In medicine, rural health or rural medicine is the interdisciplinary study of health and health care delivery in rural environments. The concept of rural health incorporates many fields, including geography, midwifery, nursing, sociology, economics, and telehealth or telemedicine.
Research shows that the healthcare needs of individuals living in rural areas are different from those in urban areas, and rural areas often suffer from a lack of access to healthcare. These differences are the result of geographic, demographic, socioeconomic, workplace, and personal health factors. For example, many rural communities have a large proportion of elderly people and children. With relatively few people of working age (20–50 years of age), such communities have a high dependency ratio. People living in rural areas also tend to have poorer socioeconomic conditions, less education, higher rates of tobacco and alcohol use, and higher mortality rates when compared to their urban counterparts. There are also high rates of poverty among rural dwellers in many parts of the world, and poverty is one of the biggest social determinants of health.
Many countries have made it a priority to increase funding for research on rural health. These efforts have led to the development of several research institutes with rural health mandates, including the Centre for Rural and Northern Health Research in Canada, Countryside Agency in the United Kingdom, the Institute of Rural Health in Australia, and the New Zealand Institute of Rural Health. These research efforts are designed to help identify the healthcare needs of rural communities and provide policy solutions to ensure those needs are met. The concept of incorporating the needs of rural communities into government services is sometimes referred to as rural proofing.
There is no international standard for defining rural areas, and standards may vary even within an individual country. The most commonly used methodologies fall into two main camps: population-based factors and geography-based factors. The methodologies used for identifying rural areas include population size, population density, distance from an urban centre, settlement patterns, labor market influences, and postal codes.
The reported number of individuals living in rural areas can vary greatly depending on which set of standards is applied. Canada’s rural population can be identified as anywhere from 22% to 38% of the population. In the United States the variation is greater; between 17% and 63% of the population may be identified as living in rural areas. The lack of consensus makes it difficult to identify the number of individuals who are in need of rural healthcare services.
Studies show that in many parts of the world life expectancy rates are higher in urban areas than in rural areas. There is some evidence to suggest that the gap may be widening in these countries as economic conditions and health education has improved in urban areas.
In Canada, life expectancy in men ranged from 74 years in the most remote areas to 76.8 years in its urban centers. For women, life expectancy was also lowest in rural areas, with an average of 81.3 years. Those living in rural areas adjacent to urban centers also experience higher life expectancies (with men at 77.4 years and women at 81.5 years). Australian life expectancies ranged from 78 years in major cities to 72 years in remote locations. In China, the life expectancy of females is 73.59 years in urban areas and 72.46 in rural areas. Male life expectancy varies from 69.73 years in urban areas and 58.99 in rural areas.
However, there are countries such as the United Kingdom where life expectancy in rural areas exceeds that of urban areas. Life expectancy there is two years greater for men and one-and-a-half years greater for women in rural areas when compared to urban areas. This may be due, in part, to smaller economic disparities in rural areas as well as an increasing number of well-educated and wealthy individuals moving to rural areas in retirement. This is a significant departure from the rural poverty found in many countries.
Access to healthcare
People in rural areas generally have less access to healthcare than their urban counterparts. Fewer medical practitioners, mental health programs, and healthcare facilities in these areas often mean less preventative care and longer response times in emergencies. The lack of healthcare workers has resulted in unconventional ways of delivering healthcare to rural dwellers, including medical consultations by phone or internet as well as mobile preventative care and treatment programs. There have been increased efforts to attract health professionals to isolated locations, such as increasing the number of medical students from rural areas and improving financial incentives for rural practices.
Canadians living in rural areas and small towns have access to half as many physicians (1 per 1,000 residents) as their urban counterparts. On average, these individuals have to travel five times the distance (an average of 10 km [6.2 mi]) to access these services. They also have fewer specialized healthcare services such as dentists, dental surgeons, and social workers. One study found ambulance service was available in only 40% of the selected sites, blood and Urine testing services in one third of the sites, and only one of the 19 sites had neonatal services. Nursing service had reduced from 26.3% in 1998 to 21.1% in 2005.
