CHAPTER 11 Rural and remote health
There are some beautiful places to live in rural and remote Australia, yet the majority of Australians live in metropolitan regions where health services are concentrated. Due to sparse health services and critical workforce shortages, rural and remote health is somewhat like a canary in a mine for the rest of the health system. By understanding more about rural and remote health we can learn much about how these shortages impact on the health and wider socioeconomic status of communities. Three issues are discussed in this first section; defining rural and remote health, Aboriginal health, and influences on Australian outback culture.
The RRMA classification was developed in 1994 based on 1991 population census data and Statistical Local Area (SLA) boundaries. It consists of three zones (Metropolitan, Rural and Remote) and seven classes and combines a distance measure with a population density measure (Commonwealth Department of Health and Ageing 2005a). The ARIA index score is based on the road distance from the closest service centres in each of four classes (as defined using 1996 census population data). ARIA index scores, and therefore ARIA categories, are capable of being updated over time as populations change. ASGC Remoteness Areas was released in 2001 by the Australian Bureau of Statistics (ABS), and was based on an enhanced measure of remoteness (ARIA+). The ARIA+ index values are based on road distance from a locality to the closest service centre in five classes of population size (instead of four — as in ARIA). ASGC Remoteness Areas categorises areas as ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’ (Australian Institute of Health and Welfare [AIHW] 2004c). The Federal government uses RRMA classifications to make decisions about the allocation of health resources, which means that some relatively large population centres are excluded from applying for certain funding.
The health status of rural and remote populations is relatively poorer than those who live in capital cities. The reason for the overall poorer health in rural areas is twofold — they have less access to health services and are more socioeconomically disadvantaged. The health status of the population declines in smaller and more remote areas. In remote areas there is a particularly higher incidence of premature deaths from injury, particularly among males. Both men and women in rural and remote areas are more likely to die in a motor vehicle accident with the incidence of deaths being double that of urban areas. The rate of injuries from falls in older people living in rural and remote areas is also higher than in cities. There is a less clear pattern for other causes of morbidity and mortality in rural and remote health outcomes. For example, there are no significant differences in stroke death rates between metropolitan, rural and remote Australia although hospitalisation rates from stroke show a pattern of increasing rates with increasing rurality and remoteness, for both men and women. Mortality and hospitalisation rates from coronary heart disease reveal higher rates in rural areas, compared to cities. Mortality rates from coronary heart disease are higher still for people living in remote areas. The overall health status of people in rural and remote areas is impacted by the relatively higher proportions of indigenous and older people living in rural and remote areas (Strong et al 1998).
One of the largest groups in rural and remote regions requiring health services are the Aboriginal and Torres Strait Islander peoples. In the late 18th and 19th centuries any community outside Sydney was considered remote (Yuginovich 2000; Forsyth 2007). Remote area nurses undertook independent responsibility for primary health care in the early 19th century in these remote and rural areas. These nurses and doctors, who worked in isolated communities and missions, unquestioningly accepted, firstly, segregation of Aboriginal peoples, then assimilation policies and their underlying paternalistic ideologies, and incorporated them into their clinical practice (Forsyth 2007). For example, The National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families was established in May 1995. It revealed the ‘stolen generation’, which represents thousands of Aboriginal children being forcibly removed from their families via the ‘Christianising of the outback’ between 1910 and 1970 (Smith 2007). Those taken to missions are said to have been more likely to have been physically and sexually abused, were much less likely to have undertaken post secondary education, three times more likely to have been in jail, twice as likely to use illicit substances, and much less likely to live in stable conditions than were other Aboriginal children (HREOC 1997).
More recently the dismantling of the Aboriginal and Torres Strait Islander Commission (ATSIC) has disadvantaged Aboriginal communities (Aldrich, Zwi & Short 2007; Smith 2007). The dismantling of ATSIC has lead to a demise in the active engagement of Aboriginal people in social policy and diminished support for programs for Aboriginal and Torres Strait Islander people (Beckett et al 2004).
