theory in rural health

Original Article

Theory in rural healthajr_1286 185..189

Jane Farmer, MA, PhD,1 Sarah-Anne Munoz, MA MSc PhD,3 andGuinever Threlkeld, BA PhD2

1La Trobe University, La Trobe Rural Health School, Bendigo, and 2La Trobe University, La TrobeRural Health School, Wodonga, Victoria, Australia; and 3University of the Highlands & Islands, Centrefor Rural Health, Inverness, UK

AbstractObjective: This paper offers theories to explain persis-tent rural health challenges and describes their applica-tion to rural health and research.Methods: Review of theories from several disciplines.Findings: Key issues in rural health are poorer healthstatus and access to health care, staff shortages,relationship-based health provision and the role of healthservices in community sustainability. These could befruitfully addressed by applying theory and findingsaround social determinants of health, economic sociol-ogy, the role of culture and capitals approaches to mea-suring assets. In particular, the concept of rural healthmight be a barrier to progressing knowledge; and rela-tional approaches, common in geography, offer a moreuseful conceptual framework for studying health andplace.Conclusions: To move beyond its current stage, ruralhealth needs to look to other disciplines’ theories andideas; particularly, it needs a more contemporary under-standing of what place means so that health status andservice provision can be improved by more thoughtfulresearch.

KEY WORDS: health policy, rural health research,rural health, rural–urban classification.

Theory in rural healthRecently, there have been calls for a theory of, or moreconsideration of theory in, rural health. Bourke et al.1

provide a rationale, suggesting the need for theory toguide development of a more coherent evidence base inrural health to guide future research and ‘found a tradi-tion’. There is a request within recent work of Hum-phreys2,3 to progress rural health research from simply

more study of ‘how do we get doctors’ to intellectuallychallenging, robust and future-oriented study that fun-damentally addresses the roots of the continuing chal-lenges of improving health and providing services in ruralplaces. This work suggests a ‘coming of age’ for ruralhealth research, a desire to shift from agitation for atten-tion to the task of building theory with the power toinform change. In this paper, we consider the theoriesthat we have found touched on or suggested by existingempirical research and propose a starting point for anoverarching relational theory to explain some of what isgoing on in rural health and suggest engagement withthese ideas and theories underpin further development ofknowledge of why health and health services differ byplace.

Explaining empirical phenomenaA theory is an explanation of empirical phenomena. Toidentify theory relevant to rural health, the main empiri-cal phenomena need to be identified. Bourke et al. statethat: ‘what typifies public perceptions of “rural health”is poorer health status, especially among indigenousAustralians, poorer access to health care and the lack ofstaff, particularly doctors.’4 Together with the empiricalexamination of these themes, other consistent themesemerging from rural health research, we suggest, are thetendency for relationship-based service provision,5

where clients and providers know each other (and mightoverlap), and the role of health services in communitysustainability.6 These key themes, the theoretical impli-cations of the research which have identified them andfurther potential explanations are now explored.

Poorer health status

The urban–rural gap in Australian health is notoriousand it extends beyond the Aboriginal–White gap toinclude rural White people also having poorer health.7

The picture is not homogeneous. Along with healthinequality, there are rural education, income and

Correspondence: Professor Jane Farmer, La Trobe University,La Trobe Rural Health School, PO Box 199, Bendigo, Victoria,3552, Australia. Email: [email protected]

Accepted for publication 20 May 2012.

Aust. J. Rural Health (2012) 20, 185–189

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© 2012 The AuthorsAustralian Journal of Rural Health © National Rural Health Alliance Inc. doi: 10.1111/j.1440-1584.2012.01286.x

economic opportunity gaps. Regional health disparitiespertain internationally for countries with high incomeinequality. Wilkinson and Pickett8 proposed that differ-ences lie in countries’ class formations and the locationof people relative to political, financial and culturalcapital; witness the notorious North-South divide in theUK, where health disparities have persisted for a millen-nium and actually increased since 2000 despite a policyemphasis on addressing health inequalities. Northernersare a fifth more likely to experience premature deathcompared with their Southern counterparts.9 There is alarge international literature on the social determinantsof health, and their mechanisms, that has some power toinform the urban–rural divide in Australia, but Smithet al.10 note that the geographical health divide remainslargely unexplored.

