Rural Health: Problems, Prevention and Positive · PDF fileRural Health: Problems, Prevention and Positive Outcomes Lauren Rickards Introduction In Australia, nearly one third of our

Rural Health: Problems,Prevention and PositiveOutcomes

Lauren Rickards

Introduction

In Australia, nearly one third of our national population —approximately 7 million Australians — live in rural and remoteareas. For all the complex reasons that health and place areassociated, the health of this spatially, economically, socially andculturally distinct group is generally quantitatively and qualita-tively different to — and often significantly poorer than —that of those living in major cities. While the benefits of thisframing of rural as the conceptual Other to an urban norm islimited (as discussed below), it does highlight a serious socialand equity issue, particularly when the influence or and differ-ences between health care services in the two spaces is consid-ered. Awareness of this issue has and continues to inspireconcerted effort among government and other organisationsto improve the health outcomes of rural Australians. Thesuccess of such efforts requires a broad conceptualisation ofhealth, including a focus on social and environmental determi-nants of health and on preventative health approaches. Inaddition, this chapter concludes that a more positive interpre-tation of health is needed, especially to build the resilience ofrural Australians in the face of severe health challenges such asclimate change.

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The perspective presented on rural health in this chapteris broad and interdisciplinary, drawing on the author’sbackground in human geography, climate change adaptationand rural change. Significantly, this chapter is focused onAustralia, and as such the perspective is Western-centric,reflecting the limits of the author’s area of expertise. Whilethere are important similarities between the developed anddeveloping world context, such as the under-provision ofhealth services in rural relative to urban areas, rural health inlow-income countries has distinctive characteristics, includinga host of health challenges not considered in detail within thischapter. Given that nearly half of the world’s population isrural, readers are encouraged to explore the large literature onrural health and development to better understand the globalcontext.

This chapter begins with a brief profile of rural health,focused on the health problems prevalent among rural individ-uals. The question of what is rural is then considered beforemajor influences on rural health are discussed. To end, aperspective on preventative and positive rural health ispresented.

A brief profile of rural health

Measuring population health in a spatially explicit — that is,category based — way is difficult. Data therefore varies as to theexact extent and characteristics of the rural–urban health differ-ential. Nevertheless, in Australia we have a relatively compre-hensive statistical picture of rural health thanks to the work ofacademic institutes such as the School of Rural Health atMonash University and the Australian Centre for AgriculturalHealth and Safety at the University of Sydney, governmentagencies such as the Australian Institute of Health and Welfare(AIHW), and non-government organisations such as the peakbody the National Rural Health Alliance (NRHA).

Some clear trends are evident. For example, people inrural areas do not tend to live as long as those in urban areas.According to 2002–2004 figures, life expectancy decreased and

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death rates increased with increasing degree of remoteness(Bullock, 2009). More specifically, males had a life expectancyof 77 years in outer regional areas relative to 79 years in majorcities, and this fell to 72 years in very remote areas (in partbecause of the large Indigenous population in such areas, asdiscussed below). A similar pattern is evident for females. Weknow too that the urban–rural differential is persistent,holding steady despite an ongoing reduction in Australiamortality overall (Bullock, 2009).

While life expectancy and general mortality rates arecommon and robust summary health measures, a morenuanced picture of the quality of rural health is needed. Whyare people in rural areas dying early? Data collected by theRural Health Information Framework is helping to provide aricher picture. It shows, for example, that people (especiallymales) living outside major cities are more likely to:

• die due to coronary heart disease and other circulatorydisease

• die due to chronic obstructive pulmonary disease

• die due to cancer (especially prostrate, lung and colorectalcancer)

• have Type 2 diabetes, asthma, bronchitis and/or arthritis

• be identified with an infectious disease (e.g., salmonella, RossRiver virus, pertussis and sexually transmitted infections)

• have poor dental and oral health

• be overweight or obese

• have a disability.

The above causes of mortality vary in important ways acrossage, gender, racial and socio-economic groups. Nevertheless,the overall pattern suggests that the mortality in Australianrural areas is, like that in urban areas, similar to the rest of thedeveloped world: predominantly the result of chronic anddegenerative conditions. That said, Australian rural populationsdemonstrate additional mortality patterns more closely associ-ated with the developing world. For example, rural and remote

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women experience higher rates of maternal, neonatal andfoetal death than their urban counterparts. In addition, ruralpeople are more likely to die from infectious diseases, as wellas from accidents, violence and poisonings. About 18–26% ofexcess deaths in regional and remote areas are due to injury.This includes a pronounced elevation of standardised mortalityrates due to motor vehicle trauma in rural areas, with ruralmen and women being an estimated 1.65 to 3.81 times morelikely to die from such an accident than their urban counter-parts. These figures do not include off-road vehicle accidents,which greatly add to motor vehicle risk in rural areas, giventhe frequent use of off-road vehicles in agriculture. Researchby Safe Work Australia indicates that a work-related fatality isover four times more likely in agriculture, fishing and forestrythan other industries, particularly in grains production andamong farmers over the age of 55 years (who are twice aslikely to be injured).