The gap in services is due, in part, to the focus of funding on higher-population areas. In China, only 10% of the rural population had medical insurance in 1993, compared with 50% of urban residents. In the 1990s, only 20% of the government's public health spending went to the rural health system, which served 70% of the Chinese population. In the United States, between 1990 and 2000, 228 rural hospitals closed, leading to a reduction of 8,228 hospital beds. In 2009, patients living in rural areas of the United States were transferred to other facilities for care at a rate three times higher than that of patients in large central metropolitan areas.
Rural areas, especially in Africa, have greater difficulties in recruiting and retaining qualified and skilled professionals in the healthcare field. In recent years, physicians from Sub-Saharan Africa have left the continent in droves. The global labor market has prompted more than 30% of physicians trained in this region to migrate to higher-income countries. It is often hard for those in rural communities to travel to clinics and hospitals for care. It is not an common practice to seek alternatives which include traditional and allopathic forms of medicine for healing. In Sub-Saharan Africa, urban and more prosperous areas have disproportionately more of the countries’ skilled healthcare workers. For example, urban Zambia has 20 times more doctors and over five times more nurses and midwives than the rural areas. In Malawi, 87% of its population lives in rural areas, but 96.6% of doctors are found in urban health facilities. Burkina Faso has one midwife per 8,000 inhabitants in richer zones, and one per nearly 430,000 inhabitants in the poorest zone. In South Africa alone, half of their population lives in rural areas, but only 12% of doctors actually practice there. This is similar to the realities in Ghana. Ghana implemented the Community-based Health Planning and Services (CHPS) program which is designed to deliver to care packages, in addition to providing them with physician care. The initiative has face problems in part due to the uneven distribution of healthcare professionals across all communities. There are community districts that are overstaffed, while others in rural districts are severely understaffed or lack formal clinic setups. One solution has been to develop programs designed to train women to perform home-based health care for patients in Rural Africa. One such program is African Solutions to African Problems (ASAP).
In order to improve health care availability in rural areas it is important to understand patient needs - hospitals need to use their distinct populations to their advantage. "Evaluating and processing patient feedback is important for understanding and solving quality of care issues in hospitals. It is critical for rural communities to understand their demographics in order to target specific care options. By involving patients in the process of identifying community needs and weak areas of service within the hospital, administrators can expect to see specialized patient care oriented feedback.
Rural areas often have fewer job opportunities and higher unemployment rates than urban areas. The professions that are available are often physical in nature, including farming, forestry, fishing, manufacturing, and mining. These occupations are often accompanied by greater health and safety hazards due to the use of complex machinery, exposure to chemicals, working hours, noise pollution, harsher climates, and physical labor. Rural work forces thus report higher rates of life-threatening injuries.
Lifestyle and personal health choices also affect the health and expected longevity of individuals in rural areas. People from rural areas report higher rates of smoking, exposure to second-hand smoke, and obesity than those in urban areas. These individuals also lead more sedentary lives according to research conducted by the CDC. Additionally, rural areas often have low rates of fruit and vegetable consumption even where farming is prevalent.
While homicide rates are lower in rural areas, death by injury, suicide, and poisoning are significantly more prevalent. The Australian Institute of Health and Welfare also reports higher rates of interpersonal violence in rural communities.
In many countries a lack of critical infrastructure and development in rural areas can impair rural health. The physical isolation of some rural communities coupled with the lack of infrastructure makes it increasingly difficult for those that live in these regions to travel to seek care in clinics and hospitals. Insufficient wastewater treatment, lack of paved roads, and exposure to agricultural chemicals have been identified as additional environmental concerns for those living in rural locations. The Australian Institute of Health and Welfare reports lower water quality and increased crowding of households as factors affecting disease control in rural and remote locations.
A Renewed Focus on Rural Health Worldwide
Since the mid-1980s, there has been increased attention on the discrepancies in healthcare outcomes between individuals in rural areas and those in urban areas. Since that time there has been increased funding by governments and non-governmental organizations to research rural health, provide needed medical services, and incorporate the needs of rural areas into governmental healthcare policy. Some countries have started rural proofing programs to ensure that the needs of rural communities, including rural health, are incorporated into national policies.
