Rural health

In medicine, rural health or rural medicine is the interdisciplinary study of health and health care delivery in rural environments. The fields of study comprising rural health include: geography, midwifery, nursing, sociology, economics, and telehealth or telemedicine.

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

Most rural communities have a large proportion of elderly people and children, with relatively few people of working age (20–50 years), resulting in a higher dependency ratio. Compared to their urban counterparts, rural individuals have poorer socio-economic conditions, less education, higher rates of tobacco and alcohol use, higher mortality rates.

Many countries have made it a priority to increase funds for rural health research. Several have also developed research institutes with rural health mandates (e.g. the Centre for Rural and Northern Health Research in Canada, Countryside Agency in the United Kingdom, the Institute of Rural Health in Australia, and the New Zealand Institute of Rural Health). 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.

Definitions
Definitions of "rural" differ greatly, varying among and sometimes within countries. Depending on which set of standards is applied, Canada’s rural population can be anywhere from 22% to 38%, while the United States' can be from 17% to 63%.

Most rural definitions have been based on geographic parameters, such as population size, population density, and distance from an urban centre, settlement patterns, labor market influences, and postal codes.

Life expectancy
Life expectancy rates are higher in urban areas than in rural areas. Life expectancy in men ranged from 74 years in the most remote areas of Canada to 76.8 years its urban centers. For women, life expectancy was also lowest in rural areas, with an average of 81.3 years. Those living in rural areas adjacent to urban centers experience higher life expectancies (with men at 77.4 years and women at 81.5 years).

Australian life expectancies ranged from 78 years in major cities to 72 years in remote locations. In China, the life expectancy of females is 73.59 years in urban areas and 72.46 in rural areas. Male life expectancy varies from 69.73 years in urban areas and 58.99 in rural areas.

Access to healthcare
People in rural areas have less access to healthcare: in 1993, only 10% of the rural population of China had medical insurance, compared with 50% of urban residents. In the 1990s, only 20% of the government's public health spending went to the rural health system, which served 70% of the Chinese population. In the United States, between 1990 and 2000, 228 rural hospitals closed, leading 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 (an average of 10 km)to access these services. They have fewer specialized health care services such as dentists, dental surgeons, and social workers. In addition, ambulance service was available in only 40% of the selected sites, blood and Urine testing services in one third of the sites, and only one of the 19 sites had neonatal services. Nursing service had reduced from 26.3% in 1998 to 21.1% in 2005. In 2009, patients living in rural areas of the United States were transferred to other facilities for care at a rate three times higher than that of patients in large central metropolitan areas.

Rural areas, especially in Africa, have greater difficulties in recruiting and retaining qualified and skilled professionals in the health care field. In Sub-Saharan Africa, urban and more prosperous areas have disproportionately more of the countries’ skilled health care workers. For example, urban Zambia has 20 times more doctors and over five times more nurses and midwives than the rural areas. In Malawi, 87% of its population lives in rural areas, but 96.6% of doctors are found in urban health facilities. Burkina Faso has one midwife per 8,000 inhabitants in richer zones, and one per nearly 430,000 inhabitants in the poorest zone. In South Africa alone, half of their population lives in rural areas, but only 12% of doctors actually practice there. The lack of healthcare workers has resulted in unconventional ways of delivering health care to rural dwellers, including medical consultations by phone, travel grants, as well as mobile preventative and treatment programs. There have been increased efforts to attract health professionals to these isolated locations, such as increasing the number of medical students from rural areas and improving financial incentives for rural practice. There are now programs in Africa designed to train women to perform home-based health care for patients in Rural Africa. One of the programs is African Solutions to African Problems (ASAP).

Working conditions
Those living in rural areas experience higher rates of unemployment. Unemployment rates in Canada were consistently higher in rural and small towns from 1976 through 1989, fluctuating between 7% and 12%. Jobs in forestry, farming and fishing, manufacturing, and mining are prevalent, often accompanied by greater health and safety hazards due to the use of complex machinery, exposure to chemicals, working hours, noise pollution, harsher climates, and physical labor. Rural work forces thus report higher rates of life-threatening injuries.

Personal health
Persons from rural areas report higher rates of smoking, exposure to second-hand smoke, obesity, and lower rates of fruits and vegetable consumption. Suicide rates, injury, and poisoning are also more prevalent rural areas, and the Australian Institute of Health and Welfare reports higher rates of interpersonal violence.

Physical environment
The Australian Institute of Health and Welfare reports lower water quality and increased 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.

Efforts to increase health
In the United States, the Health Resources and Services Administration funds the Rural Hospital Performance Improvement Project to improve the quality of care for hospitals with fewer than 200 beds. Research centers (such as the Center for Rural and Northern Health Research at Laurentian University, the Center for Rural Health at the University of North Dakota, and the RUPRI Center) and rural health advocacy groups (such as the National Rural Health Association, National Organization of State Offices of Rural Health, National Rural Health Alliance) are relatively new in comparison to other research centers. In Canada, many provinces have started to decentralize primary care and move towards a more regional approach. Recently, in Ontario, Canada, "Local Health Integration Networks" have been established in order to address the needs of the many Ontarians living in rural, northern, and remote areas.

In China, a US$50 million pilot project has been approved in order to improve public health in rural areas. China is also planning to introduce a national health care system. Australia has also recognized its issues with rural healthcare.

The 2010 United States federal budget included $73 million to improve both access to and quality of health care in rural areas.

Projects
In developing nations such as India, non-profit organizations often partner with corporate houses to execute rural health projects such as TeleDoc, carried out by the Jiva Institute of Faridabad, India. In the United States, the Extension for Community Healthcare Outcomes project uses a telehealth platform to help urban medical center specialists train primary care doctors in rural settings. Eula Hall founded the Mud Creek Clinic in Grethel, Kentucky to provide free and reduced-priced healthcare to residents of Appalachia. In Indiana, St. Vincent Health implemented the Rural and Urban Access to Health to enhance access to care for under-served populations, including Hispanic migrant workers. As of December 2012, the program had facilitated more than 78,000 referrals to care and enabled the distribution of US$43.7 million worth of free or reduced-cost prescription drugs.

Mental Health
People living in rural areas often have less access to mental health services than do those living in urban areas. Telemedicine offers a method to reduce these disparities by delivering services such as telepsychiatry through video conferencing sessions. In the United States, several programs have been established that use telemedicine to provide mental health services to rural patients. Between 2007 and 2012, the University of Virginia Health System implemented a videoconferencing project that allowed child psychiatry fellows to host approximately 12,000 sessions with children and adolescents living in rural parts of the State. In 2009, the South Carolina Department of Mental Health established a partnership with the University of South Carolina School of Medicine and the South Carolina Hospital Association to form a statewide telepsychiatry program that provides access to psychiatrists sixteen hours a day, seven days a week, to treat patients with mental health issues who present at emergency departments in the network.