Rural health

In medicine, rural health is the interdisciplinary study of health and health care delivery in the context of a rural environment or location.

Some of the fields of study comprising rural health include: health, geography, midwifery (remote locations often do not have an OB/GYN), nursing, sociology, economics, telehealth/telemedicine, etc.

Rural can be defined in many ways, such as by population density, by geographic location or other. Due to the large number of choices in the definition parties may often disagree with one another on which definition to use.

Rural Health definitions can be different for establishing undeserved areas or health care accessibility in rural areas of the United States. According to the handbook, Definitions of Rural: A Handbook for Health Policy Makers and Researchers, “Residents of metropolitan counties are generally thought to have easy access to the relatively concentrated health services of the county’s central areas. However, some metropolitan counties are so large that they contain small towns and rural, sparsely populated areas that are isolated from these central clusters and their corresponding health services by physical barriers.” To address this type of rural area, “Harold Goldsmith, Dena Puskin, and Dianne Stiles (1992) described a methodology to identify small towns and rural areas within large metropolitan counties (LMCs) that were isolated from central areas by distance or other physical features.”  This became the Goldsmith Modification definition of rural. “The Goldsmith Modification has been useful for expanding the eligibility for federal programs that assist rural populations—to include the isolated rural populations of large metropolitan counties.”

The 5W's and 1H of Rural Health
The impact of “place” on health has gained increased attention. Does where people live, work, and play make a difference in terms of access and utilization of health services? According to place does matter, in some cases. When discussing the role of place in health as a concept, health status and health behaviors, including health services utilization, are shaped by an aggregate of interacting factors encapsulated in specific geographic locations. Researchers have attempted to compare the health of rural and urban dwellers. In doing so, several questions have been brought to the forefront of this discussion including: (1) Where is rural? (2) Who lives there? (3) What is their health status? (4) Why can we expect these health outcomes? (5) When can we expect real changes? and (6) How can we help? The following sub-sections will provide insight into how these questions have been answered. More specifically, they will discuss variations in rural definitions, socio-demographic characteristics of rural dwellers, health outcomes and determinants of health across rural areas, as well as highlight the impact of policy and research on the improvement of the health of this population sub-group.

Before reviewing these sub-sections lets first consider the reasons for reviewing rural health and exactly why it deserves our attention. The rural communities found in various parts of the world, whether it be Canada, the United States, Australia, the United Kingdom, Africa, or China to name a few, have diverse social, geographic, and economic characteristics. Most rural communities have a larger proportion of elderly and children, with relatively small populations of people of working age (20 -50 yrs) which is resulting in a higher dependency ratio. Rural communities show a health disadvantage for many health measures. Compared to their rural counterparts, rural individuals have poorer socio-economic conditions, have lower educational attainment, exhibit less-healthy behaviors (smoking, alcohol consumption) and have overall higher mortality rates. Simply put, in general, rural individuals are characterized as being less healthy overall in comparison to their urban counterparts. We must try to reduce the health disparities between rural and urban populations and to do this we must conduct specialized research and then implement various policies and programs with the rural population being part of the equation (rural proofing policies or rural lens considerations).

When considering rural health a few key terms must firstly be defined. Geographically, equality suggests that there should be an even distribution of services per head of population. In equity, the equality in relation to need is the most important factor. For example, as a general rule there is a conflict between efficiency and equity in all planning and resource allocation. Where efficiency, is to provide services that maximize health benefit while minimizing cost. For example, when a province or territory is sparsely populated, more health care dollars may be put towards transportation costs. For example, almost 13% of health care spending in the Northwest Territories goes toward medical transportation which is significantly higher than the national average of less than 2%.

