CHAPTER 4 Ageing in rural areas
FRAMEWORK
Issues surrounding ageing in rural areas need to be addressed urgently. The authors of this chapter suggest that the need to define what exactly is ‘rural’ would be a good start. To provide equitable services to older people living in areas that do not support specialist skills or have access to diagnostic equipment means a change in health care planning. The added issue of culturally and linguistically diverse people who live in rural areas contributes to the difficulty of providing services for small groups. Low levels of preventive health care and monitoring the impact of chronic disease is an issue mostly due to a lack of interdisciplinary team work and case management. Attracting general practitioners and allied health professionals to rural areas has long been a problem in Australia. There have been many programs that offer incentives for these practitioners to work away from metropolitan areas but these programs do not seem to provide long-term commitment. The vignette provided highlights the real problem of ageing in rural areas and the need for innovative ways to remain independent at home. [RN, SG]
Introduction
A growing awareness of the significant ageing of our population and the subsequent impact on the finite resources that support the health and wellbeing of our population is creeping into the consciousness of both government agencies and the health care community. As many non-metropolitan populations are experiencing this trend more rapidly than metropolitan centres, the need for rural responses is pressing. The challenges of an ageing population and limited resources for health and aged care are further exacerbated in rural and regional areas where geography negatively influences health status, lifestyle habits increase the risk of obesity and tobacco and alcohol use, and affordability of health care plus professional workforce issues also exist (Allan et al 2008; Moates 2005).
If the policy goal of ageing in place1 is to be achieved for rural populations, we must find new models of interdisciplinary care that better coordinate and share limited resources across the aged care spectrum. These models must meet the challenge to provide care across settings from community to residential. Rural populations and service providers have a tradition of innovation in response to necessity, and indeed there are many initiatives currently underway that can add to our knowledge of how to best deliver care to older people in rural areas and to assist them to manage their ageing and their health in a positive way. Unfortunately many of these initiatives are not reported in the scholarly literature and health care professionals entering practice in the rural environment must brush up their investigative skills and learn to search the grey literature of reports and evaluations. Developing a network with colleagues in other rural settings is also a key to keeping abreast of innovation.
Provision of interdisciplinary care for older people in rural areas has inherent difficulties. To start with, there is no internationally agreed definition of what exactly constitutes ‘rural’ (Rygh & Hjortdahl 2007). This lack of universal definition alone must make it difficult to provide equity in division of government resources. The geographical approach seems to be the most commonly applied means of determining rurality, whereby a location is defined in relation to distance from major centres. The definition of a major centre however can also be debated when it comes to identifying the infrastructure essential to meet the needs of the surrounding population. There is also the sociological approach in determining rurality, which emphasises the differences between metropolitan and non-metropolitan contexts, underscoring the impact of socioeconomic, behavioural, attitudinal and perceptual characteristics of a defined area on access to services (University of Ballarat 2004).
There is no internationally agreed definition of what exactly constitutes ‘rural’.In Australia, there are different methods of defining and measuring non-metropolitan areas; some are focussed on the degree of remoteness, others give more weight to the rural–metropolitan distinction. The Australian Institute of Health and Welfare (AIHW) published a guide to remoteness classifications defined as follows (AIHW 2004):
Rural demography
The ageing of the Australian population is most pronounced in non-metropolitan areas, with this trend predicted to strengthen in coming years (Australian Government Department of Health and Ageing 2008; Borowski & McDonald 2007). The AIHW report demographics in terms of ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’. AIHW figures indicate that the majority of the Australian population live in major cities (66%) and approximately 31% Australians live in regional areas and 3% in remote areas. Income and education levels are lower in regional and remote communities than in major cities (AIHW 2007). The AIHW report shows that death rates in regional and remote areas are 10% higher than in major cities, with circulatory disease being the major cause of death (44%). Regional areas have proportionally fewer younger people and higher aged populations. In remote and very remote areas there are substantially fewer females than males, with numbers becoming more equal in older age (AIHW 2007). This distinctive gender pattern may have implications for the informal care network.
The ageing of the Australian population is most pronounced in non-metropolitan areas, with this trend predicted to strengthen in coming years.Another reality is that ‘rural areas’ are extremely diverse (AIHW 2007). Indigenous Australians are more likely to live outside major cities, with the percentage of the population who are Indigenous increasing significantly with remoteness. While only 1% of the population in major cities is Indigenous Australian, this figure increases to 2–5% in regional areas, 12% in remote areas and 45% in very remote areas (AIHW 2007). The Indigenous population is not ageing at the same rate as the population overall, yet it is important that this group is not excluded from planning and provision for health and aged care needs of older people, and that the diversity within the Indigenous population is recognised. The existing knowledge base for this consideration is weak. We do not yet know if the pattern of health status and disability associated with the elderly non-Indigenous population is also characteristic of Indigenous Australians, and we know very little about Aboriginal and Torres Strait Islander experiences of ageing (Cotter et al 2007).
Indigenous Australians are more likely to live outside major cities, with the percentage of the population who are Indigenous increasing significantly with remoteness.The population of rural communities is culturally and linguistically diverse (CALD). The concentration of post-war immigrants in major cities means that the representation of individual CALD groups in rural communities is often relatively small (Green 2001), posing the challenge of providing culturally appropriate services to small numbers. Patterns of settlement of some more recent immigrant groups have been more geographically dispersed (Hugo 2002), indicating that in the future the cultural and linguistic diversity of those ageing in rural communities will increase.