Research centers (such as the Center for Rural and Northern Health Research at Laurentian University, the Center for Rural Health at the University of North Dakota, and the RUPRI Center) and rural health advocacy groups (such as the National Rural Health Association, National Organization of State Offices of Rural Health, and National Rural Health Alliance) have been developed in several nations to inform and combat rural health issues.
In Canada, many provinces have started to decentralize primary care and move towards a more regional approach. The Local Health Integration Network was established in Ontario in 2007 order to address the needs of the many Ontarians living in rural, northern, and remote areas. The Canadian Institute for Health Information has developed the Rural Health Systems Model to support decision-makers and planners with understanding factors that affect rural health system performance, and the Rural Health Services Decision Guide to support decisions surrounding provision of rural health services. In China, a US $50 million pilot project was approved in 2008 to improve public health in rural areas. China is also planning to introduce a national health care system.
The WHO has done many studies on rural health statistics including, for example, showing that urban heath centers score significantly higher in service readiness than rural health centers, and the population of health workers across India where one can see the comparative numbers of workers in urban vs rural areas. Research studies like these exemplify the major problems needing attention in rural health systems and help lead to more impactful improvement projects.
The WHO also works on evaluation health system improvements and proposing better health system improvements. An article published in March 2017 highlighted the large improvement to be made in the Solomon Islands health system in a plan laid out by the Ministry of Health and Medical Services, supported by the WHO. These large scale changes move to bring health services needed by the rural population "closer to home."
Non Governmental Organizations (NGOs)
Lack of government intervention in failing health systems has led to the need for NGOs to fill the void in many rural health care systems. NGOs create and participate in rural health projects worldwide.
Rural Health Projects
Rural health improvement projects worldwide tend to focus on finding solutions to the three basic problems associated with a rural health system. These problems center around communication, transportation of services and goods, and lack of doctors, nurses, and general staff.
Many rural health projects in poor areas that lack access to basic medical help like clinics or doctors use non-traditional methods for providing health care. Approaches like Hesperian Health Guides' book, Where There is No Doctor, and World Hope International's app, mBody Health, have been shown to increase health awareness and provide additional health resources to rural communities.
An evaluation of a community organizing, mother and infant health program called the Sure Start project in rural India showed that community organization around maternal and infant health improvement leads to actual improvement in the health of the mother. The evaluation also showed that these community based programs lead to increased use of health services by the mothers.
In the United States, the Health Resources and Services Administration funds the Rural Hospital Performance Improvement Project to improve the quality of care for hospitals with fewer than 200 beds. Eula Hall founded the Mud Creek Clinic in Grethel, Kentucky to provide free and reduced-priced healthcare to residents of Appalachia. In Indiana, St. Vincent Health implemented the Rural and Urban Access to Health to enhance access to care for under-served populations, including Hispanic migrant workers. As of December 2012, the program had facilitated more than 78,000 referrals to care and enabled the distribution of US $43.7 million worth of free or reduced-cost prescription drugs. Owing to the challenges of providing rural healthcare services worldwide, the non-profit group [Remote Area Medical] began as an effort to provide care in third-world nations but now provide services primarily in the US.
In 2002, NGOs “provided 40 percent of clinical care needs, 27 percent of hospital beds and 35 percent of outpatient services” for people in Ghana. The conditions of the Ghanaian Healthcare system was dire during the early 80s, due to a lack of supplies and trained healthcare professionals. Structural adjustment policies caused the cost of health services to rise significantly. NGOs, like Oxfam, are rebalancing the brain drain that remaining healthcare professionals feel, as well as provide human capital to provide necessary health services to the Ghanaian people.
Telemedicine and rural health
For residents of rural areas, the lengthy travel time and distance to larger, more developed urban and metropolitan health centers present significant restrictions on access to essential healthcare services. Telemedicine has been suggested as a way of overcoming transportation barriers for patients and health care providers in rural and geographically isolated areas. Telemedicine uses electronic information and telecommunication technologies such as video calls to support long-distance healthcare and clinical relationships. Telemedicine provides clinical, educational, and administrative benefits for rural areas.
