These scholars further propose that communities or groups where the balance of the tension is situated within or near Concept A in each set are less ready or able to change than those where the balance tends towards Concept B. Papa et al. propose that these sets of tensions ‘intersect and interact’ (p. 61) in a broader tension (a ‘meta-dialectic’) between stasis and change. This understanding is of importance for both communities and professional change agents (including public health practitioners) alike, as it provides a conceptual framework to support the social change needed to address the underlying determinants of rural health inequity. When used together with Ottawa Charter and engagement/consumer activism principles, this provides a solid theoretical grounding for community agency-based health promotion practice (for applications of this approach see Fagan, Robertson, Pedrana, Raulli & Crouch, 2015; Robertson, 2010, 2012).
Health literacy and attitudinal factors – insights from immunisation
Health literacy, the capacity to absorb and critically analyse health information from multiple sources, has been identified as a key determinant of health (Kickbusch, 2001) and there is strong evidence of health literacy disadvantage among rural Australians, especially men (Australian Institute of Health and Welfare, 2010). According to the World Health Organization, health literacy:
goes beyond a narrow concept of health education and individual behaviour-oriented communication, and addresses the environmental, political and social factors that determine health (World Health Organization, 2009, n.p.)
Immunisation as a public health intervention provides a useful platform to briefly explore these issues. In Australia, beliefs about vaccination include that it is important (or not); is safe (or not); and the current vaccines are effective (or not) (Australian Government Department of Health, 2015). These beliefs about and attitudes towards immunisation may be influenced by previous personal experience or be the result of external influence (for example, by medical experts or anti-immunisation lobby groups). In smaller communities, a clustering of individuals with particular beliefs and practices may also shape a normative behavioural response (sometimes characterised as normative social influence) (see, for example, Nolan, Schultz, Cialdini, Goldstein & Griskevicius, 2008), for example, by vaccinating (or not) their children. Under this theoretical understanding, a pressure is exerted for individuals within that community to conform to that behavioural/social norm.
Sopheap, a Cambodian who came to Australia in 1997, has settled in Kinross and owns a thriving market garden business providing vegetables to the Laineton supermarket. In 1996, before migrating to Australia, her youngest daughter Romany succumbed to measles. She was not fully immunised because local flooding prevented the visit of vaccination team to their rural village.
Sopheap is now a passionate immunisation advocate and has written several letters to the editor of the Laineton Post in response to local anti-immunisation lobby materials printed in that newspaper from time to time. Recently published data suggests there has been an increase in the number of cases of childhood pertussis (whooping cough) infection in the Laineton LGA and that coverage levels of childhood vaccination have declined over the past 10 years, with coverage falling below 70%.
Reflecting on the theory-guided health promotion approaches, the insights from sociology on place and power relationships, the health disadvantage of rural people and the concepts of normative behavioural responses described in this chapter, answer the following:
1 How might you develop a public health response to improving vaccination coverage in the Laineton LGA?
2 How might this initiative be organised to reinvigorate consumer demand for childhood immunisation from the Laineton LGA communities and especially from their more disadvantaged and marginalised peoples?
Well-functioning rural health systems
The World Health Organization has described six key building blocks of the well-functioning health system. These include effective governance and leadership; sustainable financing; a health workforce fit for its tasks; appropriate and affordable health products; responsive service delivery; and health information and research capacity (World Health Organization, 2015).
- Health system
the organisation and coordination of human, institutional, material and financial resources for the delivery of health services.
Public health systems
In the context of public health, what ought a well-functioning preventive and promotive health system defined in this way look like? Review evidence (Rygh & Hjortdahl, 2007; Kenny et al., 2013) suggests that some key features include:
decentralised regional administrative and finance management structures, strategic planning functions and technical support services to bring executive control and decision-making closer to the points of service impact, enabling more flexible regional responses to the influence of wider external factors
consumer participation in health service decision-making, enabling service provision and its modes to be more responsive to need and demand
interdisciplinary and team-based modes of working, allowing greater agility in service reorientation in response to changing demand
In addition, many countries have also developed a range of partnerships within the health system, on the basis that these arrangements strengthen service provision. Examples include the establishment of autonomous public health agencies within ministries of health, with separate budgets and reporting lines to executive government; partnerships with specialist research institutes and academic centres; partnerships with non-government agencies in the delivery of specialised services (for example, to culturally and linguistically diverse groups); partnerships with First Nations’ community-controlled health organisations and partnerships with a wide range of private health service and health systems consultancy providers.
In Australia, for example, the delivery of a significant range of public health services, especially the implementation of preventive measures, is through private general medical practice financed by a basket of funding mechanisms and with quality assurance through professional practice guidelines supplemented by continuing professional development. Wakerman (2008) provides evidence that rural health services are more sustainable when they are primary health care-oriented, including health promotion, prevention and advocacy roles.
