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- Introduction
- The Rural Context
- Rural Health Services
- Rural Practice
- Teams in Rural Health
- Conclusion
- References
Introduction
Like beauty, rurality is very much a matter of personal perception. Most people who live in major cities consider anywhere outside the boundaries of that city to be rural. On the other hand, many inhabitants of larger rural towns or regional centres do not consider themselves to be rural. It is clear, however, that general practitioner (GPs) and others living outside the urban areas consider rural health and rural general medical practice to be distinctly different from urban practice. 1
This paper discusses key factors that determine the structure and function of rural health services, how rural health practitioners work and the nature of rural practice. In this context, the paper then describes teamwork in rural health at three different levels of the system.
The content of this paper is based on experience and knowledge gained from rural practice in the Australian setting and internationally through the WONCA World Rural Health Conferences and the world literature. 2
The Rural Context
Geography and demography are key determinants of the rural context. Relatively small populations are scattered at various distances from larger centres, such that it is impractical to provide health services in the same manner as occurs in the cities. Often, access to regional centres and to the cities may be reduced by poor climate and difficult terrain. In addition, public transport may be very limited, further reducing access for those without private transport. The standard and quality of communications between different rural communities, and between those communities and the major urban centres, may be quite variable. The trend to deregulation and privatisation of telecommunications may be counter-productive for the rural sector because the smaller populations and larger distances make these services relatively unprofitable. Consequently, those people and health service providers in rural areas who have most to gain from modern telecommunications are least likely to have full access to these services.
There is a strong feeling in rural communities that they are different from, and have special qualities not found in, the cities. 3 Sociologists describe this quality "gemeinschaft". Relationships are seen as personal and enduring; limited and unspecified in their demands; and imbued with a strong sense of loyalty not only to friends and relatives, but to the community and its members. Particularly in smaller rural communities, there is a community conception of the town as one "big happy family". By way of contrast, the city and the government are seen as distant and antagonistic. Sociologists describe this concept as "gesellschaft". The city is seen in many respects as bad and inferior, while the small rural community is good and superior.
Another aspect of the sociology and psychology of rural communities is the clear sense of behavioural norms, which translate into community views of the social roles and functions of various members of the community. While always being ready to help someone in need, the preferred attitudes and values are those of self-sufficiency, self-reliance and independence coupled with stoicism. Particularly for farmers, there is a strong focus on productivity and getting the job done, with their own health being seen as a very low priority. 4 This translates into the view that health services and hospital really are the last resort.
The nature of the rural culture affects the patterns of illness and injury in rural areas. These patterns have been shown to differ between some rural areas and cities. Clearly the popular view that "country living is healthy living" is generally false. In Australia, avoidable deaths in rural and remote areas are 40% higher than in the cities. 5 Work related injuries are more common and more severe and the injuries sustained from motor vehicle accidents also tend to be more severe. The nature of work related injuries is affected by dangers inherent in the rural lifestyle like farming, forestry and mining, and also by the rural culture with its stoicism and focus on getting the job done. This "too tough to care" attitude probably at least partly explains the higher rates of serious injuries.
Lifestyle related illnesses are also more common in rural areas than in urban areas. These are associated with significant levels of stress, higher alcohol and tobacco consumption and poor nutrition. The affects of troughs in the economic cycle in rural areas are often severe, placing extreme pressure on rural communities. Generally, counselling, support groups and other mental health services are limited if available at all. 6
Rural Health Services
For rural populations, access to health services is the major issue. People wherever they are, city or country, need to "know" that if they are unlucky enough to be seriously ill or injured they will be "saved". Generally speaking, in the cities, where there are hospital emergency departments and ambulance services, this emergency response is assumed to occur. In the rural areas, this cannot be taken for granted and people tend to be focussed on this security need. Often the way in which this felt need is expressed is through the communities’ primary focus on recruiting and retaining a doctor or doctors, and having a hospital in the area. 7
In general, people in rural and remote areas very much prefer to be cared for in their local environment. The provision of health services in rural and remote areas is significantly affected by limited funding and the poor availability of other resources. In recent times, this has been exacerbated by the general trend towards reduction of funding and infrastructure support for health services in rural and remote communities. 8
All of these issues are accentuated by often serious shortages of doctors, nurses and other health service providers in rural and remote areas.
In very small communities, some quite isolated, local services are provided by nurses. These nurses are generally supported by GPs who are some distance away and provide a visiting service. In slightly larger communities, there are usually resident practitioners who may provide all the medical services in the local hospital. If specialist and allied health services are available, they are usually at some distance from the community or may be provided on a visiting basis. The availability of health services in rural areas is seriously affected by continuing shortages of doctors and other health professionals in these areas.
Rural Practice
Over the last 10 years, major studies have been undertaken describing the nature of rural practice. 9 , 10 , 11 , 12 When compared with their metropolitan counterparts, rural GPs carry a heavier workload and provide a wider range of services. Generally, these practitioners are on call much more of the time than urban practitioners and when they are on call they are much more likely to be called out. Rural GPs are significantly more likely to be providing procedural services including hospital-based services and emergency medicine. When compared with urban practitioners, rural practitioners carry a higher level of clinical responsibility in relative professional isolation.
Although the specifics differ from discipline to discipline, this description of rural practice holds true not only for rural GPs but also for medical specialists, nurses and allied health professionals. Within their disciplines they are functioning as "extended generalists".
Rural medical practice can be seen to have three components. The first is broad, all round general practice/family medicine. Like GPs in metropolitan areas, rural practitioners provide comprehensive, continuing, community-based care dealing with both acute and chronic illnesses. In fact the rural GP is more likely to be providing all the medical services for individuals and for families.
