Rural health and families: E-Health solutions to health inequities

Christopher L Peterson
School of Public Health, La Trobe University, Bundoora VIC

PP: 296 - 301

Article Text

The report of the 1996 Australian Health Survey highlights the disparity between the health status of urban Australians and those living in rural and remote areas (Australian Institute of Health and Welfare [AIHW] 1998). Death rates from all causes were higher in rural and remote areas, with mortality and morbidity rates increasing with distance from metropolitan centres (Mathers 1994; Stocks & Peterson 1994; Strong, Trickett, Titulaer & Bhatia 1998). Death rates for all major diseases were higher in both women and men in these areas (AIHW; Strong et al). Morbidity rates and risk factors associated with a number of conditions (such as allergies and being overweight), were also greater for both women and men in rural and remote areas, although in some rural areas the incidence of high cholesterol, hypertension, and diabetes was lower than in the major cities (AIHW; Mathers 1994).

Although Sarantakos (2000) and Young, Murphy, and Strasser (2000) have indicated that there can be positive aspects to life in the country, inherent disadvantages contribute to differences in health status between urban and rural communities. Their generally lower socioeconomic status (AIHW 1998, Strong et al 1998) gives rise to a number of health disadvantages for rural and remote populations, including, in some instances, poorer nutrition and housing quality, as well as reduced access to social and cultural resources. Access to health care services is relatively poor, exposure to harsh environments is greater, and occupational hazards can contribute health inequities (AIHW; Strong et al). While these problems are common to rural areas in most developed countries, they have been exacerbated in Australia in recent years by deliberate policies that have favoured urban rather than rural development. Policy directions have thus contributed to further erosion of health infrastructure in rural and remote areas over the last decade (Hallebone 2000). Strasser (1998) has argued that rural culture, patterns of illness and injury, and the shortage of practitioners in rural areas pose problems for rural populations and families. Geographic isolation leads to problems of access to care and to a shortage of health care providers and health services, particularly in small, sparsely distributed populations. The health of indigenous people, who constitute 3% of rural populations and 13% of remote populations, was found to be much poorer than that of all other Australians (Strong et al).

Technology has the potential to provide a partial solution to the problems of access to health services in rural and remote regions. The application of information technology to the health sector is referred to as telemedicine[1], which is a 'subset of health telematics' McDonald (2000: 21). Liaw (2000) claimed that the dissemination of telemedicine will empower consumers through Internet health resources, self care tools and an improved relationship with healthcare providers. While limitations to their use do exist, advanced technologies such as Information Technology (IT), the Internet, and the use of telemedicine, telehealth, and e-health can provide some solutions to the problems associated with inadequate medical and health service provision in rural and remote areas. Service providers and recipients of health care services should be involved in the initial stages of development and implementation of these technologies.

Health Care in Rural and Remote Areas

Services that are generally accessible to the metropolitan population can be regarded as something of a luxury to some rural and remote communities, and the delivery of appropriate health services to these communities presents unique challenges.

Medical and specialist services

Resident specialists are rare in towns of 5,000 inhabitants or less, and although many towns are serviced through specialist visiting schemes, referral rates to specialists have been found to be significantly lower in small country towns. Small towns provide less preventive care, although, on the other hand, rural GPs provided significantly more obstetric and procedural work (Stocks & Peterson 1994).The reluctance of medical practitioners to move to rural and remote practices has been well-documented (Kamien & Buttfield 1990, Stocks & Peterson 1994).

Social and cultural factors

The report of the AIHW (1998) indicated that there are particular social and cultural characteristics evident amongst rural and remote populations; for example 'attitudes towards illness, poor uptake of health promotion and self-care messages, and more frequent indulgence in risky behaviours' (p.40), explain why health care is often less effective in those areas. Tredwell (1998) also argued that unless providers of health services really listen to rural communities and ensure that policies and practices are culturally sensitive, the service provisions will not be effective. This is particularly applicable to indigenous populations, where the community must be empowered if health services are to be effective.

The 'tyranny of distance' creates severe transport problems, added to which, Galbally (1998) pointed out that economic change in rural communities, changing gender roles, and the fact that farm ownership is becoming concentrated in fewer hands have had negative economic effects. She also indicated that social support in communities had broken down because of reductions in facilities provided by large companies and organisations such as banks. Galbally referred specifically to the increasing incidence of male suicide, and to high rates of accidental injuries, particularly those associated with farming activities. She also identified Aboriginal health as an area of concern because illness rates in many areas had not improved, and the problem of 'deaths in custody' had not diminished.