Baby boomers are contributing to the ‘sea/tree-change’ and the ageing of our rural populations will be influenced by this movement (Ryan 2007). While the ‘sea-change’ and more recently the ‘tree-change’ movement of metropolitan dwellers has been motivated by a perception of more peaceful and fulfilling life styles in idyllic coastal and bush settings, the reality is that worldwide rural dwellers have poorer physical health status and tend to die younger than their urban counterparts (Allan et al 2008). Competing commitments to individualism and social activism have been observed as characteristic of this generation (Huber & Skidmore 2003; Olsberg & Winter 2005), although how these attitudes will shape expectations of health and aged care services as they move through the retirement decades is uncertain. Clearly this group will challenge existing assumptions about rural stoicism and become an influence for change in rural service planning and provision.
Practice issues
Access to health services
The rural/metropolitan differences in access to health care services is reflected in figures reported by Moates (2005) that show despite 30% of Australians living in ‘the bush’ they make up only 20% of Medicare rebates supplied by only 15% of the total medical workforce in Australia. This inequity is compounded by rural dwellers also having much lower private health insurance coverage than their urban counterparts, subsequently directing more government funding to major cities rather than rural areas despite the greater need in the bush (Moates 2005).
The AIHW 2007 report states (p 7):
Preventive services such as immunisation and information allowing healthy life choices
For older people, preventive services such as influenza injections and information regarding healthy lifestyle choices and how to make them are essential in maintaining health and wellbeing, reducing burden of disease and decreasing the use of health care services. However, provision of these services in rural areas is restricted by lack of access to primary and preventative health services. General practitioners (GPs) are the main providers of immunisation services for the rural elderly, but the rural medical workforce shortage often means a scarcity of available medical appointments and the rural elderly often share the perspective that you only go to the doctor if you are sick. The dearth of health promotion services in rural areas also influences decisions regarding lifestyle choices. In many rural towns the pharmacy is the only source of health information apart from the media, where the risks of smoking and alcohol are promoted and a healthy diet and exercise may be encouraged through various advertisers. Low and dwindling numbers of pharmacists in regional and remote areas exacerbates this problem.
The rural medical workforce shortage often means a scarcity of available medical appointments.Health management and monitoring
Effective models of health management and monitoring tend to depend on the availability of a range of health professionals providing ongoing interdisciplinary care in the local community. The incidence of chronic disease increases with ageing and with the lack of preventative and information services in rural areas; subsequently the impacts of chronic disease will increasingly affect the health of our rural elderly. Despite the greater need for these services in rural Australia, there are barriers to providing health management in the form of case management as the rural health workforce shortage and centralised service system limits the number of case managers based in rural areas. Similarly, there are significant benefits from annual health assessments for older rural residents who are not yet in crisis. The rural GP workforce lacks the capacity and regularity of contact with community members to provide these assessments, but there is some evidence of scope for allied health practitioners to provide this service (Byles et al 2002; Byles et al 2007).
Specialist surgery and medical care
Older people in rural areas not only have increased need for specialist surgery, such as cardiovascular surgery related to increased incidence of cardiovascular disease, but also a greater need for specialist medical care because of age-related illness which is often accompanied by complex comorbidities. However, while there is a higher death rate from coronary artery disease in regional and remote areas than in major cities, there is a lower rate of coronary artery bypass surgery and coronary angioplasty in regional and, especially, remote areas (AIHW 2005 p248). It is not possible to provide onsite specialist surgical services and specialist medical care in every town and despite access to visiting specialists in many larger regional towns, the rural and remote elderly often need to travel great distances to access specialist care.
The rural and remote elderly often need to travel great distances to access specialist care.Emergency care; for example, ambulance
Due to restricted access to preventive services and healthy lifestyle information, and compounded by the dearth of case managers to assist with ongoing monitoring of their health, the rural elderly are more likely to need specialist surgical and medical care. However, because of access issues they are very likely to instead suffer acute exacerbations of chronic health conditions and/or develop other health problems that require emergency care, such as an ambulance. Even if they are taken away in an ambulance, often driven by local volunteers with basic first aid training (O’Meara 2003), where will it take them to? Hospitals that are fully equipped with up-to-date emergency resources are only to be found in the larger metropolitan and regional centres (Ministerial Taskforce on Trauma and Emergency Services 1999).
Rehabilitation service after medical or surgical intervention
The pattern is repeated in rehabilitation services. The current paradigm of rehabilitation is informed by the International Classification of Function (ICF), developed under the auspices of the World Health Organization. The current model is usually interpreted to mean assessment and treatment by a number of different health professionals, who bring their individual professional expertise into an interdisciplinary team, and work together using physical, social and psychological approaches. However, Australia faces a great shortage of rehabilitation professionals of all kinds. For example, in the state of Victoria, despite an ageing population, between the years 2000 and 2004 medical specialists in the field of rehabilitation decreased by 3.5%, and geriatricians by 7.7%, few of whom practise in rural areas (Productivity Commission 2005). This means that rehabilitation is often only available in metropolitan or larger regional centres, and people either do not access such programs or are transferred away from home for rehabilitation, where rehabilitation is disconnected from the social and physical environment to which they will hopefully return.
The current paradigm of rehabilitation is usually interpreted to mean assessment and treatment by a number of different health professionals.Aged care services
Appropriate aged care accommodation is often unavailable in rural communities. From independent living with appropriate community supports to retirement villages/communities to independent living units, to low level residential aged care through to high level aged care, the lack of access to accommodation choices appropriate to the needs of individuals in rural areas is a very real challenge. Aged care accommodation for special needs groups such as those with dementia, those from different cultural backgrounds and indigenous elderly is almost non-existent in rural areas.
Professional practice in the rural context
A study examining pharmacist and social worker perceptions of their ‘fit’ within rural communities ‘highlighted access to care, local context and individual personal and professional issues as factors that impinge on health care service provision’ (Allan et al 2008: 7).
A sense of belonging is essential to emotional wellbeing.
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