The second component of rural medicine is the procedural care. Dealing with emergencies is generally an unavoidable part of rural medical practice. In communities where there is no hospital, emergencies come directly to the GP’s clinic. Where there is a hospital in the town, the GP is likely to be providing medical services at the hospital including emergency services as well as in-patient services. Where the community has other residential care, such as a nursing home and/or hostel, the GPs provide medical services to their residents.
Rural GPs also provide community level care, fulfilling a significant public health role. This third component can range from a "medical officer of health" focus on clean water, sanitation, food and shelter, to preventive care through immunisation and health screening activities, to health promotion and community education. There is some evidence that rural people give more credence to health education received from their GPs than from any other source. This situation is different from that in the city and provides the opportunity for rural GPs to effect change in health related behaviours at the community level.
Teams in Rural Health
Given the serious shortages of doctors and other health practitioners, interdisciplinary co-operation and teamwork amongst health care providers tends to occur more effectively in rural than urban settings. As a generalisation, teamwork is much talked about in the cities but happens much less frequently than in the country. This teamwork is encouraged both by the rural culture, with its focus on getting the job done and "doing the necessary", and also by the special relationship between rural practitioners and their communities.
The second level of teamwork in rural health is between local generalists and distant specialists. For both medical specialists and other specialised health services, the specialist–generalist team works best when the specialists see their role as supporting the local practitioners who provide ongoing clinical care. It is unfortunate and potentially counter-productive when medical and other specialists visit other communities and provide direct clinical services unconnected to local services. As a specialist may be available in the visited community only once in two weeks or a month, ongoing management is, of necessity, in the hands of local doctors, nurses and other health practitioners. Successful teamwork occurs where specialists act as true consultants, providing clinical support and teaching for the local practitioners. High quality care is achieved through co-operation between local generalist providers and distant specialists based on mutual respect and trust. This requires recognition and acceptance by the specialists of the clinical expertise and local knowledge of the rural practitioners.
The third and critical level of teamwork in rural health care involves co-operation between the health authority/health service agencies, GPs and other health care providers, and the rural community, preferably articulated through a community representative organisation. Particularly in small rural communities, health services are most likely to be sustainable where there is active local community participation in the health service and an explicit agreement between the community and the GPs regarding general practitioner services, covering the period of contracted service, the range of services provided and after-hours availability. 13
The rapid development of communication information technologies (IT) has the potential to reduce the isolation of people living in rural and remote areas, including health care providers. Satellite television links, audio and video conferencing, the Internet and other forms of high-speed data transfer provide the means for improved education and support for doctors and other rural health practitioners. Specific telehealth applications may provide rural practitioners with rapid access to clinical specialist support.
On the other hand, extension of communication IT to rural areas may spell the end of local responsive health services. The danger is that the IT developments will be driven by city-based centralist IT enthusiasts who have no understanding of, or respect for, the rural context, rural health services or rural practitioners. Then, the IT network may well "roll out" from the cities demolishing all before it. Effective utilisation of information technologies must be based on mutual respect between urban and rurally based practitioners. 14
Conclusion
In summary, it is clear that the distinctive features of the rural context determine the function and structure of rural health services and the nature of rural practice. Rural communities are best served where there is effective teamwork between "extended generalists" (nurses, doctors and others) at the local level, between local generalists and distant specialist services, and in the management and delivery of rural health services.
References
- Strasser RP. Rural general practice: is it a distinct discipline? Aust Fam Physician 1995 May;24(5): 870–876
- Strasser R. Models of rural practice. In: Reid S, editor. South African Family Practice, South African Academy of Practice/Primary Care, South Africa, 2nd World Rural Health Congress, Durban 14 – 17 September 1997, Vol 18 No 5 October/November 1997. p9
- Dempsey K. Small town: a study of social inequality, cohesion and belonging. Melbourne: Oxford University Press; 1990
- Hegney D. Agricultural occupational health and safety; farming families presenting a challenge to wellness. Aust J Rural Health 1993;1(3):27–33
- Strong K, Trickett P, Titulaer I, Bhatia K. Health in rural and remote Australia. The first report of the Australian Institute of Health and Welfare on rural health. AIHW Cat. No PHE 6. Canberra: Australian Institute of Health and Welfare. 1998
- Human Rights and Equal Opportunities Commissions. Human Rights and mental illness. Canberra: Australian Government Publishing Service; 1993. p.678–722, 936–939
- Strasser RP, Harvey D, Burley M. The health service needs of small rural communities. Aust J Rural Health 1994;2(2):7–13
- Humphreys J, Mathews-Cowey S. Models of health service delivery for small rural and remote communities. Final Report. Bendigo: School of Health & Human Sciences; La Trobe University. Commonwealth Department of Health & Family Services RHSET Grant 329, 1999
- Strasser R. Rural practice in Victoria. The report from the Study of the Attitudes of Victorian Rural General Practitioners to Country Practice and Training. Monash Department of Community Medicine, Monash University, 1992 May
- Report of the ministerial enquiry into the recruitment and retention of country doctors in Western Australia (M Kamien Chair). Perth: Government of Western Australia; 1987
- Wise A, et al. Vocational training and education for the rural medical practitioner. Brisbane: The Queensland Rural Practice Research Group;1992
- Strasser R, Hays R, Kamien M, Carson D. Is Australian rural practice changing. Aust J Rural Health. In press 2000
- Strasser R, Worley P, Hays R, Togno J. Developing social capital: community participation in rural health services. Fifth National Rural Health Conference; 1999; Adelaide, Australia
- WONCA Working Party on Rural Practice. Using information technology to improve rural health care. Melbourne: WONCA; 1998