Telemedicine eases the burden of clinical services by the utilization of electronic technology in the direct interaction between health care providers, such as primary and specialist health providers, nurses, and technologists, and patients in the diagnosis, treatment, and management of diseases and illnesses. For example, if a rural hospital does not have a physician on duty, they may be able to use telemedicine systems to get help from a physician in another location during a medical emergency.
The advantage of telemedicine on educational services includes the delivery of healthcare related lectures and workshops through video and teleconferencing, practical simulations, and webcasting. In rural communities, medical professionals may utilize pre-recorded lectures for medical or healthcare students at remote sites. Also, healthcare practitioners in urban and metropolitan areas may utilize teleconferences and diagnostic simulations to assist understaffed healthcare centers in rural communities in diagnosing and treating patients from a distance. In a study of rural Queensland health systems, more developed urban health centers used video conferencing to educate rural physicians on treatment and diagnostic advancements for breast and prostate cancer, as well as various skin disorders, such as eczema and chronic irritations.
Telemedicine may offer administrative benefits to rural areas. Not only does telemedicine aid in the collaboration among health providers with regard to the utilization of electronic medical records, but telemedicine may offer benefits for interviewing medical professionals in remote areas for position vacancies and the transmission of necessary operation-related information between rural health systems and larger, more developed healthcare systems.
- Rural and Isolated Practice Registered Nurses
- Rural Health Care in Australia
- Medical deserts in the United States
- Community health
- Chan, Margaret (2010). Global Policy Recommendations. France: Graphic design: Rasmussen/CH. pp. 14–18. ISBN 9789241564014.
- "Rural Health Concerns". medlineplus.gov. Retrieved 2020-04-30.
- How healthy are Rural Canadians? An Assessment of Their Health Status and Health Determinants (PDF). Ottawa: Canadian Institute for Health Information. 2006. ISBN 978-1-55392-881-2. Archived from the original (PDF) on 2010-03-08.
- Healthy Horizons- Outlook 2003-2007: A Framework for Improving the Health of Rural, Regional, and Remote Australians (PDF). Australian Health Ministries’ Advisory Council’s National Rural Health Policy Sub-committee and the National Rural Health Alliance for the Australian Health Minister’s Conference. National Rural Health Alliance. 2003. ISBN 07308-56844.
- Ministerial Advisory Council on Rural Health (2002). "Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities" (PDF). Ottawa: Health Canada. Cite journal requires
- "Population density and urbanization". United Nations Statistics Division. Retrieved 8 March 2014.
- Pong, R. W.; Pitbaldo, R, J (2001). "Don't take "geography" for granted! Some methodological issues in measuring geographic distribution of physicians". Canadian Journal of Rural Medicine. 6: 105.CS1 maint: multiple names: authors list (link)
- Pitblado, JR (March 2005). "So, what do we mean by "rural," "remote" and "northern"?". The Canadian Journal of Nursing Research. 37 (1): 163–8. PMID 15887771.
- du Plessis, V.; Beshiri, R.; Bollman, R.; Clemenson, H. (2001). "Definitions of Rural" (PDF). Rural and Small Town Canada Analysis Bulletin. 3 (3).
- "Rural Definitions: Data Documentation and Methods". United-States Department of Agriculture. 2007. Retrieved January 31, 2008.
- Stephens, Stephanie. "Gap in Life Expectancy Between Rural and Urban Residents Is Growing". Center for Advancing Health. Retrieved 9 March 2014.
- Rural, regional, and remote health: Indicators of health. Australian Institute of Health and Welfare. 2005. ISBN 9781740244671. Retrieved February 19, 2008.
- Shen, J (February 1993). "Analysis of urban-rural population dynamics of China: a multiregional life table approach". Environment and Planning. 25 (2): 245–53. doi:10.1068/a250245. PMID 12286564.
- Ramesh, Randeep (25 May 2010). "Country dwellers live longer, report on 'rural idyll' shows". The Guardian. Retrieved 9 March 2014.