Where is rural?
Rural definitions are numerous, to the point where some have said “there are almost as many definitions of rural as there are researchers”. Despite increasing attempts to delineate rural from urban, no internationally recognized efforts have emerged. It would appear that several countries, including Canada, the United-States, the United Kingdom,India,Zambia,South africa,Bangladesh,Pakistan,Afghanistan,Canada,Chile,Argentina, Sri lanka, Myanmar,China,Russia,Scotland,Ireland,Greenland,Iceland,Mongolia,Oman,Saudi arabia, Abudhabi, Spain, Australia, and New Zealand have developed their own formulas to defining ‘rural’. Variations of this definition, even within the same country, have been somewhat problematic. Different formulas provide different numbers. For instance, depending on which definition is applied, Canada’s rural population varies from 22 to 38 percent. While in the United-States, it varies from 17 to 63 percent.

Most rural definitions have been based on geographical concepts, also referred to as “technical definitions”. These have included measures such as population size, population density, and distance from an urban centre, settlement patterns, labor market influences, and postal codes. Based on these concepts, there would appear to be six definitions of rural in Canada, nine in the United-States, two in the United-Kingdom, three in Australia and one in New Zealand. Further adding to the complexity of studying rural health is that certain areas share a common denomination by definition, but are very different places to live in.

Who lives there?
Rural population trends are particularly subject to change due to their migration patterns. reported a 64% drop in Canada’s rural population between 1851 and 1986. As of 2001, despite the steady decline, 30.4% of Canada’s population still lived in predominantly rural regions. Similarly, in Australia, urban areas experienced the largest growth rates between 1991 and 1996, while its remote locations experienced the lowest. Despite this pattern, 29% of Australia’s population still lived in rural or remote areas. In the UK, out-migration amongst the younger age group seeking education and employment is prevalent, although their rural areas also experience high rates of in-migration, particularly amongst the elderly and retired. Therefore, rural populations appear to be very dynamic in nature. Generally, socio-demographic statistics confirm that the rural population is primarily composed of persons under the age of 14 and over the age of 60, while urban areas are in large part composed of the working age group (30–59 years of age).

In addition to differing age groups, racial and ethnic populations in rural areas also appear to be quite diverse. For example, Non-Hispanic whites are the most widespread population sub-group (82%) in non-metropolitan areas of the United-States (66% in metropolitan areas), while African Americans constitute the largest minority group (8.4%). Interestingly, Hispanics comprise 5.4% of the rural population in America, a contrast from metropolitan areas where Hispanics have surpassed African Americans in becoming the largest minority population. The remaining 4% is largely represented by Native Americans. A noted characteristic of Canada’s rural dwellers is that nearly 50% of its Aboriginal population lives in rural and remote areas, while immigrants and other visible minorities live primarily in urban regions (88%). In Australia, nearly 40% of its Indigenous population lives in the remote hinterland. It is therefore apparent that persons who live in rural areas are not a homogenous group.

According to Xie Fuzhan, director of the National Bureau of Statistics (NBS) China's rural population stood at 737 million, 56 percent of the total population of more than 1.3 billion at the end of 2006, and has seen its rural population shrink in recent years as the country's urbanization has gathered momentum. This may also be due to the fact that 90% of rural residents do not have any type of health insurance and are experiencing very limited access to health care and are seeking better paying jobs in urban areas to be able to get coverage and also where they can have better access to care. The rural population in China was recorded at 64 percent of the total 1.3 billion in 2001 and 74 percent in 1990.

What is their health status?
Health status comparisons are typically assessed through rates of life expectancy, morbidity, and mortality. found life expectancy rates to be significantly higher in urban areas when compared to rural areas. Life expectancy in men ranged from 74 years in the most remote areas of Canada to 76.8 years its urban centers. As for women, life expectancy was again lowest in rural areas with an average of 81.3 years. Interestingly, those living in rural areas adjacent to urban centers experience slightly higher rates of life expectancy (men-77.4 years; women- 81.5 years). Likewise, Australian life expectancy ranged from 78 years to 72 years in major cities to very remote locations. In light of these life expectancy rates, it is not surprising that all-cause mortality rates of both Canadian and Australian persons increased as per the level of remoteness. In China, the life expectancy of the female population at birth is 73.59 years in urban areas and 72.46 in rural areas. Male life expectancy is 69.73 years in urban areas and 58.99 in rural areas. Most rural men are hard workers in the agricultural sector and for the most part may not be able to afford health care and the appropriate services may not be available.

