Rural and Remote

Population groups living in rural and remote areas have distinctive health concerns that relate directly to their living conditions, social isolation and distance from health services. The health and wellbeing of populations living in rural and isolated areas is generally poorer than those living in capital cities and other urban areas. Epidemiology has shown the further a person lives from a metropolitan area, the greater the risk of mortality and illness – those living in rural and remote areas also have the concern that lower socioeconomic status is related to their geographic position. The inequality between rural and urban areas is being worsened by the constant breakdown of social justice and economic infrastructure in rural areas – these changes are having an increasingly adverse impact on the health and quality of life of rural and remote Australians. People living in rural and isolated locations have higher mortality rates and also experience higher hospitalisation rates for some causes of ill health. This report compares the health of rural and remote populations with that of those Australians living in city areas.

A categorization of the areas in which Australians live has been developed – taken from a study of population and remoteness. These classifications have been divided into three main categories; metropolitan, rural and remote. Approximately 70% of Australians live in metropolitan zones – generally speaking, the lesser the population, the poorer the health experienced by the people. Life-expectancy varies within geographic location; those living in urban areas can expect to live longer than those living in remote areas, and to a lesser extent, those living in rural areas. The total death rate for those living in metropolitan areas are 6% lower than for those living in large rural centres and 20% lower than for those living in remote centres – some of this may be attributable to communities having a large number of Indigenous people; Aboriginal and Torres Strait Islanders usually have higher mortality rates and die younger than other Australians.

Rural and regional Australia is a priority population group home to disproportionate numbers of people with lower levels of education, lower employment status and job security, poorer housing and access to health care services as well suffering health inequalities within Australian Health Priorities – these inequalities exist as a result of lack of social justice and equity within the nation.

Education Levels

Remote communities can suffer from a lack of access to sources of individual and community wellbeing such as educational facilities. Statistics indicate that as population density declines, social disadvantages increases.[1] Younger people are leaving these communities to improve their chances of gaining access to educational opportunites which do not exist in many rural areas, due to the decreasing amounts of students to be educated, rural areas are experiencing a decline in standards of education corresponding with a declining access. It is important to note that education training relates to school and tertiary training as not all levels of education have the same access issues; in relation to primary and secondary schooling, the quality of education for rural and remote students is adversely affected by a combination of factors including reduced choices of subjects, a lack of library facilities, lack of access to technology and a predominance of inexperienced staff with most rural schools having a lower student-teacher ratio than urban schools. For teachers, the lack of training for isolated work, a lack of support services, lack of specialist services and a lack of professional development opportunities all combine to make isolated teaching challenging.

The high turnover of staff and, in many cases, understaffing, dramatically affects education quality teachers teach outside their specialization and there is limited access to cultural subjects such as music and drama. One of the most difficult issues for isolated children involves their distance from schools. Many communities are poorly serviced by transport services and the extra hours required for traveling to and from school places an added tension on educational prospects for many, particularly when combined with homework to be done once returned home from school. For a number of families, the only solution is to send their children away to the cities for education which places an additional financial burden on many families. Each of these tribulations has led to a high turnover of teachers, poor skills in the use of technology and overall poor future employment prospects for students. An inevitable result of the lack of access to quality education is a rising drop out rate for rural students; school drop out rates for rural students compare unfavorably with urban students. For example, in Western Australia the drop out rate varies from 25% in Perth to between 50% and 75% in rural schools[2]. The following statistics apply to the education levels of young people living in rural and remote areas; • 23% of 19-year-olds fail to achieve a basic level qualification • 13% of those aged 25 to retirement have no educational qualifications.

Employment Status

Studies have shown that people living in rural and remote areas are more likely to have poorer access to work, particuarly skilled or professional labour.[3] Unemployment is the most savage determiner of poverty and despite consistent and strong economic growth in Australia, the number of people who are unemployment is much higher than it was ten years ago[4]. Rural and remote areas of Australia have undergone drastic changes which has reduced the econmic resources available in these communities. Opportunities for young people – entertainment, employment or further education – may be limited in many towns, causing more and more people to leave the area. A reduction in population can lead to a further decline in services, failure of local businesses and growing unemployment. Some communities which have gone through such change in the past 20-30 years and are no longer the thriving communitites they once were and their primary industries are no longer as profitable as they had once been.