- Rourke, J. (2008). "Increasing the number of rural physicians". Canadian Medical Association Journal. 178 (3): 322–325. doi:10.1503/cmaj.070293. PMC 2211345. PMID 18227453.
- Ng, E.; Wilkins, R.; Pole, J.; Adams, O. (1999). "How far to the nearest physician". Rural and Small Town Analysis Bulletin. 1: 1–7.
- Halseth, G.; Ryser, L. (2006). "Trends in service delivery: Examples from rural and small town Canada, 1998 to 2005". Journal of Rural and Community Development. 1: 69–90.
- Brant, S.; Garris, M.; Okeke, E.; Rosenfeld, J. (2006). "Access to Care in Rural China: a Policy Discussion" (PDF). The Gerald R. Ford School of Public Policy, University of Michigan: 1–19. Retrieved February 27, 2009. Cite journal requires
- "Trends in rural hospital closure 1990–2000" (PDF). U.S Department of Health and Human Services. 2003. Retrieved February 19, 2008.
- Kindermann, D; Mutter, R; Pines, JM (February 2006). "Emergency Department Transfers to Acute Care Facilities, 2009: Statistical Brief #155". PMID 24006549. Cite journal requires
- "Health Workers Needed: Poor Left Without Care in Africa's Rural Areas". The World Bank. 2008. Retrieved February 27, 2009.
- Dubale, Benyam W.; Friedman, Lauren E.; Chemali, Zeina; Denninger, John W.; Mehta, Darshan H.; Alem, Atalay; Fricchione, Gregory L.; Dossett, Michelle L.; Gelaye, Bizu (2019-09-11). "Systematic review of burnout among healthcare providers in sub-Saharan Africa". BMC Public Health. 19 (1): 1247. doi:10.1186/s12889-019-7566-7. ISSN 1471-2458. PMC 6737653. PMID 31510975.
- Sato, Azusa (2012-12-01). "Revealing the popularity of traditional medicine in light of multiple recourses and outcome measurements from a user's perspective in Ghana". Health Policy and Planning. 27 (8): 625–637. doi:10.1093/heapol/czs010. ISSN 0268-1080.
- James, Peter Bai; Wardle, Jon; Steel, Amie; Adams, Jon (2018-10-01). "Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review". BMJ Global Health. 3 (5): e000895. doi:10.1136/bmjgh-2018-000895. ISSN 2059-7908. PMID 30483405.
- "Bring Health Care Services to Rural Africa". The Atlantic Philanthropies. 2012. Retrieved Dec 13, 2013.
- Wahab, Hassan (2019). "The Politics of State Welfare Expansion in Africa: Emergence of National Health Insurance in Ghana, 1993-2004". Africa Today. 65 (3): 91–112. doi:10.2979/africatoday.65.3.06. ISSN 0001-9887.
- Kritz, Jessica (March 2018). "Building cross-sector collaboration using participatory action research to improve community health in an urban slum in Accra, Ghana". The Lancet Global Health. 6: S38. doi:10.1016/s2214-109x(18)30167-0. ISSN 2214-109X.
- "Health". African Solutions to African Problems. 2013. Retrieved December 2, 2013.
- Institute, Texas A&M Rural and Community Health. "Texas A&M Health Science Center". architexas.org. Retrieved 2019-06-17.
- Bollman, Ray D. (13 Nov 2008). "An Overview of Rural and Small Town Canada". Canadian Journal of Agricultural Economics. 39 (4): 805–817. doi:10.1111/j.1744-7976.1991.tb03642.x.
- U.S Congress, 1991
- Gerberich S.G.; Gibson, R.W.; French, L.R.; Lee, T.Y.; Carr, W.P.; Kochevar, L.; Renier, C.M.; Shutske, J. (1998). "Machinery-related injuries: Regional Rural Injury Study-I (RRIS-I)". Accident Analysis and Prevention. 30 (6): 93–804. PMID 9805522.