These historical processes have further relevance today because Western lifestyles continue to compromise the health and wellbeing of Aboriginal people through chronic diseases, especially diabetes (O’Dea 1991; Shephard et al 2005). Paternalistic social engineering and institutional racism creates dependency and an inadequate response to Aboriginal mental health problems (Hunter 2006, Hunter & Milroy 2006). Rurally based researchers argue for de-colonialisation, in order to improve public health and prevention initiatives for Aboriginal peoples (Brady 2007; Burke et al 2007) and more extensive and inclusive education of health professionals in rural and remote communities (Kowal, Anderson & Bailie 2005; Bailey et al 2006; Fredericks 2006; Kelly 2006; Murray & Wronski 2006; Sherwood & Edwards 2006; Bailie et al 2007).
Pause for reflection
In 1911, the Reverend John Flynn worked at Beltana Mission in the north of South Australia. His vision to establish The Royal Flying Doctor Service (RFDS) of Australia came to fruition in 1928 in Cloncurry, Queensland. The service extended to the most remote areas in Australia, with branches in Western Australia, the Northern Territory, New South Wales and Queensland in the 1930s, South Australia in the 1950s and Tasmania in 1960 (Langford 1994). The RFDS now provides extensive clinical services in rural and remote communities. Since the 1960s many rural and remote communities have established clinics and built hospitals to attract and retain health professionals but until the 1990s rural health services continued to struggle (Cooke 2002). This is despite the fact that approximately 30% of the Australian population live in rural and remote areas and are served by only 22.4% of the medical practitioners working in Australia (Australian Medical Workforce Committee 2000).
The White Australia policy, which can be traced back to the 1850s, also has had a lasting impact on rural and remote health through the cultural values and beliefs that formed the national self-identity of Australians (Smith 2007). It provided a platform for the stereotypes of cultural groups that still exist throughout Australia today. Rural Australia developed from a strong male, convict and immigrant base that promotes the hardship and stoicism of pioneers. These social stereotypes become important factors when we look at how rural men in particular view their health. For example, men are less likely to go to their general practitioner (GP) for preventive health checks. Recent projects on rural men’s health promotion are designed to educate and encourage men to attend GPs and engage in health prevention (Hall 2003).
A complex web of socioeconomic inequalities still exists in Australian rural and remote communities as a result of limited access to health and education. Nevertheless, over the past 25 years concerted efforts to focus on rural health policy have been made with some success. The Royal College of General Practitioners conference in 1978 initiated open debate about workforce shortages. Adding to this the need for skilled practitioners in remote areas was highlighted by the Council of Remote Area Nurses, which formed in 1982. The New South Wales rural doctors’ dispute also highlighted many of the issues (Humphreys et al 2002; Hegney et al 2006). Table 11.1 summarises some of the key groups that have supported rural and remote health.
|Groups||Aims and Activities|
|National Rural Health Alliance (NRHA)||The NRHA is the peak national body for rural and remote health, comprised of 27 leading organisations committed to all aspects of the health of rural people and represented in all rural regions and communities. The NRHA is seeking clear undertakings from all political parties in support of rural health. The NRHA’s vision is equivalent health and wellbeing in rural, regional and remote Australia by the year 2020.|
|Council of Remote Area Nurses Australia (CRANA) Inc||CRANA was founded in 1983 when 130 remote area nurses from across Australia came together in Alice Springs to put remote health issues on the national agenda. Concern about the poor health status of people who live in remote areas and the inequities, quality and accessibility in services available to these Australians was and remains the catalyst for action.|
|The Australian Rural Nurses & Midwives (ARNM)||ARNM aims to promote quality health care through excellence in rural nursing and midwifery practice and by supporting nurses and midwives in the development and delivery of health care services in rural Australia.|
|Services for Australian Rural and Remote Allied Health (SARRAH)||SARRAH is nationally recognised as a peak body representing rural and remote allied health professionals. SARRAH, established in 1995, is a ‘grassroots’ organisation able to address the very particular needs of the individual rural and remote allied health professional. The primary object of the association is to develop and provide services to enable allied health professionals who live and work in rural and remote areas of Australia to confidently and competently carry out their professional duties in providing a variety of health services.|