Many areas have been hard hit by the loss of public jobs and changes in employment patterns on famrs and agricultural industries these economic changes have resulted in fewer employment opportunities for local people leading to much higher levels of unemployment. The reduction of primary industries has had an effect on local businesses as fewer famers are able to spend money at local businesses causing them to struggle to remain open. Those who are employed are more vunerable to injury due to the nature of the work required – such as the operation of heavy machinery in farming and mining. Due to the mostly declining population in rural areas, less public and leisure services are becoming available – again limiting job and training opportunities for local residents. Social traditons are being dramatically altered as families lease their land and alter work patterns – more males are seeking paid employment whilst the females work on the land.

The following statistics apply to employment rates of people living in rural and remote areas; • 3% of those aged 25 to 55 are officially unemployed (180,000 people) • 4½% are economically inactive but want paid work (340,000 people). • 7½% of 18-24 year-olds (60,000 young adults) are officially unemployed.

Economic Status

Social inequality and disadvantage is typically associated with low income and with those groups that have high levels of dependency on the social security system. In 1996, of the 3.3 million people living in the most socially and economically disadvantaged areas; 1.9 million lived in major urban and a further 650,000 lived in other areas defined as being highly accessible. The remaining 830,000 lived in areas with lower of access, with 140,000 living in the remote or very remote parts of the country. Many communities have been affected by an economic recession in the agricultural sector or by drought, creating a cycle of poverty and reducing services. Income levels differed considerably among people living in the most disadvantaged districts depending on where they were situated – household incomes in rural and remote areas have generally been found to be lower than in metropolitan areas. Those in remote or very remote rural localities had the lowest incomes – with the average household per capita earning between $171 and $156 per week[5] which compared to $229 per week amongst those in major urban areas.

In 2001 the average capital city household’s income before tax was $57,000 a year – this was almost one quarter higher than average incomes in major urban areas and rural areas and was one third higher than incomes in regional towns. Remote communities, many with significant Indigenous populations tended to have more children than in urban areas. Also in 2001, 18% of people in rural districts living in households with incomes below the most commonly used threshold of low income. Of the 18% of people living in households below 60% of average income in 2001, around 40% had an income of less than two-thirds of the threshold. Coupled with lower incomes for people in regional and remote areas, the price of goods such as food and petrol is higher. In rural and remote communities, the cost of basic food is regularly up to 10% higher (and sometimes up to 23% higher)[6] than in metropolitan and regional centres. In addition, stores in remote locations are less likely to have basic food items or healthy food choices and are often a considerable distance from residents.

Housing

Poor health is directly linked to poor housing and housing infrastructure. In rural and remote areas where there is below standard housing it is also likely that the drinking and washing water is contaminated, sanitation is poor and the houses are unsafe. Due to the lower socioeconomic status of many rural communities there is a high prevalence of government funded housing and poor housing conditions, it has been revelaed that 65% of heads of households in social housing in rural areas have no paid work – compared to 35% of more urban areas – statistics also show that domestic violence and unemployment is more likely to occur in homes such as these. Much public housing is of poor quality or needs extensive restoration to meet changing community expectations and needs, and the long term practicability of social housing is under relentless strain.

Housing is fundamental to people’s health and well being as well as contribution to the economic and social life of the community – public policies and programs that ensure sufficient and equitable access to affordable, appropriate and secure housing are a critical part of strategies to reduce poverty, improve living standards and create sustainable communities in rural and remote areas. Public and community housing are fundamental in the decline of poverty and both social and economic inequalities within rural communities. Decades of urban citizens buying second homes in the countryside has resulted in inflated housing prices in rural areas; this generally puts buying a home suitable for a family in these areas an impossibility for most local people. Over the 5 years leading up to 2001, housing costs in rural areas rose by more than 12 per cent – this compared with costs rising only 3.5 per cent in major urban areas [8] is quite dramatic and detrimental to the lower income families of rural areas.