- Pickett, W.; Hartling, L.; Brison, R. J.; Guernsey, J. R.; Program (1999). "Fatal work-related farm injuries in Canada, 1991-1995". Canadian Medical Association Journal. 160 (13): 1843–1848. PMC 1230438. PMID 10405669.
- Iglehart, John K. (2018). "The Challenging Quest to Improve Rural Health Care". New England Journal of Medicine. 378 (5): 473–479. doi:10.1056/NEJMhpr1707176. ISSN 0028-4793. PMID 29385378.
- Walsh, Bryan (23 July 2013). "In Town vs. Country, It Turns Out That Cities Are the Safest Places to Live". Time. Retrieved 9 March 2014.
- Butterfield, Fox (13 February 2005). "Social Isolation, Guns and a 'Culture of Suicide'". The New York Times. Retrieved 9 March 2014.
- Essendi, Hildah; Johnson, Fiifi Amoako; Madise, Nyovani; Matthews, Zoe; Falkingham, Jane; Bahaj, Abubakr S.; James, Patrick; Blunden, Luke (2015-11-09). "Infrastructural challenges to better health in maternity facilities in rural Kenya: community and healthworker perceptions". Reproductive Health. 12 (1): 103. doi:10.1186/s12978-015-0078-8. ISSN 1742-4755. PMC 4640392. PMID 26553004.
- "Physical access to primary health care in Andean Bolivia". Social Science & Medicine. 50 (9): 1177–1188. 2000-05-01. doi:10.1016/S0277-9536(99)00364-0. ISSN 0277-9536.
- Aday, L. A.; Quill, B. E.; Reyes-Gibby, C. C. (2001). "Equity in rural health and health care". In Loue, Sana; Quill, B.E. (eds.). Handbook of Rural Health. New York City: Kluwer Academic-Penum Publishers. pp. 45–72. ISBN 9780306464799.
- "A New Era of Responsibility" (PDF). United States Office of Management and Budget.
- Humphreys, J; Hegney, D; Lipscombe, J; Gregory, G; Chater, B (February 2002). "Whither rural health? Reviewing a decade of progress in rural health". The Australian Journal of Rural Health. 10 (1): 2–14. doi:10.1046/j.1440-1584.2002.00435.x. PMID 11952516.
- "Rural proofing guidance". Department for Environment, Food & Rural Affairs. Government of the United Kingdom. 16 May 2013. Retrieved 9 March 2014.
- "What makes rural New Zealand different". Ministry for Primary Industries. Government of New Zealand. 17 September 2010. Retrieved 9 March 2014.
- Ottawa Charter for Health Promotion (PDF). First International Conference on Health Promotion. World Health Organization. November 21, 1986. Archived from the original (PDF) on February 18, 2012. Retrieved February 15, 2009.
- "Population health profile: North East LHIN" (PDF). North Bay, Ontario: North East LHIN: North East Local Health Integration Network. 2006. Retrieved January 20, 2009. Cite journal requires
- "China launches rural health project". China Daily. 2008. Retrieved March 2, 2009.
- Leslie, Hannah H; Spiegelman, Donna; Zhou, Xin; Kruk, Margaret E (2017). "Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania". World Health Organization. 95 (11): 738–748. doi:10.2471/BLT.17.191916. PMC 5677617. PMID 29147054.
- "The health workforce in India". World Health Organization. Retrieved 2017-12-10.
- "Grand challenges for the next decade in global health policy and programmes". World Health Organization. Retrieved 2017-12-10.
- "Health closer to home: transforming care in the Solomon Islands". World Health Organization. Retrieved 2017-12-10.
- "Rural Healthcare Workforce Introduction - Rural Health Information Hub". www.ruralhealthinfo.org. Retrieved 2020-05-24.
- Strasser, Roger (2003-08-01). "Rural health around the world: challenges and solutions*". Family Practice. 20 (4): 457–463. doi:10.1093/fampra/cmg422. ISSN 0263-2136. PMID 12876121.
- Weisgrau, Sheldon (1995). "Issues in Rural Health: Access, Hospitals, and Reform". Health Care Financing Review. 17 (1): 1–14. ISSN 0195-8631. PMC 4193574. PMID 10153465.