While non-intentional injury among male farmers andfarm managers was 19.5% higher than among other similarlyaged men between 1999 and 2002, intentional injury was evenhigher (20.5%). Intentional injury points to the issue of suicideand mental health in rural areas. While for rural women thereis no statistically significant difference in suicide rates relativeto urban women, 2007 figures from the AIHW (which arelikely to be an underestimate of the true extent of the problembecause of reporting issues) indicate that men in regional andremote areas in Australia are 1.3 to 2.6 times more likely to dieas a result of suicide relative to those in urban areas, particu-larly among disadvantaged groups and Indigenous males.While suicide rates have declined to a degree in urban areas,they have remained relatively constant in rural areas andincreased among some groups of females. Suicide is closelyrelated to mental health, but mental illness is generally nomore prevalent in rural areas than urban. As discussed furtherbelow, what does differ is access to lethal methods of self-harm, cultural attitudes to mental health and access to healthcare services.


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What is rural?

To understand statistics on rural health like those above, it isimportant to consider what is meant by ‘rural’. Rural popula-tions are those that live and/or work in rural areas. To manypeople, the dominant characteristic of rural areas is lowpopulation density. This is perhaps particularly the case inAustralia where we have one of the most urbanised popula-tions in the world living within a small fraction of the nation’sland, leaving a relatively small number of ‘rural people’ livingacross a relatively large land mass. While as indicated above,nearly a third of Australians live in rural and remote areas, theyare heavily and increasingly concentrated in regional centresand country towns. While estimates vary depending on classifi-cation criteria (as discussed below), one estimate is that only8% of the population lives outside of regional centres, whichwith major cities make up only 8% of the total land area. Whatthis means is that some rural people within Australia are oftenextremely geographically isolated, creating a host of specificchallenges and issues when it comes to health, and healthservices in particular. It is in recognition of the relativecommonness and consequence of such isolation that thecategory of ‘remote health’ — often bundled together withrural health, as in the journal Rural and Remote Health — hasbeen created. The separate categorisation of remote health alsoreflects the important health issues by the indigenousAustralians, who make up approximately 20% of the popula-tion in such areas (AIHW, 2000), which are discussed in aseparate chapter in this book.

A second way of understanding ‘rural’ is as an environ-ment or, more specifically, a land use. One of the reasonspopulation densities are low in rural areas is that the predomi-nant industry (at least traditionally) in such areas uses largeareas of land. That industry is, of course, agriculture (andpastoralism), which use approximately 60% of Australia’s landarea. Combined with large areas also devoted to the othermajor land-based primary industry — mining — and to

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varying degrees of conservation, these land uses preclude highpopulation densities. The third characterisation of rural, then,is as an occupational or sectoral classification — as in ‘the ruralsector’ — which means that rural populations are often associ-ated with particular industr ies and jobs. Together, thegeographic and occupational particularities of rural areascreate unique (and diverse) social settings for rural and remotepopulations. They add to the fourth way in which ‘rural’ isoften interpreted, which is as a lifestyle and culture. All ofthese elements of ‘rurality’ have implications for health.

Definitions of ‘rural’ have long been debated in academiaand policy. Various measures of degree of remoteness havebeen used. While on the one hand, determining where the‘cut-off ’ point between rural and urban, or major city and ‘therest’, lies along the continuum of population patterns is atheoretical point, it is also highly consequential for the statisti-cal picture of rural health that is developed, and for subsequenthealth resourcing targeted specifically at ‘rural’ areas. It isbecause of this that the Australian government’s recentdecision to replace the Rural Remote and Metropolitan classi-fication system with the Australian Standard GeographicalClassification — Remoteness Areas system has been contro-versial (McGrail & Humphreys, 2009). The slightly differentmeasures of rural that such classification systems use (e.g., theaverage distance between service centres or the total popula-tions within Statistical Local Areas) change the way someindividual areas are categorised and thus whether they areeligible for rural-only funds.

One of the reasons classification systems can result inunintuitive results for certain areas is the diversity that existswithin rural populations. As the ‘Other’ to urban populations,rural populations are stereotyped as being a homogenous (and,therefore, often boring) group. Inadvertently perpetuated bythe use of categories like ‘rural health’, this bracketing of ruralpopulations as one and the same risks being not only dismis-sive but inaccurate. Rather than being a single ‘conservative,


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independent, cohesive or individualistic’ group (Fraser et al.,2002, p. 289), Australia’s rural population and places are highlyheterogeneous.

One, albeit unidimensional, way of beginning to recognisesuch heterogeneity is to distinguish finer grades of remotenessthan simply rural. The new Australian Standard GeographicalClassification — Remoteness Areas system, for example,identifies five categories: major cities, inner regional, outerregional, remote and very remote. Standardised ratio data ontotal mortality (2002–2004) reflects the value of developingthis more detailed picture, with a continuum evident from theurban reference of a 1.00 mortality level in major cities, to1.69 in very remote areas (Bullock, 2009). In other words,when finer grade divisions of remoteness are used, it becomesevident that mortality levels actually track remoteness, under-lining the significance of remoteness (or a factor correlatedwith remoteness) as an influence on rural health. Conversely,finer-grade analysis of other measures such as the birthweightof live-born singleton babies reveal a non-linear relationshipwith degree of remoteness, which suggests that other strongerfactors are in play.