Access to Health Services

Citizens of rural and remote districts face several obstacles which reduce their access to adequate and appropriate health care. Access to services is restricted in rural and remote areas for a number of reasons including; geographical isolation, harsher environmental conditions, lack of medical professionals, an altered attitude towards illness, a deficiancy of infrastrcture and transport as well as the need for confidentiality. Generally speaking, rural and remote communities have less access to general practitioners, hospitals, specialist treatment, promotion programs and preventative treatments when compared with urban areas. Many people in rural and remote areas experince isolation and do not seek appropriate health services due to the distanes they must travel in order to access it. The thought of traveling a long distamce can deter people from accessing health services they need – it may delay them from seeking preventative information and services such as screnning for cancer. Living long distances from social support can discourage those seeking help for mentel illnesses as well as developing social networks.

Telecommunications assist in lessening the impact of geographical isolation, however the cost of this infrastructure is often sifnificant for rural and remote centres. Exposure to somewhat harsh environments such as drought, flood and fire is another factor influencing the utilization of health serives for many rural Australians, these environmental conditions often make access by road an impossibilty -restricitng transport to a service. People living in rural and remote zones have less access to health care compared with those living in the metropolitan areas. Indicators of hospital services, expenditure and medical personnel such as general practitioners, pharmacists and nurses were used to recognize aspects of rural and remote health access disadvantage. Some important findings included[9]: • The supply of GPs and pharmacists falls sharply in the rural and remote zones, with approximately only 12% of medical specialists located in rural and remote areas. • Lower rates of bulk billing

• Nurses provide a higher proportion of health care in rural and remote Australia than in metropolitan Australia • The number of medical specialists per person is significantly lower in rural areas than in the metropolitan zone • capital cities have 30% more hostel accommodation for the aged than the rural zone and three times more hostel places per capita than remote areas • Medicare data indicate that people living in rural and remote zones are using fewer services than those in urban areas

Often, people living in rural and remote areas have a differing attitude towards illness than those living in more urban areas. People residing in rural areas are liable to be more tolerant of injury and illness, accepting it as a part of life, be more self reliant and independent and be more likely to treat themselves before seeking medical attention. This way of thinking means that in some cases, conditions worsen before a professional is conferred with. In some rural areas, a person’s decision not to seek medical attention may be caused by a lack of confidentiality. A lack of confidentiality can deter people form seeking the support required to deal with a health concern. In less heavily populated areas people are more easily identified and recognized – this leads to concerns that other people in the community will have a knowledge of ones personal medical history – this is particularly regarding sensitive issues such as mental illness or drug dependence.

Major Inequities for any of the six of Australia’s Health Priorities

CVD
Cardiovascular disease includes a variety of heart diseases, stroke and related vascular diseases. The risk factors leading to CVD are tobacco smoking, physical inactivity, high blood pressure and being overweight. With greater prevalence of smoking, lower rates of physical activity and more restricted access to healthy food – people in rural and remote Australia are more likely to be at risk of cardiovascular disease than those living in the city. It has been found that death rates from cardiovascular disease are slightly higher in rural and remote areas for males but not for females.[10] Although there are no significant differences in stroke death rates between metropolitan, rural and remote Australia; hospitalisation rates for stroke show a pattern of increasing rates with rurality and remoteness, for both sexes.

CANCER
For head and neck cancer, stomach cancer, lung cancer and prostate cancer, patients in rural and remote were more likely to be diagnosed with non-localized disease than patients from highly accessible areas. This may be due to the lack of preventative treatment to find and treat cancers in remote and rural areas. For all other cancers there was no significant association between remoteness and spread of disease. The following statistics[11] revealed some inequalities for males and females living in rural and remote areas:

• Smoking related cancer – highest in males and females in very remote areas. • Alcohol related cancers – highest in males in very remote areas. • Head and neck cancer – highest in males in remote areas

A survey of risk factors in NSW in 1997 and 1998 found that people in remote areas were more likely to be current smokers and less likely to live in a smoke free household or have smoking restrictions enforced in their workplace. Also, people in remote areas were more likely to drink more than the recommended amount of alcohol per week. This information is valuable in understanding the prevalence of smoking and alcohol related cancers in rural and remote areas. For all cancers considered together, people living in accessible areas of Australia were at no greater risk of developing or dying from cancer than were people from remote areas.