The common leading causes of death in rural areas include higher risks of cardiovascular and respiratory diseases, as well as injury (i.e., poisonings, motor vehicle accidents). Again, further adding to the complexities of rural health, there are exceptions to the abovementioned statistics. For instance, opposite trends were found in New Zealand where urban dwellers were more likely to have been diagnosed with heart disease, asthma, arthritis, and osteoporosis than their rural counterparts. These conflicting results confirm that much still needs to be learned regarding the impact of ‘place’ on health.

Why can we expect these health outcomes?
‘Determinants of health’ are a combination of elements that influence health status. While the Public Health Agency of Canada has outlined 12 key determinants of health ((1) Income and Social Status; (2) Social Support Networks; (3) Education and Literacy: (4) Employment/Working Conditions; (5) Social Environments; (6) Physical Environments; (7) Personal Health Practices and Coping Skills; (8) Healthy Child Development; (9) Biology and Genetic Endowment; (10) Health Services; (11) Gender; (12) Culture), these generally represent complex interactions between, social and economic factors, individual behavior and physical environment. Although ‘determinants of health’ are generic elements set out to interpret health outcomes in any population, these may greatly differ across geographical locations.

A.	Education and Literacy
According to the “How Healthy are Rural Canadians?” report, persons living in rural locations had lower rates of secondary school graduation. In Australia, similar results were reported with only about 30% of adults in rural areas having completed secondary school in comparison to about 48% in major cities. Not surprisingly, young people from rural locations were also less likely to pursue post-secondary education.

B.	Income and Social status
Rural persons also reported higher percentages of low income status, likely a result of their lower education levels. confirmed income gaps ranging from $4,821 to $3,725 between 1980 and 2000, all in favor of Canada’s urban regions. In the United-States, the rural-urban income gap has been calculated at 23% ($27,776 vs. $36,079). China’s focus on growth along the coasts has led to a large urban-rural income gap. There is also a wide gap in provision of social and health services between the regions. In 1993, only 10% of the rural population had medical insurance compared with 50% of urban residents.

C.	Employment and working conditions
Those living in rural areas also experience higher rates of unemployment. Bollman’s data pertaining to Canada (1992) demonstrates unemployment rates to be consistently higher in rural and small towns from 1976 through 1989, fluctuating between 7% and 12%. The ‘service’ industry is currently the dominant occupation in rural and small towns, although the forestry, farming and fishing, manufacturing, and mining labor forces are still very much prevalent. These latter occupations are often accompanied with greater health and safety hazards due to the use of complex machinery, exposure to chemicals, working hours, noise pollution, harsher climates, and task related physicality. Such health and safety hazards can explain the higher rates of life threatening injuries that are reported from the rural workforce.

D.	Personal health practices and coping skills
There also appears to be strong urban-rural differences in several health behaviors. According to the “How Healthy are Rural Canadians?” report, persons from rural areas report higher rates of smoking, higher exposures to second-hand smoke, higher overweight/obesity rates and lower rates of fruits and vegetable consumption. Suicide rates, injury and poisoning were also important contributors to the higher mortality rates found in rural areas. In addition, the reported substantially higher rates of interpersonal violence (i.e. homicide) in rural areas when compared to major cities. It should also be noted that lower levels of stress and a higher sense of community belonging were found as levels of rurality increased.

E.	Physical environment
identified additional evidence of environmental variations in determinants of health. This particular project reported lower water quality and crowding of households as factors affecting disease control in rural and remote locations. As well, insufficient wastewater treatment, lack of paved roads and exposure to agricultural chemicals has been identified as additional environmental concerns for those living in rural locations.

