Rural and remote public health in Australia: Building on our strengths

The governments of Australia have agreed that ‘People in rural, regional and remote Australia will be as healthy as other Australians . . .’1 To eliminate current health inequalities between metropolitan and rural Australia, we need to enhance disease prevention and health promotion efforts based on a better understanding of the nature of rural–urban inequalities. We also need to recognise that a deficit view of the bush is neither helpful nor justified. Future effort should acknowledge rural and remote area advantages and build on the strength of rural and remote public health infrastructure, ingenuity and practice. Mortality and morbidity rates for many common diseases continue to be worse in rural and remote areas compared with metropolitan areas.2 Mortality rates increase with increasing remoteness, as health loss, many diseases, risk factors and key socioeconomic determinants do.2–4 However, this mortality trend is not consistent for all causes or for gender in comparable countries.5 Aggregated national data may also not adequately describe regional variations. It is likely that differing social and economic factors across comparable countries drive differing rural health outcomes.5 This is evident in different Indigenous populations.6 In Australia, tobacco smoking, elevated blood pressure, high cholesterol, alcohol and overweight and obesity are the commonest preventable risk factors for health loss, all of which are amenable to preventive measures.4 The need for effective primary prevention and health promotion is thus an ongoing challenge for rural and remote public health practitioners. At the same time, the relationship between health and place is complex and requires unraveling.7 We are familiar in Australia with the essential relationship between Indigenous peoples and lands. Perceptions of health and illness, and health-seeking behaviour are different for many rural residents,8 and qualitative evidence suggests that rural residence can be beneficial to feelings of well-being.9 Residents ‘imbue rural places with health enhancing properties . . .’.9 Consequently, continually characterising the rural context as high risk and negative may be in contrast to residents' beliefs and undermine health promotion initiatives. This point is underscored by the fact that the major cause of health loss in Australian women is anxiety and depression.4 Hence, knowing ‘What is it about rural places or the rural experience that contributes to differential health outcomes? How is rurality embodied . . . ?’10 is critical to understanding the complexity of health outcomes and perceptions of well-being in order to design appropriate prevention and health promotion interventions. What do we mean by rural public health? If public health is defined as society's organised and institutionalised efforts to maintain health and prevent illness, it is apposite to ask whether rural public health consists of the same metropolitan efforts transferred to a different environment, or whether it is distinguished by a different geographical, demographic, historical and sociological context. In the following, I suggest that the nature and practice of public health in rural and remote areas are different in a number of significant and advantageous ways from the urban setting. Historically, urban public health activity in cities has focused on problems of high population density – preventing the spread of infectious diseases in the old public health paradigm, and more recently the problems of increasing urbanisation and non-communicable diseases.11 On the other hand, rural public health is concerned with location-specific problems such as agricultural accidents, isolation and poor availability of health services, as well as underlying determinants such as lesser socioeconomic conditions and lack of educational opportunity. In contrast to densely populated cities, geographical distances are large and social distance small in rural regions. The multiple roles of public health practitioners in rural and remote areas also differentiates rural public health practice. Leeder, in an excellent overview of international public health, highlights the tension between clinical medicine and public health approaches, and its reflection in policy and funding.12 In small rural and remote communities in Australia, however, clinical expertise is often the prerequisite for building credibility and the relationships which enable public health activity –‘It’s about being a primary care practitioner with public health tools in the kit bag' (D. Lyle, pers. comm.). Third, whereas epidemiologists analyse large databases ‘at a distance from the original local issue which might have provoked a need or desire for information’, the local public health practitioner often has to deal with small numbers, problems requiring immediate attention which affect residents and those with whom they come into contact on a daily basis.13 Public health practitioners in small rural and remote communities wear many hats: clinicians, researchers, educators, advocates, community service club members and significant members of those communities. In Australia, they are also members of strong rural professional organisations which constitute powerful, well-organised forces for national advocacy. These roles – at local and national levels – are critical in terms of the professional and community linkages necessary to move evidence into action. Finally, the multiple roles of individual public health practitioners, the smaller