Beyond merely adding categories along a single neatdimension of rurality, diversity within the rural sector demandswe attend to the far messier and complex patterns created bymultiple socio-demographic, cultural, political, economic andenvironmental factors. Such diversity is growing as individuals,families, towns, regions, and sectors are affected differentiallyby and respond differentially to the range of influences uponthem. While overall most rural population centres are declin-ing, for example, others are growing, and such quantitativepatterns disguise and facilitate a range of demographic shiftsshaped by myriad other trends and pressures, includingdrought and climate change, falling terms of trade and thechanging role of agriculture in the economy, and negative orstereotyped representations of rural populations in the urbanmedia. Perhaps more than anything else, rural Australia is

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characterised by change, and this continual and unpredictabledynamism also represents and introduces its own health issues.

Tackling rural health requires that we understand not justwhat health outcomes manifest in rural populations but how therural setting influences individuals’ health outcomes — that is,how rurality is embodied. The diversity of outcomes indicated inthe section above underlines that it is far from a simple question.It is also one we are far from fully answering. As Pong et al.(2009) recently commented, we still do not know:

… why generally speaking, there is progressive deteriora-tion in health status as one moves from cities to the mostremote regions. Is it because of distance from urbancentres, or is it due to other socioeconomic factors, suchas lower income, lower educational attainment, higherunemployment and poorer access to health services inmore remote locations? (p. 64)

We turn now to the ambiguous issue of the possible causalrelationships underlying the patterns of poor rural healthoutcomes described above.

Influences on rural health

Determining what shapes health outcomes is a difficult andmultidisciplinary undertaking. On the one hand, there areindividual-level factors, such as genetics and other bodilyfactors. On the other hand, there are factors common to areasand communities, such as the qualities of the natural environ-ment and the type of health infrastructure or occupationsavailable. There are then a myriad of factors that are simultane-ously individual and collective, such as mental outlook andhealth behaviours, for the division between the individual andpopulation level is incomplete and problematic. Epidemiologydemonstrates how individualised factors are not distributedevenly across populations but are clumped in different areas,while sociology and psychology underline the deeply social —that is, group — nature of seemingly individualised behav-ioural choices and psychological stances.


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The division between social — that is, human — andenvironmental factors is also problematic. This is in partbecause there is no neat division between what is ‘social’ andwhat is ‘natural’ (especially in the context of anthropogenicclimate change), and in part because the more specific idea ofa simple, objective and one-way flow of influence from theenvironment to human health is inaccurate. The division ofsocial and environmental elements is also challenged by thefact that ‘environmental effects’ are mediated via subjectiveperceptions, which operate at least to a degree at the level ofthe individual.

These points are of particular significance in consideringrural health. As described above, ‘rural’ variously refers to aparticular environment and social setting, including the strongpresence of the agricultural sector, which shapes characteristicsof both the landscape and community. These environmentaland social contextual factors have positive and negative effectson health. Understanding how they contribute to the fullnature, extent and underpinnings of the rural-urban healthdifferential is difficult. Existing research suggests that ruralityper se is not the cause of this differential as much as socioeco-nomic, demographic and social factors. For example, datasuggests that rural populations are generally characterised bythe following negative health determinants:

• lower income levels

• lower employment levels

• lower education levels

• lower ‘health literacy’ (understanding of health issues)

• higher rates of daily cigarette smoking

• higher levels of risky or high-risk alcohol consumption

• lower levels of healthy exercise, and

• higher (and increasing) average age.

Without going into detail, this section discusses some ofthese factors in the context of environmental and social influ-ences on health in rural settings, both positive and negative.

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In the rural environment, the first stand-out feature of the’natural’ landscape is that it is (by definition) more ‘natural’than the urban landscape to the extent that it is considered tobe less modified by human influence. While the differencebetween a large national park and an intensively managedagricultural landscape is considerable, relative to an urbanenvironment dominated by tall buildings, heavy traffic andintense social stimuli, such a landscape can be understood asmore ‘natural’. Health-wise, this environmental context has anumber of implications. To the extent that urban environmentsconsist of a convergence of negative health influences, such asair, noise and artificial light pollution, lack of natural light andspace for relaxation or exercise, stressful social situations and around-the-clock work culture, rural environments emerge ascomparably health-creating. While there is little data on thehealth benefits of rural areas, there is little doubt that someexist. The health benefits of country air, open space and aslower pace of life conducive to greater bodily awareness andrelaxation have long been pursued, such as through the pasttradition of country-based preventorium retreats for children(Grose, in press). Most telling, perhaps, is that rural residentsgenerally report a relatively high level of perceived health andsatisfaction with their lives.