INJURY
Injury is a chief factor of mortality in Australia and there is a strong pattern of increasing mortality from injury with increasing remoteness, particularly for males. This paradigm is particularly due to the nature of the harsh environment in remote and rural areas, the dominance of more hazardous jobs in rural areas such as mining and farming, as well as a lack of access to medical services in case of injury, resulting in a much higher death rate with injury as the cause of mortality.

Some statistics from the AIHW have shown that;

• death rates for all causes of injury in males living in other remote areas were double those of males living in capital cities • males living in other rural areas experienced death rates from injury around 50% higher than those living in capital cities • death rates from road vehicle
accidents show a prominent pattern of increase with increasing remoteness • both males and females living in other rural areas die in road vehicle accidents at more than double the rate of those living in capital cities. • The death rates for men dying from road traffic accidents in other rural areas and remote centres are respectively 108% and 154% higher than in capital cities

Hospitalisation often follows the same pattern as mortality:

• hospitalisation rates for injury, with much higher rates in the rural and remote zones compared to the metropolitan zones • hospitalisation rates for falls in people aged 65 years or more show higher rates in rural and remote zones • male hospitalisation rates due to burns in the remote zone were seven times those of males living in capital cities • both males and females living in the rural zone also experience higher hospitalisation rates from burns than those from capital cities, with rates around one-third higher than in capital cities[12]

Alcohol plays a significant role in many of the injuries. In 1992 alcohol misuse was partly the cause of 37% of all road injuries, 34% of falls, 44% of fire injuries, 34% of deaths by drowning and 7% of machine injuries in rural and remote areas. Information from the Australian Institute of Health and Welfare shows that men in large rural areas, remote centres and other remote areas have a greater incidence of high alcohol consumption than men in the nation’s capitals and are more likely to partake in high risk behavior leading to injury.

Mental health
People that live and work in rural, regional and remote communities experience stress related health problems, in particular psychiatric disorders 28% more than urban citizens – the effects of severe rural hardships, such as economic burden and job loss, lack of education and loliness in isolation may lead to an increase in stressful events, subsequently aggravating the symptoms of mental illness, such as depression. Social issues and behaviours which are sometimes indicative of mental health problems, such as violence and self-harm, appear to occur at higher rates in rural and remote areas. In Australia, suicide rates have consistently been found to be higher in rural than in metropolitan areas – there is an excessively high youth suicide rate for males living in remote areas. A lack of services that provide support for youth in these situations results in young people often developing a sense of hopelessness about the future – these burdens, along with a generally increased access to firearms, has been recognized as factors contributing to these heightened suicide rates.

Diabetes
Diabetes is a key factor for increased death rates in people in rural and remote areas, however people living in rura and remote areas are not considered in the high risk category for suffering with diabetes. People in rural and remote areas may suffer more commonly from diabetes due to a number of increased lifestyle risk factors such as; higher levels of obesity, a relatively lesser amount of physical activity, more unhealthy eating practices as well as heightened rates of dangerous alcohol consumption. There seems to be several barriers for the treatment and prevention of diabetes in rural areas, such as; a lack of availability of technology available for screening and diagnosis as well as a level of stigma which surrounds diabetes and being diagnosed.

Asthma
Reported rates of current asthma were higher in rural health areas than urban health areas for both males and females. Among females, there was a clear trend of escalating reported rate of asthma with increasing remoteness of location[13], with the highest rates reported by females living in very remote areas being 15.5%. Amongst males the pattern was very different – males living in moderately accessible areas had the highest rate of asthma suffering – 10.7%, which then dropped sharply to 1.3% among males living in very remote areas – more than six times lower than the state average for males. According to the ARIA classification,[14] those from rural and remote areas were more likely to report interference with daily behavior or three or more days unable to carry out normal activities due to asthma. Rural residents are slightly less likely to use asthma preventative and reliever medications than those living in urban areas. The leading difference was for preventative use, with epidemiology showing that 30.4% of males from rural areas reporting using preventative medications on at least half of days in the previous month, compared with 37.4% of males from urban areas.[15]