scale, and the high need/low resource environment have served to incubate change and innovation.14 Rural health policy has been conducive to building a rural academic public health infrastructure and some effective public health interventions. The most recent wave of rural health policy activity formally commenced with the first National Rural Health Strategy in 1994.15 Medical workforce and health service access problems, advocacy by professional and other rural groups, combined with the rise of Hansonism in the late 1990s, led to a burst of new rural health policies – some focusing on public health issues. In Australia, University Departments of Rural Health had a specific public health brief, particularly in relation to models of health service delivery, education and workforce issues.16 The Commonwealth Primary Health Care Research Evaluation and Development program provided additional research capacity to the University Departments of Rural Health. The marked increase in rural health research publications since 2000, many of which relate to public health or health services research, coincided with the establishment of increased academic capacity in rural and remote areas.17 In 1997, the National Rural Public Health Forum was held in Adelaide. Organised by the then Department of Health and Community Services, Department of Primary Industry and Energy, and the National Rural Health Alliance (NRHA), it produced a 6-point plan to increase prevention and health promotion activity in rural and remote areas.18 Few recommendations, such as a call for a National Rural Public Health Strategy, were implemented. However, information arising from this meeting was used in the reformulation of the rural health policy into its successor, Healthy Horizons. One of the eight principles emphasised by this document was public health. Mainstream and specific rural programs, such as the Rural Chronic Disease Initiative, were implemented with growing recognition of the epidemic of chronic disease. There are many examples of excellent public health interventions relating to re-orienting health services to chronic disease management,19,20 assessing environmental hazards,21 addressing risk factors22 and structural change in other sectors affecting health outcomes.23,24 Many of the most innovative interventions were developed in remote, under-resourced areas of Australia in order to improve Indigenous health, the most pressing public health priority. Nonetheless, rural health policy and research have focused largely on health services and workforce issues rather than underlying determinants of health or more proximal risk factors. This is understandable in the context of continuing poor access to services in these areas. However, we now have considerable information about the impact of rural educational programs, particularly medical ones, and about effective and sustainable health service models.25 There are also well-evaluated efforts at re-orientation to chronic disease management.23,24 What is now needed is to extend appropriate, sustainable, well-evaluated service models that have the capacity to address existing health inequalities. Moreover, given evidence that differences in rural and remote areas result in differing health outcomes,5 it is timely to focus on those important social and economic factors outside of the health sector that contribute significantly to increased risk that underpins health loss. Successful, widespread public health interventions to eliminate rural–urban health differentials will require an appropriate policy framework. In Australia, rural health professional and consumer organisations, such as those making up the NRHA, have kept rural health squarely on the agenda for government and other non-government groups through organised advocacy. With a new federal government that explicitly prioritises prevention and health promotion, there are opportunities to fund appropriate, well-evaluated public health measures and integrate them into primary health care services. The current review of Healthy Horizons will ideally result in a national rural health policy and plan with benchmarks and targets that will continue to reflect public health priorities and approach, and better coordinate Commonwealth/state efforts. Importantly, the research agenda needs to address only those knowledge and implementation gaps that continue to hinder decision-makers with respect to health service issues. Moreover, there needs to be greater focus on understanding the links between rurality, behaviour, and health and well-being. The Inaugural Rural Health Scientific Conference scheduled this year provides an opportunity to better define this agenda. Despite the strong evidence of health inequalities relative to metropolitan Australia, many rural and remote residents feel a sense of well-being and strong connection to where they live. The nature of rural public health practice and the current academic infrastructure provide a solid foundation for undertaking a strengthened public health effort in rural and remote Australia. There are many examples of the innovation that is possible in this tough environment. Rural and remote public health practitioners play multiple roles in our communities with strong links to services and to community organisations, and through national professional and other rural organisations. These strengths provide a significant opportunity to move away from the deficit model of rural and remote health and strengthen public health effort. I am grateful to David Lyle and John Humphreys for their helpful comments.