Community participation and consumer engagement
Recently, the modes of community participation and consumer engagement in rural health systems planning and development have been more closely examined (Preston, Waugh, Larkins & Taylor, 2010). The roles of communities and the manner of their engagement have been characterised as a ‘central tenet of public health policy and practice’ (South & Smith, 2014). The models draw on the experiences of consumers as experts to understand local health systems. Local health consumers assist in designing, developing and promoting health services in ways that are appropriate for local consumers (see also Chapter 4). Aboriginal health services and multipurpose services in Australia are examples of rural health services that involve consumer participation.
- Community participation
active involvement by civil society in government service decision-making and planning.
Putting this all together: a framework for rural health
Bourke, Humphreys, Taylor and Wakerman (2012a, 2012b) have proposed a framework suggesting that six concepts can be used to understand particular issues and scenarios in rural and remote health. This framework encompasses an understanding of:
geographical isolation (the geography, environment and relative location)
the rural locale and the social interactions of people in the local area (including interactions over alcohol, sport, to save a hospital, and so on)
local health responses, including local health services, consumer groups and local actions involving health care
broader health systems that provide funding, health protocols, professional bodies and advocates and the systems shaping health from outside the locale
broader social systems that shape social life in rural and remote settings from outside, including media, culture and the social determinants of health, and
power that drives the interaction of the other five to determine issues given prevalence.
For example, the actions of local residents to promote immunisation in Laineton by using local networks, local health providers and broader health funding systems and information enable free access to immunisation for children. The work of groups of consumers and nurses to set up a program along with the health services and the networks of Sopheap and others to engage disadvantaged families resulted in an increase in immunisation rates. Broader health systems supported this local group to challenge power relationships that excluded families from immunisation in the past. Such understanding brings into play local actors and services, geography and isolation as well as social structures and broader health systems. Change for rural and remote health, this suggests, is required at all levels, including local action, change to broader structures and systems as well as challenging the power imbalance between rural and urban locations (Bourke, Humphreys, Taylor & Wakerman, 2012b).
Community consultations undertaken by the Laineton local council in the development of its Public Health and Wellbeing Plan have identified a demand for emergency contraception (the ‘morning-after pill’), reflected in comments by respondents to a question in the community survey probing the costs of travel outside of Laineton to obtain services for themselves or their families that are not available locally.
The Laineton District Hospital is a publicly funded 30-bed facility located within an administrative structure containing seven other similar hospitals. The hospital provides emergency care to the district, as well as acute medical and surgical services. It also offers antenatal and maternity, child and adolescent health, and sexual and reproductive health services.
Due to financial constraints and recruitment difficulties, the hospital does not have an internal pharmacy. Medication dispensing services are provided to the hospital by the only local private pharmacy, which is open until 7.00 pm each week night and until 5.00 pm on Saturdays and noon on Sundays. However, due to reasons of conscientious objection by the two pharmacists, the dispensary does not stock or dispense the ‘morning-after pill’. The nearest pharmacy that will provide such medication is 60 kilometres away and is not serviced by direct public transport.
1 You are the Director of Public Health in the Laineton region. What will you do with the knowledge of (a) higher rates of unplanned pregnancy in Laineton; and (b) the local limitations of emergency contraception provision?
2 How will you navigate the sectoral (public and private) and health systems governance and operational hierarchies to address this situation?
3 How might you include local residents, community groups and broader health systems?
Summary
This chapter has sought to characterise the health of rural peoples through the disciplinary lenses of population health, rural sociology and clinical practice.
A trans-disciplinary understanding of the concept of rurality, its dimensions and the limitations of its uses in public health planning and practice in rural settings
You will have concluded from your debates on the character of rurality, its conception as a determinant of health and the different attempts to establish its dimensions, how broad the concept is, how significant the lack of uniformity of its application in national and global contexts and how critical the need for good data and information at a local level to underpin effective public health planning and practice.
The broader determinants of health in relation to their impact in rural settings
Your learnings from the study of the determinants of health and their distribution will have highlighted the relationship between socio-economic factors, health service access and poorer health outcomes. You will have discerned that census and other data from different countries point to a more variable relationship between rurality, socio-economic status and health outcomes.
Adapting health promotion and public health planning and practice principles to rural settings
You will have reflected on the clinical evidence that highlights the importance of individual and group health-seeking behaviour in understanding variable health outcomes in diverse rural settings. You will be ready to explore more deeply the insights from social theory on the dynamic tensions shaping the potential for change in communities; from sociology on power relationships and the social reproduction of rural disadvantage; and from understandings of the constructed nature of rurality and its meaning to different individuals and peoples. Your learnings will enable you to plan the application of these strong theoretical underpinnings to community agency-based health promotion initiatives in your own situations.
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