Assisted by developments in information technology andtransport infrastructure that are helping to overcome some ofthe hold cities have conventionally had on many professions,increasing numbers of urban residents are being drawn to lifein rural areas character ised by a high degree of naturalamenity, motivated in part by notions of the healthfulness ofsuch locales and the quasi-agricultural lifestyles many under-take there. In making their move, these ‘tree-changers’ oftencontr ibute to the healthfulness of their destinations byworking to make real their vision, using their typicallysubstantial cultural capital to further enhance the high amenityenvironment they are after, and often creating a positivefeedback loop between a valued space, its tourist appeal and its


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economic viability. At the same time, however, they paradoxi-cally undermine its achievement through the sheer weight oftheir own and tourist numbers, which bring with them someof the problems they are seeking to escape, such as traffic andcrowded streets, particularly in the most accessible peri-urban‘rural’ environments.

While there is more than a grain of truth to idyllic imagesof the rural as a health-giving space, we need to ‘move beyondan undifferentiated assumption that all elements of a landscapewill be equally therapeutic for everyone’ (Conradson, 2005:pp. 345–346). Moreover, the poor health of many ruralresidents suggests strongly that there are other realities at work.As realised by anyone who has tried to cycle along a countryroad frequented by transport trains or buy high-quality freshfruit or low-fat milk in a small town general store, trying tolive out your vision of a healthful rural idyll can be challeng-ing. In particular, most rural areas do not enjoy the sort ofnatural amenity that attracts tree-changers and tourists togather and attempt to enhance selected health benefits (Barr,2009). Rather, they are characterised more simply by theprivately owned and managed landscapes of primary indus-tr ies, which, despite improvements in the integration ofenvironmental sustainability concerns into managementpractices, are conventionally designed singularly for commer-cial production. This has a number of implications for healthdeterminants. Relative to cities, such areas offer space in thesense of an escape from buildings, but often less publicallyowned or green space of the sort that encourages and enableshealthy behaviours such as walking. While much of Australianagriculture is ‘low-input’ relative to the rest of the world, suchareas can also expose people to high levels of environmentalpollutants as a result of the commercial use of inorganicchemicals. For example, ‘spray drift’ from pesticide applicationin agricultural areas is an ongoing regulatory challenge forgovernment organisations. One way that tree-changersimprove the health-giving amenity of areas they relocate to is

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by using their cultural capital to campaign against suchproblems.

As indicated by the discussion about farm injuries, thefarm landscape is also characterised by numerous physicalhazards, from large animals and machinery to barbed wire,dams, flammable liquids, industrial noise and weapons. This isexacerbated by a traditionally low level of compliance withoccupational health and safety regulations and guidelines, duein part to restrictions on personnel, capital and education. It isin recognition of the risky nature of the farm environmentthat special attention has been directed at reducing farminjur ies by groups such as the Australian Centre forAgricultural Health and Safety, mentioned above, and theCollaborative Partnership for Farming and Fishing Health andSafety Program developed by various research and develop-ment corporations.

Exposure to physical hazards is also increased in the ruralenvironment in other ways. Highlighting connotations of wildnature as frightening rather than nurturing, and evident inrecent discussions about different populations’ vulnerability tothe impacts of climate change, rural populations are oftenconceptually positioned as more ‘exposed’ and ‘sensitive’ tonature in general. At one level this interpretation of the ruralsimply reflects the projected spatial distribution of the mostsevere climatic changes expected under climate change, as wellas the relative prevalence of natural hazards including danger-ous wild animals in rural areas. Yet, it also reflects the way wehave designed urban infrastructure to insulate ourselves fromnatural variability and environmental conditions in general.Water shortages, for example, seem like merely a theoreticalnotion or regulatory idea in the city when drinking watercontinues to flow from the taps. But for many rural communi-ties, drought literally means an absolute lack of water fordrinking, washing and other normal life demands (as well asagricultural production). Whether because of a sole reliance onlocal rainfall or limited water infrastructure, in the country,drought is not about simply having a dirty car or a wilted


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garden, but can be a matter of bodily (as well as commercial)survival. Water quality as well as quantity is a serious issue indrought and the impact of poor water quality, as well as lowquality fresh fruit and vegetables, on rural health is emergingas a key research question. The poor quality as well as lowquantity of road infrastructure is another climatically exacer-bated issue rural communities face, which contributes to thepronounced elevation of motor-vehicle accident mortality inrural areas.

It is critical to note, of course, that the ‘protection’ fromthe environment we enjoy in urban settings can be danger-ously illusory, particularly under extreme climatic conditionsof the sort increasing in frequency and severity under climatechange. In such situations, the relative self-sufficiency of ruralresidents, used to relying on electricity generators and watertanks, can be a source of relative safety and thus health.Murphy (2001), for example, found that when severe icestorms shut down the highly centralised electricity system inCanada in 1997, the electricity-free, agriculture-based Amishcommunity were virtually unaffected, whereas thousands ofcity residents perished from cold due to their dependence onelectricity-run heaters. While modern agriculture is Australia isfar from the Amish ideal (being heavily fossil-fuel dependent),it nevertheless holds that rural independence from centralisedinfrastructure can shift at times of widespread system failurefrom being a negative health determinant to a positive one,relative to urban populations, demonstrating the dynamicnature of the relationship between health and place.