From non-health disciplines, there are suggestions thatpolicy has not helped rural Australia respond to thechallenges of globalisation. Tonts and Haslam-McKenzie11 describe the changes inflicted on rural Aus-tralia by governments’ neo-liberal policies from the1980s, resulting in lack of support for agriculture andclosure of services that have depleted rural Australia ofworking, earning people. Over this period, a change alsooccurred in how Australians view city versus country.Brett notes that the city now has ‘the upper hand and thecountry has been pushed aside’, continuing: ‘it wasn’talways thus. Once the country believed itself to be thetrue face of Australia; sunburnt men and capable womenraising crops and children, enduring isolation, hardshipand a fickle environment, carrying the nation on theirsturdy backs’.12 Psychosocial stress related to low societalstatus makes for ill health, as studies of health in relationto occupational status and material standards haveshown.13 While commentary often implies a link betweeninaccessible rural health services and poor health status,evidence is inconclusive. There is clearly a social justiceargument that all of a country’s population should haveaccess to primary, preventive and emergency services.14

Systematic attention to links between accessibility toinfrastructural, economic and cultural assets and regions’

health would both illuminate health status and underpinstudies to inform appropriate structural responses.

Poorer access to health care

Poorer access to a range and choice of services is anaspect of rural life that is shared internationally and isthus perhaps the fundamental shared issue of globalrural health.15 It is a regular research focus and has beenexplained by theories of regional economics, profes-sional socialisation and public sector managerialism.Range and choice of health services are poorer due tocosts, inability to make sufficient revenue for privateproviders and low volume of types of cases meaningskill decay; hence, traditionally, rural providers wouldbe forced into generalism to fill their caseload and makeends meet. Movements to specialism within the profes-sions, evidence-based medicine, clinical governancerequiring high volume of cases and increasing use ofexpensive technologies have not helped provision ofrural health care.

Lack of staff

The well-documented workforce shortages, particularlyof medical staff, might be understood as issues of cultureand socialisation; however, cultural fit seems neglectedin rural workforce studies, apart from where interna-tional practitioners are concerned. Bourdieu’s conceptof ‘habitus’ explains how individuals accrue social rules,values, dispositions and norms from living within asocial group and context.16 Habitus allows individualsto ‘fit in’ to their context. Those who have grown up ina rural area are able to feel ‘culturally comfortable’ inrural areas. Habitus, together with Bourdieu’s notion of‘cultural capital’ could be applied to understanding whyit is difficult for doctors to fit into rural communitieswhere there are few peers with shared experiences,tastes and the trappings of middle-class intelligentsia.17

What is already known on this subject:• There is significant research about rural

health’s challenges, but it might be repetitiveand ‘stuck’ in terms of producing solutions.

• Key rural health researchers have called fortheory.

• Geographers have noted that healthresearchers have an overly ‘conventional’understanding of the role of place in health.

What this study adds:• Identifies theory from other disciplines that

explain rural health’s key problems.• Notes the importance of considering health

status and health services as the product ofsociological, cultural, political and economicforces at micro to macro levels

• Suggests benefit in moving from rural healthto studying health and place, with place seenas the meeting place of multiple influences onhealth

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© 2012 The AuthorsAustralian Journal of Rural Health © National Rural Health Alliance Inc.

Relationship-based services

This dimension of rural health provision might be usedby health practitioners as an asset that can mediate forpoorer access and has the potential to impact on healthstatus; for example, the GP, Julian Tudor Hart, famouslyimproved the health status of villagers of Glyncorrwg,Wales by routinely measuring their blood pressure. Con-versely, there is a ‘dark side’ to relationship-based healthcare in that health professionals might feel they arenever off duty, while in turn, they might make detri-mental assumptions about patients’ health based onjudgements formed from observing them or theirfamilies over many years. To assist us move fromdescription to theory, there is a literature in economicsociology that explains the types of interactions thatresult from ‘embeddedness’; for example, reciprocityand non-rational approaches to consuming services.18

As Granovetter highlighted, ‘behaviour and institutions. . . are so constrained by ongoing social relations thatto construe them as independent is a grievous misunder-standing. . . most behaviour is closely embedded in net-works of interpersonal relations’.18

Community sustainability

A consistent theme is health services’ contribution torural community sustainability. Cocklin and Dibden19

proposed the promising concept of a capitals frameworkthat can be used to explain how aspects of a communitycontribute to social, economic, human and institutionalcapital stocks through engendering participation, lead-ership, local spending, applying their intellect and quali-fications for community good and the symbolic role ofhealth institutions in community identity and confi-dence. Prior et al.20 tested the validity of the capitalsframework for showing (and potentially measuring)rural health services’ contributions to communities inScotland and Australia.