Seeking Health Care in Rural and Remote Communities

Recent qualitative studies (Humphreys, Keleher & Verrinder (1999); Humphries 2000) provide interesting insights into the way rural families make health-care decisions. The help-seeking behaviour of rural families was assessed through the collection of notes taken by participating families at the time their decisions were made, rather than obtaining this information retrospectively. Families used diaries kept in the home as the method of recording how they made their decisions about the use of health care services. The studies found that most families did not select a GP as the first provider of primary care. In fact, a whole range of providers were chosen as possible sources of health care and advice. This evidence indicates that rural families are flexible in their health seeking behaviour. While telemedicine and telehealth technologies are providing some bridge to the problems posed by distance, these technologies also have associated problems that will be discussed in this paper.

E-Health/Telehealth: Addressing Rural and Remote Health Needs

It has been reported that rural and remote health workers make extensive use of IT whenever it is available. Telephones, which can provide an appropriate way of dealing with referrals, are used by all health workers, and fax machines, video-players, teleconferencing, computers, and pagers are also widely used. Many health workers are using satellite TV, CD-Roms, and satellite phones more frequently, and videoconferencing and the use of databases is also increasing. Many allied health professionals also use video cameras. Internet-based support groups have the potential to offer considerable assistance to isolated families, particularly those dealing with health problems such as chronic illnesses.

According to O'Connor, Peterson, and Whitfield (2000), there are several aspects of rural and remote health issues that are addressed by the provision and development of telehealth services. Firstly, telehealth can provide a more equitable access to health services in rural and remote area. Through the use of tele-homecare, other home monitoring devices and online monitoring services, for example, advanced technologies can bring services to isolated populations. Secondly, it addresses the maldistribution of medical and health services throughout rural and remote areas. Telehealth services, through the use of telephone, fax (used at times to transmit x-rays), videoconferencing for psychological consultations, and tele-radiology can compensate for the lack of medical and health services in rural areas. For families with complex and multifaceted needs this could reduce the need for extensive travel, and provide specialist advice and second opinions. In addition, telehealth can provide opportunities for community development by providing a communication infrastructure. As telehealth and other online services become available, linkages between outlying families and other communities can be established and strengthened. (O'Connor, Peterson & Whitfield 2000). This can promote social aspects of family health, and have important implications for meeting social and psychological needs. These authors, however, issue a warning: Telehealth in itself should not be seen as a solution to health problems exacerbated by distance. Many of the technologies have received scant evaluation, and in some cases their implementation thus far has been driven more by the technological imperative of growth and development than by the demand of meeting practitioner and consumer needs. Visiting specialist, dental, gynaecological, and related services will probably always be required to service these communities. But again, advanced technologies and Telehealth can substantially help to reduce the isolation for families. In addition, there is also a need to incorporate a human element into health care, together with technological developments to meet a range of rural and remote sociocultural and psychological needs. E-health has the potential to solve a number of problems of distance, but its success in the longer term will be a function of the degree to which it meets the real health needs of consumers and health practitioners.

Online mental health services also have the potential to redress some of the gaps in mental health strategies for rural and remote populations. In some senses online services cannot provide all of the support, and there will be a continued need for interpersonal communication at a face to face level. This requires the availability of well-trained support staff in rural and remote locations. However, the provision of specialised staff at distance locations working online does alleviate much of the pressure of maldistribution of specialised staff in rural and remote locations, and ensures a specialty backup to existing rural and remote locations. Leeder (1998) has identified suicide amongst first generation immigrant families as a cause for concern, and questioned the capacity of people to provide care to the extent that it is needed in rural communities. Scott (1998) also argued that service delivery to rural Vietnam Veterans was poor. Areas previously targeted by health policy initiatives of the Veteran Community in Rural and Remote Areas (1996) were post-traumatic stress disorder, transport, podiatry, mental health, problems with medication, and health information. A model of online care that is designed to meet the needs of rural and remote populations, particularly at a time when mental health in rural areas is a key issue, has been proposed by Yellowlees (2000). He argued that 'the provision of mental health services to isolated populations, nationally and internationally, is the single most important therapeutic gain in mental health in the past century', and, 'in Australia, telemedicine is now routinely used in many rural regions, especially in Queensland, where the Queensland Telemedicine Network has more than 180 videoconferencing sites. The Network is the most active telepsychiatry program in the world, providing 600 hours a month of mental health consultations and education across the state' (Yellowlees 2000: 44).