Demographic shifts are another major change (and indica-tor of other changes) that is strongly affecting rural popula-tions. On the whole, the rural population is shrinking, dueboth to mortality and out-migration (mostly by youngwomen). This has two negative effects on health: a reductionin health status as the remaining population becomes struc-turally more aged and male; and a reduction in health servicesas local populations fall below the critical mass often deemed

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necessary to support them. As demonstrated by the tree-changers discussed above, however, re-population is alsooccurring in some areas. While in the case of tree-changersthis could be imagined to produce at least a partially positivehealth effect on the basis of the socioeconomic capitalpossessed by the newcomers, an almost opposite process ofrepopulation is occurring in low amenity rural areas such asthe Southern Mallee in northwest Victoria, where socioeco-nomic migrants are moving in to take advantage of the cheaphousing on offer. Not only does this process involve theimportation of health issues, including risky health behaviours,but the cultural clash emerging between some newcomers andexisting residents seems to be a significant source of stress (eg.Rickards 2007). This is not only a negative health determinantin its own right but a motivator to leave the local rural area,worsening the issue of depopulation for those that remain.

The issue of culture brings us to a further critical point inunderstanding patterns of rural health, which is the role ofcultural attitudes towards health and community interaction. Itis well known that rural identities, especially among males, areshaped around ideals of individualism and stoicism. While sucha stance can be a positive attribute in some cases, it can alsocontribute to underplaying health risks (e.g., in relation tousing machinery) and a disinclination to seek help whenneeded (Campbell et al., 2006). Paradoxically perhaps, there isalso often a strong emphasis on the value of community inrural areas, at least those in which members know each otherwell. Community cohesion and social capital are thereforetypically higher in rural areas than urban ones, which isthought to have a strong positive effect on health, both directlyvia improved psychological wellbeing, and indirectly viaimproved socioeconomic status. Traditionally, however, suchcohesion and capital is frequently developed through jointactivities revolving around unhealthy drinking practices, albeitoften following the healthy practice of team sport. Forexample, during the recent drought an important source of


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community interaction was lost with the closure of somesporting facilities (namely ovals) and teams (due to memberwithdrawals). While this is a negative on health, qualitativeinterview data (e.g., Rickards, 2007) suggests that for some thiswas accompanied by a significant reduction in alcoholconsumption, which is a negative influence on health bothdirectly and indirectly via the association between intoxicationand high-risk behaviours. Overall, it can be seen that therelationship between community interaction and health in therural environment is not clear cut.

Risky sexual practices are one of the high risk behavioursassociated with intoxication. The way in which sexual issuesare handled in rural areas is a window onto some of theserious issues that exist with a further key socio-environmentaldeterminant of health to which we now turn: health services.

Rural health services

Recent research by the Centre for Excellence in Rural SexualHealth at the University of Melbourne highlights some of theissues rural young people face in accessing health services forsexual health. These issues illustrate some of the broaderproblems that exist with health services in rural areas. First,there is the issue of inadequate numbers of service providers,including female GPs. Then, there is the question of access.This is in part a function of transport options, which areespecially limited for (underage and low income) rural youth.Third, is the perceived issue of privacy and confidentiality insmall rural populations. For rural youth, discussing risky healthbehaviours or anything for which they may fear reprisal withan adult who they know is in contact with their parents canbe extremely unappealing. Beyond such concerns, which are aquestion of the professionalism of rural health workers, thesmall population of rural areas means that simply one’s utilisa-tion of health services can be visible to others. Combined withthe strong value that is typically placed on privacy in ruralculture, for some rural residents simply being seen in a

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doctors’ surgery can be a cause of embarrassment (Rickards,2007).

These issues of service numbers, accessibility and privacyare just some of the challenges of health care provision in ruralareas. Rural health services have been strongly critiqued asboth quantitatively and qualitatively inadequate, both inrelation to achieving equality with urban populations and inrelation to meeting actual (often greater) rural health needs.‘Inadequate, inaccessible and diminishing health services’ inrural areas emerged as a principal human rights concern forthe Australian Human Rights Commission back in 1999.Despite this awareness, nearly 10 years later an Audit of HealthWorkforce in Rural and Regional Australia about the state ofrural health services found the situation little improved, andthe Office of Rural Health was created by the government in2008 in response.

Quantitatively, rural areas require that services are notonly allocated along conventional lines of number of servicesper local government area or cost-effectiveness, but that, giventhe often large size of local government areas and higher percapita costs of providing services in relatively isolated areas, theissue of accessibility is taken into account. Accessibility is afunction of availability and appropriateness. Availability, inturn, is a function of what infrastructure and staffing isprovided. In many rural places, essential health infrastructure,including service centres and equipment, is simply missing. Itis in recognition of this gap that the federal government estab-lished the National Rural and Regional Health InfrastructureProgram in 2010, which provides funding for local projects ofup to $500,000.