Explaining rural healthAn alternative approach to understanding place couldhelp rural health research, providing an overarchingtheory drawing points from some of these theoreticalbeginnings into a larger framework that holds the pos-sibility of more robust explanation. As a starting point,why we use ‘rural’ is worthy of critique because itimplies a unified, fixed and identifiable space that isempirically unproven. An Organisation for EconomicCo-operation and Development policy document onrurality suggests ‘if you have seen one rural place, youhave seen one rural place’.21 McGrail and Humphreys’analysis of rural classifications highlights ‘[r]ural Aus-tralia . . . is extremely heterogeneous’, later noting

‘there is no “natural” rural–urban classification’.22

Further, Humphreys repeatedly distinguishes Australia’s(alongside Canada’s) rurality by noting that the ruralityof ‘geographically large countries’ is distinct.3 Remotehealth has also been distinguished.23 For a category weare so set on defining, we are also keen to differentiateits many forms. Perhaps ‘rural health’ has become acatch-all term with a breadth of focus that is blinding usto understanding what lies beneath? As has been high-lighted, the terms rural and remote are recent imposi-tions of government for facilitating resourceallocation.12 Cummins et al.24 analyse such ‘rather con-ventional’ ways that space and place have been regardedin health research, noting preoccupations with geo-graphical scale, fixedness and assumed neutrality. Theycontend ‘most medical geographic research has usedgeographic space merely as a framework in which datacan be ordered. This extremely limited role for geogra-phy in the structuring of mortality, morbidity and healthcare rests on the simplistic use of space as an organisingframework for recognising regular associations . . . aconceptualisation of people as agents, and what is more,of people as agents influenced by the different placesituations in which they find themselves, is missing’.24

Cummins et al.24 advocate a ‘relational’ understand-ing of space and place that understands ‘place’ as thecrossing in time and space of various forces and flows(including people, economic opportunities, naturalresources, social assets, politics, cultural mix, infrastruc-ture and history), and so as defined not only by the localbut also by relatedness to other places. This emphasis onthe intersecting and multidirectional relationshipsbetween economy, society, nature and culture in ourunderstanding of place raises questions about twoassumptions that have often informed rural healthresearch: that rural places and non-rural places are dis-crete and that the objective characteristics of a ruralplace are fixed for all inhabitants of that place.

Massey25 refers to ‘the event of place’, highlighting the‘throwntogetherness’ of place that unites a host ofhuman and nonhuman features in time. Places andactors within them (including people and health ser-vices, and also family, work and social networks, localand distant community and business organisations, gov-ernment, policy and regulatory arrangements) can beviewed as nodes in complex and extended networks.Cummins has underscored the implications of this forindividuals, who, while residing in a particular place,might experience different social and material resourcesand vulnerabilities through their relatedness to otherplaces via family, work and wider organisational andeconomic networks. All elements of place are thus proneto external influences, and also to affecting other nodesand networks; and constantly changing as new staffmembers come and go, politics change, global and local

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economic effects are felt. Places can affect and beaffected by forces and flows at different scales; forexample, some impacts (such as national policy) mightbe felt by all regions, whereas some impacts might be atmeso level (e.g. state health service policy) and someimpacts might be local (e.g. a mine opens or closes).Understanding rural places as multifaceted and chang-ing nodes connected to such a variety of dynamic forcesand flows, that is as relational places, helps in studyingthe association between the contextual effects of placesand the compositional attributes of population, andhow these affect health and the ability to provide healthcare.

Place is the omnipresent, but often unremarked vari-able in rural health research, perhaps we should beacknowledging it more. For example, when consideringrural health gaps, do we consider the range of pertinenteconomic, social and opportunity differences that distin-guish rural from urban places – and the impact of that onhealth? And even when describing micro-level casestudies, do we move beyond merely describing a staticcontext to considering how the forces at play in placeaffect what we find for individuals, groups and services?

ConclusionIn this paper, we consider some theories to explain thephenomena observed in rural health. It is important tobuild theory with robust capacity to interpret evidenceto address rural health’s challenges. While engaged inthat process, it is important to remember ‘the event’ thatis place and its relatedness and that we are engaged instudying phenomena produced by the intersection ofpeople, politics, environment, history and economicopportunity. This could lead us to understand ruralhealth as a set of issues, to innovate with methodologyand to explore new avenues. We suggest that movingrural health research beyond its achievements inproblem description and advocacy requires a criticalengagement with theory and findings from several dis-ciplines and applying this knowledge within an under-standing of place that sees it as a meeting point of therelations that shape health and service provision. Thisunderstanding can enhance theory development toinform intervention. For instance: what can a relationalunderstanding of place contribute to our explanation ofhealth status and the points of greatest leverage inaddressing differentials?; or, what can relational under-standing add to theories of culture and socialisation toinform workforce recruitment and retention?

AcknowledgementsThe authors would like to acknowledge colleagues atUHI and La Trobe, and elsewhere, who have indulged in

conversations about rural health and research; in par-ticular, Dr Fiona Smith at Dundee University GeographyDepartment and Fran Sheean, Lecturer in Nursing at LaTrobe Rural Health School.

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