F.	Health Care Services
“Some would say that there is an “inverse care law” in operation. People in rural communities have poorer health status and greater needs for primary health care, yet they are not as well served and have more difficulty accessing health care services than people in urban centres”. During the 1990s, only 20% of the government’s public health spending went to the rural health system that served 70% of the Chinese population.

A reoccurring theme in relation ‘rural and remote’ demography is that its population density is low and dispersed. In relation to the current discussion are the impacts of these characteristics on health care services, more so the inability of rural and remote locations to sustain health care services at accessible locations. For example, between 1990 and 2000, 228 rural hospitals closed in the United-States (7.8%), which lead to a reduction of 8, 228 hospital beds. Canadian rural and small town dwellers have half as many physicians (1 per 1000) as their urban counterparts, and on average, have to travel five times the distance to access these services (10 km).

While an increase in local hospital closures within rural and remote locations have resulted in a reduction of primary care and an increase in travel, these have not been the sole rural health care issues. confirmed that “good rural health care does not depend on the presence of a very small hospital that cannot, in today’s environment, provide genuinely acute care” (p. 1803). Additional health care concerns have included quality of care, specialization of services, ambulatory care and emergency treatment, all factors that have inadvertently impacted the health of rural persons. found reductions in specialized health care services such as dentists, dental surgeons and social workers, between 1998 and 2005 in selected rural areas of Canada. In addition, ambulatory services were only available in 40% of the selected sites, blood and urine testing services in one third of the sites, and only one of the 19 sites had neo-natal services. As well, and particularly of concern for the aging rural population, nursing services had reduced from 26.3% in 1998 to 21.1% in 2005.

It is apparent that rural and remote locations are plagued with problematic health care services. In large part, distance, isolation, and dispersed populations have been the leading causes of these problems. These common characteristics of ‘rural’ have led to difficulties in recruiting, as well as retaining, qualified and skilled professionals in the health care field. The urban and more prosperous areas are disproportionately home to the countries’ skilled health care work force in most if not all countries in Sub-Saharan Africa. For example, urban Zambia has 20 times more doctors and over five times more nurses and midwives than the rural areas. In Malawi, despite 87 percent of its population living in areas considered rural, 96.6 percent of doctors are found in urban health facilities. In Burkina Faso, there is one midwife for approximately 8,000 inhabitants in the richer zones, against one for nearly 430,000 inhabitants in the poorest zone. Many remote regions and districts do not have a single doctor, nurse or midwife to provide assistance to those that need it most. These abovementioned issues have resulted in innovative ways of delivering health care to rural dwellers, including over the phone medical consultations, travel grants, as well as mobile preventative and treatment programs. Further, there have been increased efforts to attract health professional to these isolated locations, for example increasing the number of medical students from rural areas and improving financial incentives for rural practice

When can we expect real changes?
The many research centers (Center for Rural and Northern Health Research: Laurentian University, the Center for Rural Health at the University of North Dakota, RUPRI Center to name a few) and the many rural health advocacy groups (National Rural Health Association, National Organization of State offices of Rural Health, National Rural Health Alliance, to name a few) working hard on rural health issues have not been around for very long in comparison to other research centers. Health promotion initiatives are currently being undertaken in many rural areas with more and more emphasis placed on the participation of rural individuals to better improve specific programs. Only time will tell if any real changes shall occur, but for the time being we need to concentrate on implementing divers programs and initiatives in order to reduce the gap between rural and urban populations. In Canada, many provinces have started to decentralize primary care and now have a more regional approach to health care. Recently, in Ontario, Canada, Local Health Integration Networks (LHIN) have been created in order to address regional issues used to decentralization planning and decision making. The Northeastern and Northwestern LHIN’s have been established with the hopes of being better able to suit the needs of the many Ontarians living in rural, northern and remote areas which have to face many different problems than their urban counterparts.