Staffing the use of such infrastructure is perhaps an evengreater issue. The well-known doctor and nurse shortage inrural areas is even worse for many specialist and allied healthfields, such as paediatr icians, cardiologists, psychologists,midwives, dieticians, social workers, occupational therapistsand pharmacists. While the culture of voluntarism in rural


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communities meets this need in part (e.g., community-basedemergency services), and brings with it attendant capacitybuilding and social capital benefits (Skinner & Joseph, 2007),relying too heavily on non-professionals is not possible orappropriate in many cases. But, despite various payment andtraining schemes aimed at attracting health professionals torural areas (based in many cases on controversial rural classifi-cation schemes like those discussed above), significant vacan-cies remain. Health carers’ reluctance to work in rural areasreflects the challenges of rural health work. These go beyondthe personal challenges of living in an often unfamiliar ruralsetting, including a perceived lack of opportunities for partnersand children, to professional challenges often exacerbated bylow staff numbers. Relative to an urban norm, these issuesinclude:

• poor infrastructure and services to work with

• fewer colleagues and less professional support and develop-ment

• more challenging and varied cases, including being requiredto work beyond one’s area of expertise or comfort level

• fewer choices and opportunities for specialisation

• longer and less predictable hours

• traditionally, lower pay (now being addressed)

• frequently, a large amount of travel

• a more blurred division between personal and professionallife, creating the sense that one is ‘never off duty’.

While variants of the above actually draws some professionalsto rural health work, for many the above challenges result in ahighly stressful work environment that creates its own healthissues for those involved. Despite a range of incentivisationschemes, research has found that those who are attracted toand remain in rural health work are often those who have arural background. This has led to renewed efforts to expose allhealth students to the rural setting during their training and to

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encouraging rural students into the health professions. Thelatter ‘grow our own’ approach relies on attracting rural youngpeople back to their home communities. As such, it faces theproblem underpinning the loss of young people from ruralareas, which is that often such young people receive themessage, intentional or not, that leaving one’s rural roots and‘moving on’ to the city is a sign of progress and success thatdistinguishes a region’s ‘best and brightest’ from those withmore limited options (Gabriel, 2002). Further training ofexisting rural health professionals is also being pursued as ananswer to some of the issues above, both to address capacityshortfalls and increase the professional appeal of rural work.

The second element of the accessibility of rural healthservices is its appropriateness. Manifest in utilisation rates, thisis a function of the physical and economic accessibility ofservices, mentioned above in relation to youth. For patientsneeding to travel long distances to access specialist services,accommodation is also often required, along with othercomplicated family arrangements. ‘Whole of journey’ care istherefore an increasing priority within rural health. The socialand cultural appropriateness of services also affects utilisationrates. The individualism, stoicism, low health literacy and adesire for privacy mentioned above as characteristics of therural population, lead to low levels of help-seeking behaviour,especially in relation to sensitive or taboo topics such as sexualhealth, mental health and substance abuse. Exacerbated by thetime, energy and financial costs of physically accessing services,this disinclination results in high levels of foregone care. While20–30% more rural males have a disability than in urban areas,for example, many do not access disability services.

An ongoing and often successful response to the issues ofavailability and appropriateness is a model of decentralisedhealth care that allows local solutions to be developed. As withall cases of devolved control, however, such an approach runsinto the challenge of consistency. This is especially apposite inthe implementation of large top-down ideals and initiatives,such as the one we now discuss: preventative health.


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Preventative and positive rural health

Counter to the curative approach that continues to dominatehealth policy around the world, there is a growing swingtoward more preventative approaches in a slow response tocalls by the WHO since the mid-1980s. Preventativeapproaches aim to ‘design out’ (to a degree) certain preventa-ble and expensive health problems such as type 2 diabetes,some cancers and depression by tackling their major riskfactors. Responses include health services such as vaccinationand antenatal care designed to avoid the occurrence of someconditions and others focused on early detection (eg bowelcancer screening) and early intervention in order to try tominimise the health impact of disease.

In Australia, preventative health is focused on reducingthree well-known risk factors: smoking (the largest singlecause of preventable death and disease), alcohol and obesity. Allthree are strongly prevalent in rural areas and relate to volun-tary health behaviours, namely substance use, diet and exercise.Voluntary health behaviours emerge out of a complex combi-nation of structural and individual factors of the sort discussedabove. In rural areas, an important aspect of a response to theabove conditions is the provision of appropriate infrastructureand services, such as bicycle paths and healthy food options.

Also important in reducing smoking and alcohol areregulatory responses such as bans on smoking in public placesand restrictions on the serving of alcohol. Research on thelargely successful efforts over the last two decades to reducesmoking (primarily in urban areas) illustrates that smoking isoften strongly socially cued. Therefore, it loses its appeal inenvironments where others are not smoking due to smokingbans. Furthermore, bans on smoking can have a far broaderimpact by serving as a social proof — that is, a message aboutwhat is socially acceptable — which reduces the appeal ofsmoking at other times, including in private, and sets inmotion a cycle of reducing the social norm of smoking(Trotter et al., 2002).

