Jennifer A. Deaville, BSc (Hons), PhD, PGDip (Public Health).
Rural communities in the UK have always faced many health challenges, and they are not going away. The BSE crisis in the late 1990s and the outbreak of foot-and-mouth disease in 2001 were two recent events that focused national attention on the rural economy.
Greater understanding about the wider determinants of health in recent years (Acheson, 1998) has also brought the health and well-being of rural populations under scrutiny.
Unlike the USA, Canada and Australia, where rural health-care issues have been tackled for many years, it has only recently been recognised in the UK that rural populations may have different needs, not necessarily met by urban health-care models (Deaville, 2001).
What is rural?
Even within an area as small as the UK, there is a huge diversity in terms of the nature of rurality. Commonly agreed features include, for example, a scattered population, community atmosphere, strong local networks and limited local employment (Department of Health, 1996). But the spectrum varies greatly. It can range from remote uplands, where rurality can be defined easily by land use, to small rural commuter villages close to urban centres, where rurality is more of a social construction (Johnston et al, 1994). In other words, developing a measure of rurality to apply across the UK is particularly difficult.
Arguably, the lack of a measure has hampered academic research and disadvantaged rural areas in the development of the deprivation indices used to allocate resources (White, 2001).
Due to the lack of a consensus definition of rurality, researchers tend to develop their own measures that are appropriate for a particular study, but cannot then be compared with other areas or studies. Consequently the evidence base for rural health issues is limited. The Office of the Deputy Prime Minister (2002) has recently reviewed definitions of 'rural' and 'urban' and to date has produced a categorisation of rural wards and local authorities in England only. A similar exercise is planned for Wales. If researchers and policy-makers were to use this categorisation widely, the level of comparable evidence for rural areas could improve.
This paper focuses on three challenges:
- Health and well-being issues, including zoonosis, mental health problems, accidents, distance from specialist centres and reluctance to seek help
- The need to support health professionals who feel isolated
- The lack of evidence-based research.
Box 1 examines health and well-being issues.
The challenges for health-care delivery
Health-care delivery problems include:
- Access for patients and practitioners to specialist services
- Psychosocial issues such as the stigma associated with seeking help.
Physical access: The most obvious challenge for delivering health care in rural areas is access, particularly the physical distance between services and patients. This not only causes problems with time, but also costs the patient money.
The impact of physical distance on uptake of services is seen through 'distance decay studies' (Haynes and Bentham, 1982; McKee et al, 1990). These show a decreasing rate of service use with increasing distance.
Health staff are also affected by distance: many practices in rural areas have larger areas to cover than their urban counterparts. More unproductive time and money are spent travelling to see patients, attending meetings and accessing continuing professional development for staff (Deaville, 2001).
While it is difficult to reduce distances, developments such as technology are helping. For example some rural areas are making more use of electronic health, such as audio- and video-conferencing, for many aspects of their work. Mobile and branch surgeries, while not reducing travel much for health professionals, take some of the burden away from patients (Bentham and Haynes, 1992).
There are also socio-cultural barriers (Box 2).
Issues for professionals
Providing support for rural health professionals is a major challenge. Issues that affect them include:
- Access to continuing professional development
- The broad work profile.
The barriers to access outlined above also affect staff. Distance and remoteness can mean an increased feeling of professional isolation, increased clinical responsibility due to distance from specialist and emergency services, and a broader work profile. Research has shown a greater role for rural primary care in emergency work, minor surgery and obstetrics (Deaville, 1998).
The socio-cultural issues also affect staff. On the positive side, rural health professionals can have a very close relationship with the community in which they work, but it also means greater personal involvement and little anonymity for themselves or their families in rural communities. The recent foot-and-mouth outbreak in the UK demonstrated the close relationship between rural health professionals and their rural communities. For example, those who lived on farms were unable to leave to go to work during the outbreak, or were unable to return home for long periods of time (Deaville and Jones, 2001).
Most innovation in supporting rural health professionals has focused on delivering appropriate education and access to continuing professional development at locations nearer to their base. One example is through the local education programme run by the Institute of Rural Health, another is the use of information technology.
The evidence base for rural health
Last but not least, rural health faces the challenge of a lack of evidence on which to base practice. Most research in the UK has been based in urban areas due to the location of most centres of learning, the assumption that urban populations represent the general population, convenience and sufficient numbers for statistical analyses.
Recognition that health and well-being issues for rural populations are different and that urban models of care are not necessarily appropriate have led to the need for rurally relevant research. However, the advantages in undertaking research in urban areas are often disadvantages for research in rural locations. Small numbers mean that statistically robust research is often difficult, and while including larger geographical areas may increase the sample size, it is also likely to include different types of 'rural', be more expensive and difficult to implement.
Much research is done locally by enthusiastic rural heath professionals who have identified an issue and undertake a small-scale study. This is commendable because they are often at a distance from research support and it is difficult to obtain funding for small-scale local studies. However, the results of these small-scale studies are infrequently published due to the lack of findings that can be generalised.
Rural health care provides a number of particular challenges in the scope of work professionals are required to undertake as a result of being at a distance from specialist services, and in the particular issues related to service delivery. The physical and sociocultural barriers to access for patients in rural areas cannot be underestimated. There is evidence that utilisation rates decrease with distance from the service (Deaville, 2001). It is believed that this is of relevance to general practice although there is limited evidence as to why distance decay happens. Studies have hinted at a lower need for services with increasing distance from them. This is not true and barriers to access are resulting in hidden needs. This is particularly evident for stress and mental health issues, where stigma, fear over confidentiality and stoicism act as strong barriers against rural residents seeking help.
The changes in primary care as part of the latest NHS reforms should provide opportunities to meet these challenges, through the greater emphasis on profiling the needs of local populations.
Changes in primary care are focusing on local needs, with the development of primary care groups in England and local health groups in Wales. In Wales this is being endorsed by a focus on community strategies, a requirement from the Welsh Assembly Government (www.wales.gov.uk), to establish needs and develop strategies to meet those needs.
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