Another area in which telemedicine promises much is aged care. Banks and Togno (1999) argued that by providing a viable option to the relocation of specialised geriatric medical staff to rural and remote locations, telehealth services can be used for the provision of more equitable health to ageing populations in rural and remote locations. Technology is already established in those regions, and they cite evidence that shows that some consumers even prefer online to face-to-face services. Banks and Togno refer to 53 telehealth programs that could cater for diseases in the ageing. There is at present only one project catering specifically for aging populations; a Melbourne based project to assist GPs with online services in diagnosis and treatment including osteoporosis, dementia, post-herpetic neuralgia, balance failure and incontinence. With this service, rural and remote GPs could access specialist advice and services via the Internet from a number of metropolitan bases, including the North-West Hospital and National Ageing Research Institute (NARI). Telehealth services in the US offer specialist support to rural and remote populations using cameras, digital stethoscopes and miniature dermatology cameras for the examination of skin lesions and other related conditions. Telehealth applications in Australia therefore have room for growth and expansion (Banks & Togno), particularly in the area of aged care. Ageing populations are typically high consumers of health services, and there is great potential for the development of telehealth and related online services for this section of the community in rural and remote regions.

A caveat in relation to the introduction and implementation of Telehealth is that consumers and providers of services must be involved in the decision making and implementation of such services. In the past, too many programs have been implemented by government agencies, software companies, and technologists without adequate 'on the ground' consultation with service users. In addition, Telehealth experts from other disciplines such as sociology, law, politics, economics, and psychology need to be involved to align decisions that are made purely within a technologist paradigm. In addition, McDonald, Hill, Daly, and Crowe (1998) have pointed out that few evaluations of Telehealth services have been carried out, and that some effort needs to be put into evaluating the quality and outcomes of existing programs, prior to implementing new programs.

Funding and provision of telemedicine

Much of the present funding for telehealth/ telemedicine is through government grants, little coming from infrastructure funding (Walsh 2000), indicating that in many senses the implications of telehealth have not yet been taken seriously by senior managers. Walsh (2000), for example, states that at present the Alfred Hospital (a large metropolitan hospital in Melbourne) spends only a small proportion of its budget on telehealth. Coiera (1997: 224) argued that 'it seems reasonable to think of telemedicine as the remote communication of information to facilitate clinical care.' He maintained that initially, telemedicine provided a link between clinicians and rural and remote areas, but now 'the healthcare system suffers enormous inefficiencies because of its poor communications infrastructure' (Coiera, p.224).Telemedicine can reduce such costs and is now seen by the government as a major area for development and research.

Liaw (2000) regrets that there is 'in the telehealth developments to date, relative lack of focus on the wants and the needs of consumer, patient, and to a lesser extent, the clinician'. Clearly this lack should be redressed when implementing effective telemedicine developments. He also questions the quality of most online health information resources; to be successful, programs must appeal to clinicians and patients alike. The programs 'should facilitate patient learning and empowerment, improve patient decision-making, encourage patient-clinician partnerships in decision-making and improve the quality of care' (p.31). Liaw continues that in order to be successful in providing a solution to many of the rural and remote health problems, telehealth needs to be implemented with a patient and clinician focus, meeting these needs in the implementation of programs. Management-focussed approaches which emphasise the aspirations of bureaucrats and whose implementation methodologies are based on the needs of hardware and software providers will not necessarily provide specific solutions for rural and remote populations.

Conclusion

As a substitution for and supplement to local health care in rural and remote areas, telehealth does offer a partial solution to the inequitable distribution of health services across Australia. Its successful implementation will depend upon good evaluation as well as the provision of services that lend a human face to the technology. There is also the potential to lift some of the heavy service burden from service providers who are already working in the bush, particularly if the associated hardware can provide networks and linkages for community development. Rural and remote families will then be able to make more informed health care decisions without the traditional transport, cost, and waiting time problems.

[1] Telemedicine refers to 'all electronic communication facilities related to clinical care, with an emphasis on interactive video-conferencing, computers and telemetry' (McDonald, Hill, Daly & Crowe 1998, p.xiii). In Australia, it means the provision of health services at a distance. 'Telehealth' means the development of services and policies with a telemedicine component. E-Health has recently been introduced into the professional vocabulary, and refers to the total use of IT in health. Telehealth is generally a more encompassing term than telemedicine. Telehealth is often referred to in the literature as the provision of health services at a distance, using advanced technologies and information technologies. Telehealth involves a range of technologies, from low level, such as telephone and fax services, to high level technologies such as videoconferencing, teleradiology, the Internet, and even the recently developed virtual feeling technologies for cardiac surgery. Telemedicine, a term that has been used for a longer period of time refers to the more specific provision of health care services (eg, teleradiology) accounting, in Victoria for about 10% of the advanced and IT services provided. The remaining 90% generally refers to telehealth, the majority of which are video-conferencing services.

View references

Navigate: Archives | Contents | Top of page

Search

Translate

Related Publications from eContent Management