- Babu, Elizabeth (2010-03-03). "Where There Is No Doctor". JAMA. 303 (9): 885. doi:10.1001/jama.2010.244. ISSN 0098-7484.
- Hebert, E.; Ferguson, W.; McCullough, S.; Chan, M.; Drobakha, A.; Ritter, S.; Mehta, K. (October 2016). "mBody health: Digitizing disabilities in Sierra Leone". 2016 IEEE Global Humanitarian Technology Conference (GHTC): 717–724. doi:10.1109/GHTC.2016.7857357. ISBN 978-1-5090-2432-2.
- Acharya, Arnab; Lalwani, Tanya; Dutta, Rahul; Rajaratnam, Julie Knoll; Ruducha, Jenny; Varkey, Leila Caleb; Wunnava, Sita; Menezes, Lysander; Taylor, Catharine; Bernson, Jeff (13 November 2014). "Evaluating a Large-Scale Community-Based Intervention to Improve Pregnancy and Newborn Health Among the Rural Poor in India". American Journal of Public Health. 105 (1): 144–152. doi:10.2105/AJPH.2014.302092. ISSN 0090-0036. PMC 4265916. PMID 25393175.
- "Challenges Facing Rural Health Care: A Conversation With Brock Slabach, Senior Vice President for Member Services at the National Rural Health Association". Agency for Healthcare Research and Quality. 2013-04-17. Retrieved 2013-09-29.
- "Field-Based Outreach Workers Facilitate Access to Health Care and Social Services for Underserved Individuals in Rural Areas". Agency for Healthcare Research and Quality. 2013-05-01. Retrieved 2013-05-13.
- "When both states and markets fail: asymmetric information and the role of NGOs in African health care". International Review of Law and Economics. 22 (1): 61–80. 2002-07-01. doi:10.1016/S0144-8188(02)00069-8. ISSN 0144-8188.
- Wahab, Hassan (2019). "The Politics of State Welfare Expansion in Africa: Emergence of National Health Insurance in Ghana, 1993-2004". Africa Today. 65 (3): 91–112. doi:10.2979/africatoday.65.3.06. ISSN 0001-9887.
- Migration in a Globalizing World: Perspectives from Ghana. Sub-Saharan Publishers. 2018. ISBN 978-9988-8829-1-4.
- Telehealth use in Rural Healthcare. Rural Health Information Hub website. https://www.ruralhealthinfo.org/topics/telehealth Published October 2011. Updated August 7, 2017. Accessed February 15, 2018.
- Rural Health. HealthIT.gov Website. http://www.healthit.gov/providers-professionals/frequently-asked-questions/487#id157 Accessed November 3, 2014.
- Smith, A.; Bensink, M.; Armfield, N.; Stillman, J.; Caffery, L. (2005). "Telemedicine and rural health care applications". Journal of Postgraduate Medicine. 51 (4): 286–293. PMID 16388171.
- McCrossin, R (2001). "Successes and failures with grand rounds via videoconferencing at the Royal Children's Hospital in Brisbane". Journal of Telemedicine and Telecare. 7 (2_suppl): 25–8. doi:10.1258/1357633011937047. PMID 11747651.
- Hornsby D. Videoconference Usage Report: May 2000. Brisbane: Queensland Telemedicine Network (Queensland Health);2000
- Saslow, Eli (16 November 2019). "The most remote emergency room: Life and death in rural America". The Washington Post.
- Strong; et al. (1998). "Health in rural and remote Australia: The first report of the Australian Institute of Health and Welfare on rural health". Australian Institute of Health and Welfare. Retrieved 6 June 2014. Cite journal requires
- "Remoteness classifications". Australian Institute of Health and Welfare. 2004. Retrieved 6 June 2014.
- Beshri, R.; Alfred, E. (2002). "Immigrants in rural Canada". 4. Ottawa: Statistic Canada. Cite journal requires
- "Canadian rural population trends" (PDF). Agriculture and Agri-Food Canada Publication. Canadian Rural Partnership Research and Analysis (2138/E). 2002. Archived from the original (PDF) on July 26, 2003.
