A significant proportion of people live and work in rural areas, and rural mental health is important wherever psychiatry is practised. There are inherent difficulties in conducting rural research, due in part to the lack of an agreed definition of rurality. Mental health is probably better in rural areas, with the exception of suicide, which remains highest in male rural residents. A number of aspects of rural life (such as the rural community, social networks, problems with access, and social exclusion) may all have particular implications for people with mental health problems. Further issues such as the effect of rural culture on help-seeking for mental illness, anonymity in small rural communities and stigma may further affect the recognition, treatment and maintenance of mental health problems for people in rural areas. Providing mental health services to remote and rural locations may be challenging.
Rural culture and countryside form a significant part of our society. A large minority of the British population lives in rural places: around 30% in England and Wales, and 20% in Scotland. Most (98%) of Scotland’s landmass is classified as rural. The degree of rurality differs between different countries, but remains significant in the world’s high-income countries; for example, in the USA 25% of the population and 90% of the landmass are considered to be rural. Despite this, our way of life remains predominantly urban. Services such as healthcare, higher education, transport and communication links are all centralised, and people living in rural areas are generally expected to travel to urban centres to access them. Government policy has for the most part reflected this urban bias.
Although it is not often thought of in these terms, psychiatry in the UK is likewise a predominantly urban specialty. Large units and in-patient facilities are usually based in cities, and services serving rural communities are centralised as far as is possible. Psychiatric research is almost entirely conducted on urban populations, although we rarely consider this. Yet a large proportion of the patients with whom psychiatrists work live in rural places, and their life experiences may well relate to their rural environment. Geographic mobility within the UK is relatively high, and patients commonly move between urban and rural environments. Many of the issues identified within rural research – such as difficulties in accessing services and maintaining anonymity within a small community – are also pertinent to patients in urban areas. Rural mental health is important wherever psychiatry is practised.
Background and historical context
Although most great nations have been built around cities, the bulk of the population lived off the land, and it is only in the past couple of centuries that industrialisation has brought a majority of people into towns and cities. The effects of the industrial revolution started to be felt in the UK in the latter half of the 18th century, and in much of Europe and North America shortly after. In other parts of the world, the process of industrialisation is not yet complete, and some countries are continuing to experience rapid urbanisation as a consequence (Goldberg & Thornicroft, 1998).
This article concerns itself with the research that has developed as people have tried to identify and study the features that differentiate ‘urban’ from ‘rural’. I explore this almost entirely from the rural perspective. There is a large literature looking at different aspects of urban life; but there is surprisingly little overlap with rural research, or indeed acknowledgement that the concept of rurality only makes sense as the counterpart of urbanicity.
Defining rurality
Although the idea of rurality appears conceptually simple, there is no universal agreement about what it actually means. In the past, research tended to present a dichotomy in which ‘rural’ was everything that was ‘not-urban’, but recent classification systems have tried to identify the degree of rurality and urbanicity. There are no a priori theoretical grounds for developing such a classification system, but definitions can be broadly divided into spatial, socio-economic and sociological.
Spatial classifications depend on factors such as population numbers, population density, and distance to cities and other urban centres.
Socio-economic classifications look at factors such as the principal employment in an area (for example, farming v. financial) and other socioeconomic characteristics of the population. Service-based definitions have been used in healthcare (for example, defining rural primary care by identifying the perceived differences between urban and rural general practice).
Sociological definitions consider the subjective aspects and experiences of rurality; for example, asking the study participant or researcher to decide for themselves whether they would define themselves as rural. Although pure sociological definitions tend to be less used in mental health research, unless a system of classification considers the look or feel of a place, people included in the research may disagree about the findings. It may be useful also to include rural attributes such as community cohesion, stoicism and self-sufficiency in a definition of rurality.
More complex definitions combine several of the above aspects.
‘Rurality’ and research
There is no evidence-base to suggest that any of these ways of defining rurality is superior to any other; however, the choice of definition may substantially affect the results of research. For example, using different definitions of rurality generates different proportions of rural population (Australian Institute of Health and Welfare, 2004), and even if the overall proportion is similar, different people within the sample will be described as rural (du Plessis et al, 2002). Whether infant mortality is found to be higher in urban or rural areas depends on the definition of rurality that has been used (Farmer et al, 1993). Several researchers have suggested that the whole concept of rurality in research is mostly useful as an aid to helping develop healthcare and other social policy.
Rural environments differ greatly around the world, and this has led to the suggestion that different definitions are required in different countries. In keeping with this, most high-income countries have now established one (or a small number) of agreed definitions for use within their own regions. Unfortunately, these are sufficiently dissimilar that comparisons of international research are extremely tricky. Even within a single country, the rural environment may be quite diverse, and it may not make sense to compare the environment of a crofter living on a remote Scottish island to that of a commuter in Essex. There is an increasing tendency to distinguish both rural and remote, where the term remote is used purely to denote geographic distance, and this may be helpful in further defining rurality, as rural locations may range from a few miles to a few hundred miles from an urban centre. Even then, the concept and reality of remoteness varies greatly between different countries. The Scottish Executive defines places as remote if they are greater than 1 hour’s drive from a settlement of 10 000 or more. In Alaska, around a third of the population lives in places without road access, and places are defined as remote when they can be reached only by boat, aeroplane or snowmobile.
It is essential to know how rural has been defined when evaluating rural research. For research that will be used to influence health services and policy, it is probably best to use the accepted classification system for the country concerned. With exploratory research, or comparative international research, it may even be best to return to the simple dichotomy of ‘urban’ and ‘not-urban’.
There is relatively little research looking at rural mental health in the UK, and in this article I have drawn heavily from the international literature. The primary findings and underlying concepts may therefore be valid, but because rurality differs so much between countries, it is always necessary to reflect how these might apply in general to the UK population, and more specifically to the community in which the psychiatrist works.
Given the inherent difficulties in defining rurality, it could be argued that it is simply not a useful concept either for research purposes or in clinical practice. However, the concept of rurality has both face value and utility. At government level it can be used to drive policy decisions and address inequalities in society. At an individual level, it is helpful to think about the meaning of rurality when working in a rural environment or with rural patients. It can also be useful to consider what features have been used to identify a patient as rural, and how their rurality may affect their illness and treatment. If we ignore the concept of rurality we will neglect a major element of the complex society in which we live.
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Laura Anne Nicholson
Laura Nicholson is a specialist registrar in the psychiatry of learning disabilities with the West of Scotland Deanery (Department of Learning Disabilities, West House, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK. Email: laurarobinson@doctors.org.uk). Her current research interests are rural mental health and learning disabilities, and she has spent a number of years working as a psychiatrist in rural Scotland.
