Author’s note [1]
Kristen Glenister, Claire Quilliam, Olivia Mitchell, Lucinda Aberdeen, Carol Reid, Brahmaputra Marjadi.
In Australia, approximately one third of people live outside of major cities, that is, in rural or remote locations. ‘Rural health’ emerged as a recognized field in the 1990s and focusses on inequities in health service access, and health outcomes experienced by rural residents. Rural Health is more than ‘health in another location’. It is considered by some as mythical, at best, or forgotten, at worst, in the Public Health landscape. These perceptions fuel misconceptions about rural health, which we will dispel in this piece.
Rural health equals farmer health
Over decades, farmer numbers have declined as farms have become larger and, at times, less viable. Agricultural workers account for 2.2% of Australia’s total workforce, and the majority (82%) work in rural areas. While farmer health is a recognised and important research area, rural health is a broader field and often the largest employer in rural towns is in the service, health, tourism or education sector.
Rural health equals Indigenous health
This misconception may stem from the assumption that most Aboriginal and Torres Strait Islander people in Australia live in rural areas; whereas the largest populations live in urban centres. However, percentage-wise, up to 32% of rural/remote populations are Aboriginal or Torres Strait Islander, while this proportion is less than 2% in major cities. Inequity in health service access affects all rural populations, regardless of Indigeneity. Aboriginal and Torres Strait Islander peoples, wherever they live, experience higher levels of chronic ill health and lower life expectancy than non-Indigenous people, underpinned by the legacy of colonisation and experience of racism in accessing mainstream health services. Aboriginal Community Controlled Health Organisations (ACCHOs) were developed to deliver culturally safe, contextually responsive care and equitable access to health care. Learnings from the success of ACCHOs in delivery of person-centered care could be used in the health system reform proposed in the Rural Area Community Controlled Health Organisation (RACCHO) model. However, improving Aboriginal and Torres Strait Islander health will require different and nuanced approaches in urban and rural areas.
Rural people must be healthier
This myth may have come from the perception of rural living as an antidote to high density living in cities with polluted air, lack of greenspace, and sedentary lifestyle. However, on average, chronic diseases are more prevalent in rural areas than in cities, and contribute to poorer health, higher rates of potentially avoidable hospitalisation, and lower life expectancy. Social determinants of health, poor health literacy and poor health behaviours further exacerbate these issues. Food insecurity exists in rural areas, even in ‘food bowls’, and can have health and social consequences at all life stages. Water fluoridation and poor quality drinking water remain issues in rural Australia. Thus, public health approaches to these issues will ‘take health outcomes out of a vacuum and place patients within the environmental, social and economic context in which they live’.
There is no diversity in rural communities
An old country saying states, “If you have seen one rural town, you’ve seen one rural town”. Each rural community is unique by population, geography and multiculture, but also burden of disease, healthcare needs and access to health services. Cultural diversity has been ever-present and ever-changing in rural areas, in part due to migrant and refugee group settlement outside cities. Migration makes a fundamental contribution to the fabric of rural communities, but also to economic viability and growth. Other aspects of diversity, such as gender or sexuality diversity, may be less ‘visible’ in rural areas, potentially due to stigma, isolation and discrimination.
Rural health is a tale of woe
Innovation, adaptation and resilience have been ongoing features of rural Australia, arising from necessity and determination for action. Examples include the Royal Flying Doctor Service, Tele-stroke and Tele-emergency services and nurse/nurse practitioner-led models of care. Social capital is considered to be higher in rural areas than in metropolitan areas, likely to due to a shared understanding of the challenges of rural life, and a need for self-reliance. These attributes will be increasingly important, as rural communities will continue to be on the front line of climate change and associated bushfires, floods, and drought.
Living rurally is the problem
Former Prime Minister Tony Abbott’s 2015 quote ‘Fine, by all means live in a remote location, but there’s a limit to what you can expect the state to do for you if you want to live there’ appears to be at odds with Medicare, Australia’s principle of universal access to healthcare. Medicare and Pharmaceutical Benefits Scheme underspending in rural areas means that rural people are missing out on an estimated $4 billion of services that they need.
Build it and they will come
Access to health services is complex, and includes issues of distance and ability to travel, cost and ability to pay, need and the ‘right care in the right place at the right time’, optimal ‘fit’ for the patient, as well as awareness and perception. One-size-fits-all solutions are not realistic. Access to health services is hampered by health workforce shortages and maldistribution, and dispersed populations. Telehealth is crucial to rural healthcare delivery, and can assist to overcome distance, time and cost. However, telehealth is not suitable in all clinical situations, can introduce inequity for people who do not have access to internet or devices, experience poor mobile phone coverage or lack digital skills or confidence, and must not be an excuse to disinvest in rural health.
‘Cash Splashes’ will solve rural health challenges
Innovative solutions to rural health issues will rely on flexible, place-based long-term funding, but also self-determined rurally informed policy founded on collaboration and partnerships, with bipartisan support from multiple levels of government. In addition, a ‘whole of workforce’, multidisciplinary approach is essential. Health professionals working in rural areas often enjoy a broad scope of practice, autonomy and strong connections to place and community, but need to be adequately supported and structural barriers removed.
Rural health is an exciting field, characterised by continual change, innovation and passionate people. Tackling rural health challenges will require an ‘integrated network of solutions’ and public health principles. Dispelling rural health myths is an important first step.
[1] We acknowledge that terminology for Aboriginal and Torres Strait Islander people is complex and can be contentious. We have referred to the PHAA ‘Aboriginal and Torres Strait Islander Guide to terminology‘.
Image: Ashkan Forouzani/Unsplash