- "China's rural population shrinks to 56% of the population". Peoples Daily Online. 2007. Retrieved February 27, 2009.
- Countryside and Community Research Unit (2003). "The demography of rural areas: A literature review" (PDF). Archived from the original (PDF) on July 9, 2007. Retrieved February 20, 2008. Cite journal requires
- Countryside Agency (2002). "Rural Proofing – Policy Makers' Checklist" (PDF). Wetherby, UK: Countryside Agency Publications. Cite journal requires
- Department of Primary Industries and Energy & Department of Human Services and Health (1994). "Rural, Remote and Metropolitan Areas Classification 1991 Census Edition" (PDF). Retrieved January 31, 2008. Cite journal requires
- "Rural and Urban Area Classification Collection". Department for Environment, Food, and Rural Affairs. 1 May 2014. Retrieved 5 June 2014.
- Department for Environment, Food, and Rural Affairs (2005). "Defra Classification of Local Authority Districts and Unitary Authorities in England: An Introductory Guide" (PDF). Retrieved January 31, 2008. Cite journal requires
|journal=(help)CS1 maint: multiple names: authors list (link)
- Economic Research Service (1998). "Rural Median Household Income Increases". Rural Conditions and Trends: Socioeconomic Conditions Issue (8): 28–30.
- Johnson, K. (2006). "Demographic Trends in Rural and Small Town America" (PDF). Reports on Rural America. 1: 1–36.
- Liu, L; Hader, J; Brossart, B; White, R; Lewis, S (June 2001). "Impact of rural hospital closures in Saskatchewan, Canada". Social Science & Medicine. 52 (12): 1793–804. doi:10.1016/s0277-9536(00)00298-7. PMID 11352406.
- Ministry of Health (2007). Urban-Rural Health Comparisons: Key Results of the 2002/03 New Zealand Health Survey. Wellington, N.Z. ISBN 978-0-478-30742-9.
- Mueller, K.J (2001). "Rural health policy: Past as a prelude to the future". In Loue, Sana; Quill, B.E. (eds.). Handbook of Rural Health. New York City: Kluwer Academic-Penum Publishers. pp. 45–72. ISBN 9780306464799.
- Pong, R.W.; DesMeules, M.; Manuel, D.; Guernsey, J.; Kazanjian, A.; Wang, F. Health Services Utilization in Rural Canada: Are There Distinct Rural Patterns?. Centre for Rural and Northern Health Research, Laurentian University.
- Ricketts, Thomas C.; Johnson-Webb, Karen D.; Taylor, Patricia (1998). "Definitions of Rural: A Handbook for Health Policy Makers and Researchers" (PDF). Chapel Hill: North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, University of North Carolina: 13. Cite journal requires
- Romanow, R. J. (2002). Building on values: The future of health care in Canada. Ottawa, Ontario: Commission of the Future of health Care in Canada.
- Singh, V. (2004). "The rural-urban income gap within provinces: An update to 2000" (PDF). Rural and Small Town Canada Analysis Bulletin. 5 (7).
- Statistics Canada (2003). "Aboriginal people of Canada: A demographic profile" (PDF). Ottawa. Cite journal requires
- Statistics New Zealand (2008). "New Zealand: An Urban/Rural Profile". Archived from the original on 27 January 2008. Retrieved January 31, 2008.
- U.S. Congress (1991). "Rural America at the Crossroads: Networking for the Future" (PDF). Washington, DC: U.S. Government Printing Office. OTA-TCT-471. Cite journal requires
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- Rural health publications - Australian Institute of Health and Welfare
- Office of Rural Health Policy – United States Department of Health and Human Services
- National Rural Health Association
- National Organization of State Offices of Rural Health
- Office of Rural Health – Health Agency of Canada
- Rural Wisconsin Health Cooperative
- Health Resources – USDA, National Agricultural Library, Rural Information Center.
- Rural Health Information Hub
- Rural Health Education Foundation – Australia
- New Zealand Rural General Practice Network - New Zealand