ABSTRACT
Those living in rural settings may experience particular challenges to their mental as well as physical health, which together with issues relating to healthcare access can lead to disparities in outcomes. This commentary looks at the relationship between mental and physical health in rural areas and highlight the urgent need for a holistic approach to healthcare in these regions.
Introduction
Rural areas may represent an idyll or ‘simple, innocent and virtuous...pastoral myth’,1 whereas others may think of them stereotypically as lacking economic, social and cultural opportunity.2 While rural and remote areas may share some characteristics, such as small, dispersed populations, a more agricultural or tourism-based economy and long drive times to service centres, they also contain a diversity of landscapes, economic activities and social and cultural norms. Perceptions and experiences of rurality can shift over time; across, for example, the seasons or the life-course.
It has been established that mental health can impact on physical health and vice versa.3 In rural and remote areas, there are particular contextual influences that can influence both physical and mental health. These environmental determinants of health, such as social networks, climate and socio-economic landscapes, relate to common influences on health in the Global North including diet, physical activity and connectedness, but play out in particular ways within rural communities. The experience of health or ill-health within these rural areas varies based on individuals' characteristics.
There is a mental health crisis globally which requires ‘efforts to increase access’ to services and activities that support mental wellbeing.4 Within the Global North, public discourse and awareness of mental health and wellbeing has increased in recent decades. Policy suggests a need to support and improve mental wellbeing. In doing so, connections between poorer mental health outcomes and poorer physical health outcomes may be alleviated. Efforts to support and improve mental health and wellbeing cannot leave rural and remote areas behind. Within the UK, around 17% of the population live in rural areas; this is higher in the EU at 25% but lower in the USA where 14% of the population live rurally. However, on a global scale, the rural population makes up around 43%.5 Providing healthcare services to such areas can be challenging and expensive.6,7 In this commentary, we delve into the intricate relationship between mental and physical health in rural areas and highlight the urgent need for a holistic approach to healthcare in these regions.
Multiple layers of disadvantage
In the Global North, environmental determinants of health influence mental and physical health within remote and rural areas. Rural communities often face geographic isolation, limited access to healthcare services, and limited assets to support wellbeing. Rural areas can be affected by layers of disadvantage which affect individuals' and communities' mental wellbeing outcomes and access to supports.8 People may experience, for example, geographical isolation from physical services, digital isolation from adequate broadband for online support, social isolation related to small population size and dispersed settlement patterns and stigma from visibility.6
The COVID-19 pandemic has impacted negatively on mental health, perhaps most on those experiencing multiple forms of disadvantage and thus heightening rural health inequalities.9 Poorer mental health outcomes are associated with increased life stressors in areas such as employment, housing, social isolation and stigma. Other contextual factors impacting on health and wellbeing in remote and rural areas include extreme environmental events; fuel poverty; physical distance from services, particularly specialist services; normalisation of risky behaviours; visibility; social connectedness and historical memory. In smaller communities in particular, people living with a long-term condition can feel visible and stigmatised. Certain population groups that experience poorer mental health outcomes are over-represented within rural populations, such as older people and land-based workers. Thus, rural residents can experience ‘multiple layering of remoteness and isolation’.8 Some of the groups within rural populations that may particularly experience ‘multiple layerings’ of isolation and disadvantage include seasonal and land-based workers, people living with long-term conditions, those living in poverty and young women. This can be reflected in some statistics showing, for example, loneliness within the older rural population and higher age standardised rates of suicide in some rural areas.
Rural life brings with it unique stressors that can strain mental health, such as economic instability, agricultural challenges, and limited employment opportunities. Environmental factors such as natural disasters, climate change impacts and isolation from healthcare infrastructure can add additional pressure. These stressors, when combined with limited access to mental health services, create a perfect storm that hampers the wellbeing of rural residents. This can be seen in the example of West Virginia,10 where ‘healthcare deserts’ (areas where ‘basic affordable health care is not accessible for residents’) emerged from a combination of rugged physical geography, ageing demographics and high socio-economic deprivation. This is reflected in not only poorer physical health outcomes for the state's population but also in its having the second highest level of mental health problems within the United States.
The interplay between mental and physical health is a complex phenomenon, with one often influencing the other. In rural areas, a lack of statutory mental health services locally can also have detrimental effects on physical wellbeing. Unaddressed mental health issues can lead to behaviours such as substance abuse, poor nutrition, and sedentary lifestyles, which contribute to the development or worsening of long-term conditions such as heart disease and diabetes. Difficulties in recruitment and retention of rural health care professionals exacerbates this problem.
While outdoor interventions and rural landscapes have been seen as ‘therapeutic’ within much recent literature, our research has shown that rural landscapes are not always experienced as health-promoting by those who live and work within them.6
The need for place-based responses
Our previous research has shown a relationship between place and mental wellbeing in rural and remote communities.6 Given the strong connections between local place, environmental factors and individual and community health and wellbeing, place-based approaches to support are needed for remote and rural communities. Interventions designed and tested in urban environments do not necessarily translate successfully into remote and rural areas and context needs to be considered in intervention and services design.
Social prescribing has been suggested as one way to address upstream determinants of ill-health by linking patients from primary care to sources of support within the community. Primary health care is stretched and attending for reasons related to the upstream determinants of mental or physical wellbeing may not require pharmaceuticals.11 By making changes to the environments that influence upstream determinants, theory suggests we can promote health and wellbeing and potentially avoid or mitigate the impacts of stressful circumstances–avoiding statutory services use, demand for acute care and physical health deterioration. We need preventative, locally based support for those most at risk of health inequality within remote and rural areas.
Addressing the mental and physical health needs of rural areas requires a multifaceted approach that acknowledges their specific challenges and contexts. In many rural areas, community organisations and third sector services are the backbone of holistic wellbeing support and further integration (and funding) with statutory services and infrastructure could be beneficial. When we asked residents of a rural area of the Scottish islands what their priorities would be for mental wellbeing, they discussed the need for community-based support systems, sitting alongside adequate availability of health care professionals within rural areas. Previous research in Scotland has suggested that community-based supports in rural, remote and island areas may be most successful if they incorporate appropriately forms of local, cultural, social, lay, non-clinical, knowledge and peer support.
By acknowledging the unique challenges faced by rural residents, fostering community support systems, and integrating community-based services with statutory care, we can begin to bridge the gap and pave the way for healthier, more resilient rural communities. Through a holistic approach to health and care we may be able to support rural mental and physical health – this needs to be an approach that considers place and the social determinants of health. Promoting healthy lifestyle choices, ensuring access to fresh food, and creating opportunities for physical activity (through physical access and behaviour change) could help prevent and manage long-term conditions. Our qualitative work with rural communities also suggests that destigmatising mental health supports and services will be key to addressing the growing mental health crisis within remote and rural areas.
Remote and rural health care systems need urgent attention and concerted efforts to bridge the gaps in healthcare access and outcomes. Transforming rural health systems will require strategies that address geographical, workforce, socioeconomic, and cultural challenges.
- © Royal College of Physicians 2023. All rights reserved.
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