16 psychological wellbeing and intervention needs for children in these communities.
Within rural NSW communities a child's psychological wellbeing is statistically significantly lower than the Mellor's (2005) Australian norms on a parent report SDQ measure. This study found that rural contextual factors did not significantly contribute to SDQ scores. Rather, personal and family factors had a greater and significant contribution to well-being. This is an important finding that requires further investigation. It would be prudent to consider the implications of this finding to provide early intervention for children and families living in rural and remote communities in the hope of preventing worsening mental health outcomes with time. These findings suggest that government policies and programs need to target the strengthening of communities in rural areas to benefit child wellbeing. Further, policies to minimise the impact of low income families' household stress should be considered by policy makers through initiatives to support families and children with poor psychological well-being, with affordable, universal and accessible services provided in a timely way.

Consent for publication -Not applicable
Availability of data and materials -The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests -The authors declare that they have no competing interests
Funding -ARMHS was funded by the National Health and Medical Research Council (Project Grants #401241, #631061), and also supported by a Research Capacity Building Grant to the Australian Rural Health Research Collaboration.
Authors' contributions IP researched the background for the project and was the primary writer of the manuscript with the guidance of SL and DP. TH, KO and IP analysed and interpreted the data. To ready this manuscript for publication IP, TH and DP edited the manuscript. All authors read and approved the final manuscript.