|The Australian Rural and Remote Workforce Agencies Group (ARRWAG)||ARRWAG is a national non-government organisation, funded by the Commonwealth Department of Health and Ageing. Established in November 2000, ARRWAG supports and represents the seven Rural Workforce Agencies (RWAs) that operate in each state and the Northern Territory of Australia. ARRWAG aims to improve access to the health workforce, specifically in rural and remote Australia. The central focus of ARRWAG is on national health workforce policy. As such, ARRWAG provides information and policy advice on health workforce issues through the provision of workforce data analysis, planning and research, program development and evaluation. ARRWAG also has contractual obligations to support organisations that are not incorporated, such as the National Rural Health Network, which represents the interests of undergraduate medical, allied health and nursing students.|
|The Australian College of Rural and Remote Medicine (ACRRM)||ACRRM is the peak professional organisation for rural medical education and training in Australia. The college has around 2500 members, comprising fellows, registrars, practitioners and students, who practise in regional, rural and remote communities throughout Australia. The college’s core function is to determine and uphold the standards that define and govern competent unsupervised rural and remote medical practice. Fellowship awards are conferred to rural medical practitioners who have been assessed as meeting the college standards for rural practice. This qualification is required to be maintained by doctors participating in professional development programs that are relevant and accredited for rural practice.|
|The Australian Rural Health Education Network (ARHEN)||ARHEN was established in November 2001 to optimise the outcomes of the University Departments of Rural Health (UDRH) Program by encouraging a coordinated approach to the activities and the strategic direction of the program. It acts as a communication and coordination conduit for the participating organisations and also between the Commonwealth and other government and non-government organisations and the participating organisations. It also provides proactive activities on behalf of the participating organisations based on the agreed business plans and programs of the participating organisations.ARHEN provides advice to the Commonwealth on the direction of Commonwealth initiatives to create a national network of rural health education and training, in particular with respect to the UDRH Program.|
|Health Consumers of Rural and Remote Australia (HCRRA) Inc||HCRRA is a not-for-profit organisation that works to improve rural health outcomes by involving consumers in the planning, implementation, management and evaluation of health services throughout non-metropolitan Australia. Members of HCRRA are given the opportunity to represent the views of people who live in rural and remote Australia in the planning and implementation of a broad range of health issues that directly affect them. HCRRA receives funding from the Rural Health Support, Education and Training Program in the Department of Health and Ageing.|
|The National Rural Health Network (NRHN)||NRHN represents 22 Rural Health Clubs with approximately 5000 members located at universities throughout Australia. The NRHN is a multidisciplinary network representing medical, nursing and allied health students aiming to increase the health workforce and health outcomes for rural and remote Australians.|
In the late 1980s, the Australian Health Ministers’ Advisory Council (AHMAC) supported a consortium of regional universities in establishing the Australian Rural Health Research Institute in recognition that health professionals often needed training to fulfil their roles in rural and remote communities. In 1991, the Rural Doctors Association of Australia held a national rural health conference in Toowoomba, Queensland, and this instigated the establishment of the National Rural Health Alliance (Humphreys et al 2002). State jurisdictions also established rural health units and the Australian Journal of Rural Health was launched in 1993. The National Health and Medical Research Council (NHMRC), under the auspices of AHMAC, provided an overview of the state of rural health research in Australia and developed recommendations, which formed the framework for a future Rural Health Strategy. AHMAC endorsed the recommendations and funded the implementation of the Rural Health Strategy (Patterson 2000). The National Rural Health Strategy was endorsed by AHMAC in 1994. The strategy was reviewed in 1996, finding that rural and remote communities share many distinctive characteristics, including isolation, difficulty in accessing services, shortages and maldistribution of health professionals, and specific health needs for certain subgroups often associated with harsh environments. To improve access and effectiveness of health services, better transport and communication systems are needed — including improved capacity for e-health and telemedicine initiatives (Dillon, Loermans & Davis 2005; Liaw & Humphreys 2006).
AHMAC also endorsed The National Mental Health Strategy in 1992 to assist people with a mental illness to have access to improved services and support, with community-based services as the option of first choice (see Chapter 13). In 1996 the National Aboriginal Health Strategy was endorsed by AHMAC but there has been limited success implementing the strategy. The most recent rural national policy statement, ‘Healthy Horizons’ recognises the value of national associations and interest groups and promotes the need for research, distinctive needs of rural and remote communities and calls for better health in Aboriginal communities (Humphreys et al 2002). The poor health status of Aboriginal and Torres Strait Islander people has remained one of the top priorities for the National Rural Health Alliance of the past 17 years (Gregory 2006).