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The social nature of smoking — and of not smoking —points to the strongly cultural aspect of voluntary behaviourchange, especially for behaviours associated with pleasure,relaxation, socialising and rebellion such as smoking, eatingand drinking. Educational messages targeted at individuals andbased on fear are therefore likely to have limited impact. Thisis especially so within a rural populace that typically valuessocial cohesion, is suspicious of top-down directives, has a highrisk-taking threshold in relation to personal safety, has highlevels of health satisfaction and is facing multiple, substantialthreats to its survival. Thus, Chapman et al.’s (2009) suggestionthat GPs should be used to deliver health warnings aboutsmoking to rural adolescent patients as part of an effort toaddress the growing smoking ‘epidemic’ among this group isfar from an optimal solution. This is especially the case giventhe infrequency with which adolescents are likely to visit theirGP, for the reasons of access and privacy outlined earlier, orbecause they have encountered reprisal and disapproval on thefew occasions they have done so.

Agr icultural extension — the industry devoted toimproving the agricultural practices of farmers — providesmany insights about the limitations of a top-down approach tobehaviour change in a rural setting. Extension best practicenow recognises, for example, that: individuals most often havestrong reasons for behaving as they do and any alternativebehaviour is assessed in light of the perceived benefits of theexisting practice; for this reason and the transaction costsinvolved, all behaviour change is itself a risk for farmers andneeds to be approached as such; the identity of the messengerand a relationship of trust is crucial; and peer opinion usuallyholds substantially more sway than that of outsiders (Pannell etal., 2006). Extension scholarship also notes the particularchallenges of motivating behaviour change for preventativepurposes. As Rogers (1983) notes, by definition preventativeinnovations are often not very compatible with individuals’current values, attitudes or lifestyles because if problems can be


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prevented, they are often a matter of choice and are thusactively pursued. This highlights the importance of respectingthe trade-offs involved for individuals in any suggested behav-iour change, rather than presuming that individuals are simplyirrational. Introducing preventative practices is also difficultbecause their results are delayed and often exist only as an‘absence of effect’, which given the lack of a scientific control,is impossible to properly observe. The latter is particularlyimportant among farmers who usually demonstrate a prefer-ence for material or experiential proof (including the experi-ence of peers) over theoretical evidence. This points to thestrong influence of social norms in the rural setting, both inrelation to maintaining certain (unhealthy) behaviours and,once a ‘critical mass’ is reached, in perpetuating a (healthy)behaviour change.

Agricultural extension best practice has developed out ofthe failed application of the traditional ‘deficit model’ ofbehaviour change in which the existing situation is framed as aproblem, and the problem is framed as a lack of knowledge(rationality) within an individual, group or situation. Inkeeping with the negative attitude toward farmers that under-lies this mostly historic approach in agricultural extension, thewhole of the rural population has frequently been perceivedthrough a deficit lens: as deficient, in myriad ways, relative tothe urban norm, struggling to catch up and keep up. Anapproach to rural health focused solely on bringing ruralhealth outcomes into line with urban ones inadvertently feedsinto this negative cultural positioning of the rural as charac-terised by lack (Bourke et al., 2010). One alternative to this‘me too’ approach is to adopt more of a postmodern ‘differentvoice’ attitude that celebrates the rural as different notdeficient. The worth of such an approach is seen in thesuccessfulness of many extension and health initiatives thatstart from a position of local knowledge and values and engagethe community in shaping goals and pathways. Yet, culturalrelativity also runs the risk of papering over real and significant

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equity issues between groups. Rural health needs may betempered by subjective local perceptions and statisticalartefacts but they nevertheless remain a genuine cause forconcern. How then to proceed?

Salutogenesis provides a promising approach. Based on thework of Aaron Anonovsky, salutogensis is a future-orientedand open-ended model for health based on creating, enhanc-ing and improving physical, mental and social wellbeing(Becker et al 2010). It does not deny the existence of impor-tant health deficiencies, represented by disease in the conven-tional pathogenesis model, but rather interprets health as morethan their absence. Rather than aiming merely to cure ormanage disease, or — in the case of preventative health — toavoid the occurrence or impacts of disease, salutogenesis movesbeyond this disease focus and the conservative notion ofneutralisation to a more proactive, generative approach towellbeing. Positive health is the ultimate preventative cure,acknowledging the eventual inefficiency of trying to stem thegrowing wave of ill-health, problem by individual problem. Asin other arenas including climate, disturbance is the normrather than exception and demands a comprehensive ratherthan issues-based approach.

There is a promising synergy between reframing rural asmore than the absence of an urban presence or ideal, andreframing health as more than the absence of disease. Bothdemand a more positive approach. Their combination in ‘ruralhealth’ would create a subject area that incorporates but is notlimited to an urban comparison and which encourages andcommemorates uniquely rural models and initiatives.Preventative health priorities like reducing smoking, alcoholconsumption and obesity would be taken on board, butrepositioned in ways that celebrates the positive life-enhancingalternatives on offer, like the social and sporting advantages ofbeing able to achieve fitness goals with clearer lungs and head,and pride in creating a healthful rural community (morehealthful than ‘urban competitors’). Building on the appeal


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already noted by tree changers in some rural areas, investmentin the natural and physical amenity of rural areas could help toposition positive health as an ideal characteristic of ‘the rural’,along with innovation and resilience.