Social inequities within rural and remote communities are a result of a current lack of social justice. Given the relatively poor geographic access to health services, lower socio-economic status and employment levels, and exposure to comparatively harsh environments and occupational hazards, it is not surprising that the health status of those people living in rural and remote Australia is worse than those living in urban areas. Social justice principals need to be applied to the inequities of this population group in order for them to be resolved; social justice is the value system which encourages equity, diversity and supoprtive environments, it is essentially achieved by promoting the interests of those most disadvantaged in society. The chief principal of applying social justice is equity; equity is not merely giving everyone an equal amount of resources for improving their health, if this was the case all current inequities would conitnue to exist. Equity needs to be focused on ensuring that all individuals within society, especially priority groups such as rural and remote Asuatralians, have equal opportunities for achieving optimal health, until this happens – those in rural and remote areas may continue to suffer these severe health inequities.

:: Bibliography ::

websites

• http://www.aihw.gov.au/ruralhealth/overview.html
• http://hsc.csu.edu.au/pdhpe/core1/identify/2587/3_1_2_2rural.htm • http://www.ncbi.nlm.nih.gov/entrez/query.
• http://www.deh.gov.au/esd/national/indicators/report/value16.html • http://www.dotrs.gov.au/regional/summit/program/background/pdf/ • http://www.pravara.com/loniagenda.html
• http://www7.health.gov.au/hsdd/horizons/horizons4.pdf • http://www.hollows.org/upload/3385.pdf
• http://www.hreoc.gov.au/pdf/human_rights/rural_occpaper.pdf • http://www.aihw.gov.au/publications/aus/ah02/ah02-c04.pdf • http://www.heartfoundation.com.au/downloads/cvd.htm
• http://www.cancercouncil.com.au/html/research/cancer_updates • http://www.adca.org.au/publications/Drug
• http://www.asthma.crc.org.au/Burden_of_Asthma_in_Australia.pdf • http://www.csu.edu.au/faculty/health/cmhealth/COS/Publications • http://www.responseability.org/Eweb/E%20MHT%2011.htm • http://www.healthinsite.gov.au/expert/Diabetes_Mellitus

newspaper article

SYDNEY MORNING HERALD: Slicker in the city? It ain’t necessarily so, November 10, 2004 Ross Gittoes

Books

• PDHPE application and inquiry. HSC course
Stan Browne, Karen Lambert, Deb Clarke, Vicki Jeffreys. • Communities in Australia: Life in a Farming Community John Barwick & Jennifer Barwick
• Communities in Australia: Life in the Outback
John Barwick & Jennifer Barwick
• Communities in Australia: Life in a Country Town
John Barwick & Jennifer Barwick
• Excel HSC & PRELIMINARY PD, HEALTH AND PE
Fay Courtney & David Thomas

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[1] AIHW 1998b p.9
[2] http://www.dotrs.gov.au/regional/summit/program/background/pdf/alston_paper.pdf [3] http://www.aihw.gov.au/publications/phe/rrrh-smsf/rrrha-smsf.pdf [4]
http://coss.net.au/news/upload/info
[5]http://65.542fAusstats%2fabs%40%2ensf%2f0%2fb454091b9b5b0a65ca256a7100188a4c%3fOpenDocument [6] (ABS 1990; Public Health Services 2001).
[7]http://bin/linkrd?_lang=EN&lah=f79df142898d4a67a5352caa673cd75f&lat=1100150560&hm___action=http%3a%2f%2fwww%2epoverty%2eorg%2euk%2frural%2fincome%2ehtm [8] http://smh.com.au/news/Ross-Gittins/Slicker-in-the-city-It-aint-necessarily-so/2004/11/09/ [9] http://www.aihw.gov.au/publications/health/hrra/hrra-c00.pdf [10] http://www.aihw.gov.au/publications/health

[11] http://www.cancercouncil.com.au/html/research/cancer_updates/downloads/update_12.pdf [12] http://www.aihw.gov.au/publications/health/hrra/hrra-c00.pdf [13] http://www.health.nsw.gov.au/public-health/nswhs/asthma/asthma_intro.pdf [14] http://www.health.nsw.gov.au/public-health/nswhs/asthma/asthma_intro.pdf [15] ARIA classification