An over (US) $ 50 million dollar pilot project has been approved in order to improve public health in rural areas in China. According to the Ministry of Health, the program is designed to seek ways for the improvement of rural health services and sustained improvement of health level of local people. This is a step in the right direction, and will hopefully present rural China with real changes. More importantly, China is also planning to introduce a national health care system. In Australia, much progress has been made in the past decade. The most important aspect is that recognition and acceptance of the need for a distinctive approach which addresses the diversity of rural and remote Australia has been achieved. Other achievements have been made in rural infrastructure, networking and collaboration, mew models of service delivery and in research. The 1990s have been the best of times and the worst of times in rural health delivery in the United States. They have been the best of times because the influence of rural health advocates on policy development has never been stronger. The community of analysts and advocates has more breadth and depth than ever before. They have been the worst of times, because a certain emphasis has been placed on cost containment during the past 15 years which has resulted in actions that threaten the financial viability of rural providers.

How can we help?
In light of the above mentioned discussion, rural health issues have become increasingly interesting, and not to mention, complex. A few key points have arisen from this discussion that may be worth summarizing. First, there have been several attempts at delineating rural from urban. Variations of ‘rural definitions’ have left little hope for international comparisons. Second, the geographical diversity across countries, and within, mean that a generic geographical description of rural is unlikely. Third, rural dwellers are not a homogeneous group, different ‘types’ of people live under this label. Fourth, although health outcomes are generally poorer in rural areas, some discrepancies have left in doubt its direct causation. Finally, the possible determinants of health are numerous and to pin point specific factors that predicts health outcome in rural persons is nearly impossible. There is much more to ‘rural health’ than meets the eye. In studying rural health, one must look beyond geographical location and consider interactions among a multitude of influential factors. As stated by, “there is no one size fits all solution” (p. 160) to rural health. In other words, health issues in one area are not necessarily problematic in another.

Therefore, in an attempt to better understand and improve the health of rural persons, increased attention from academics and decision makers is needed. Continued research would contribute to our understanding of the impact of ‘place’ on health. Many countries have made it a priority to increase funds for rural health research and others have yet to act upon the specific recommendations made about this funding. For instance, several countries have developed research institutes with rural health mandates (i.e. Centre for Rural and Northern Health Research- Canada; Countryside Agency- United Kingdom; Institute of Rural Health- Australia; New Zealand Institute of Rural Health- New Zealand). While research plays a fundamental role in speaking for rural dwellers, it also provides decision makers with evidence based information. With that said, ‘rural proofing’ practices have been implemented to ensure rural needs are not overlooked in policy making. Policy makers at all levels of governance play a critical role in ensuring the health of rural populations. Policies ensuring safe living conditions right through to accessible health care services will result in equal health outcomes across rural and urban locations.

RURAL HEALTH PROBLEM IN VILLAGEBold text In developing nations like India, non-profit organizations often join hands with corporate houses to execute rural health projects and bring about improvements in the health levels of rural people.

TeleDoc, a project carried out by Jiva Institute of Faridabad, India, used leading-edge communications technology to bring high-quality healthcare and health related information directly to rural villages. This low-cost, highly effective and broadly applicable networking solution was developed and executed by Partap Chauhan, an Indian Ayurvedic doctor known for his pioneering work in online Ayurvedic medicine, and Steven Rudolph, an American educationist and researcher. In 2003, this project won the World Summit Award in the e-Health category.

Eula Hall founded the Mud Creek Clinic in Grethel, KY to provide free and reduced priced healthcare to the insured and under-insured in the mountains of Appalachia.

Issues in rural health

 * Underserviced delivery due to a lack or maldistribution of resources, both in terms of money and labour.
 * Lack of specialty services. Medical specialists often do not have enough 'critical mass' of patients to allow them to economically serve a low population area. The hardship on patients can be particularly demanding in some illnesses, say cancer, in which treatment requires regular long distance travel.

United States
The 2010 United States federal budget includes $73 million to improve both access to and quality of health care in rural areas. This funding will strengthen regional and local partnerships among rural health care providers, expand community- based prevention interventions, and promote the modernization of the health care infrastructure in rural areas.