The latter points to a further synergy. Like salutogenesis,resilience theory is based on the idea that disturbance andstress is normal and that proactive behaviour is constantlyneeded to achieve positive outcomes. Both highlight therationality of investing in such outcomes, including the valueof having a certain level of ‘redundancy’ in a system (such as anindividual or community) in order to buffer it from externalshocks. In the context of climate change, such redundancy isbecoming more important than ever. Moreover, adaptation toclimate change is usefully conceived as not simply the elimina-tion or management of climate change impacts, but as apositive life-creating process (Rickards, 2010), albeit one thatrequires us to overturn many existing unhelpful unhealthymodels, starting perhaps with the dominant models of ruraldeficiency and pathogenesis.

Finally, key to the celebration of the rural is the funda-mental role it plays in the health of Australia as a whole, andbeyond. Through the increasingly acknowledged close associa-tion between rurality, agriculture, food, and health (Lock et al.,2010), as well as the influence of rural land management onwater quality, the health of the rural population can be seen asan important means to urban health. This is especially so whenthe significant contribution of farming to climate change isconsidered, which underlines the importance to urban healthof supporting a healthy rural community capable of adaptingto severe mitigation needs. As a massive environmental healthissue, climate change illustrates the final point which is thatrural health is inseparable from environmental health. Thus,not only does rural health require that environmental condi-tions are tackled as a key health determinant (adopting amodel of positive presence rather than simply absence ofobvious problems), but the contribution of positive rural

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health to the health of land, water and climate needs to berecognised and valued.

References Australian Institute of Health and Welfare. Rural, regional and remote

health: indicators or health status and determinants of health. Canberra:AIHG, 2008.

Barr N. The house on the hill: the transformation of Australia’s farmingcommunities. Canberra: Land and Water Australia and Halstead Press,2009.

Becker C., Glascoff M, Felts, M. Salutogensis 30 years later: where do we gofrom here? International Electronic Journal of Health Education2010;13:25–32.

Bourke L, Humphreys J, Wakerman J, Taylor, J. From ‘problem-describing’ to‘problem-solving’: challenging the ‘deficit’ view of remote and ruralhealth. Australian Journal of Rural Health 2010;18:205–209.

Campbell H, Bell M, Finney, M (eds). Country boys: masculinity and rurallife. PA: The Pennsylvania State University Press, 2006.

Chapman A., Bunker S., Dunbar J., Philpot B., McNamara K., Baird A.,Vartiainen E., Laatikanen T, Janus, E. Rural smokers: a prevention oppor-tunity. Australian Family Physician 2009;8:352–356.

Conradson, D. Landscape, care and the relational self: therapeutic encountersin rural England. Health and Place 2005;11:337–348.

Fraser C, Judd F, Jackson H, Murray G, Humphreys J, Hodgins G. Does onesize really fit all? Why the mental health of rural Australians requiresfurther research. Australian Journal of Rural Health 2002;10:288–295.

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Grose E. Landscape and children’s health: old natures and new challenges forthe preventorium. Health and Place, doi:10.1016/j.healthplace.2010.08.018

Lock, K., Smith, R., Dangour, A., Keogh-Brown, M., Pigatto G, Hawkes, C.,Fisberg, R. and Chalabi, Z. (2010) Health, agricultural, and economiceffects of adoption of healthy diet recommendations. Lancet 2010;376:1699–1709

Murphy R. Nature’s temporalities and the manufacture of vulnerability: astudy of a sudden disaster with implications for creeping ones. Time andSociety 2001;10:329-348.

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Pong R., DesMeules M, Lagace, C. Rural-urban disparities in health: howdoes Canada fare and how does Canada compare with Australia?Australian Journal of Rural Health 2009;17:58–64.

Rickards L. Critical breaking point: the effects of drought and otherpressures on farming families. Report for Birchip Cropping Group,2007. http://www.bcg.org.au/cb_pages/news/Critical_ Breaking_Point.php

Rickards L. Governing the future under climate change: contested visions ofclimate change adaptation. Working Paper, Victorian Centre for ClimateChange Adaptation Research, 2010. http://www.vcccar.org.au/content/pages/scenarios-climate-adaptation

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�Lauren Rickards is a Research Fellow at the University ofMelbourne with the Primary Industries Adaptation ResearchNetwork, the Victorian Centre for Climate Change AdaptationResearch, and the Melbourne Sustainable Society Institute. Sheis currently working on a range of interdisciplinary projectsconcerned with climate change adaptation. A Rhodes Scholar,she was previously an Associate Partner with rural consultingfirm RMCG and Vice-Principal of an academic college.

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Rural Health: Problems, Prevention and Positive · PDF fileRural Health: Problems, Prevention and Positive Outcomes Lauren Rickards Introduction In Australia, nearly one third of our