Does living in rural areas make a difference for health in Québec?
Introduction
The cover of the Canadian edition of the newsweekly Time recently read, “Slow death. Canada's small towns are fading away. Should you care?” (Catto, 2003). This headline may seem excessively alarmist, but for several years in Canada, the situation in many small, essentially rural communities has been a real cause of concern (Bollman, 1992; Troughton, 1999). Many are grappling with multiple difficulties whose consequences for the health of rural residents can be serious (Pong et al., 1999; Troughton, 1999). But what is the reality? Does living in rural communities rather than cities really make a difference in terms of people's health? If so, to what extent? What factors might explain this situation, and how do they contribute to this difference? Are all rural communities the same in terms of health? These questions may be legitimate, but they are difficult to answer given that current knowledge on the health status of rural populations—the key issue—is relatively weak and sparse (Pong, 2000).
From the literature, it appears that Canadian rural populations show poorer health than their urban counterparts, both in terms of general health indicators (i.e., standardized mortality, life expectancy at birth, infant mortality, health perception, and functional health) (Pampalon et al., 1990, Pampalon et al., 1995; Pampalon, 1991; Wilkins, 1992; Mitura and Bollman, 2003) and certain health problems such as suicide (Leenaars et al., 1998; Masecar, 1998), motor vehicle accidents (Thouez et al., 1991; Warda et al., 1998; Kmet et al., 2003), infectious, respiratory and hypertensive diseases, stomach cancer (Pampalon, 1994), and being overweight (Mitura and Bollman, 2003).
From the literature, it also appears that some specific health problems might be linked to agriculture, forestry, fishing, and mining—considered harmful activities—in rural communities of Canada (Pong et al., 1999). These include certain cancers (Graham et al., 1977; Godon et al., 1989a, Godon et al., 1989b; McDuffie et al., 2002), pulmonary disorders (Dosman et al., 1987, Dosman et al., 1988; Senthilselvan et al., 1997; Pahwa et al., 2003); and various types of contamination and poisoning (Frank et al., 1990; Levallois et al., 1998; Strauss et al., 2001; Thompson, 2001). Studies have also focused on lifestyles, namely smoking and sedentarity, which seem to be more prevalent among rural populations in Canada (Mitura and Bollman, 2003) and specifically Québec (Pampalon et al., 1990, Pampalon et al., 1995; Pampalon, 1994; Pitblado et al., 1999). Québec studies also indicate that excessive alcohol consumption is more prevalent among urban populations (Pampalon et al., 1990, Pampalon et al., 1995). However, drunk driving by young people is of particular concern in rural areas of Québec, if only due to the lack of alternative means of transportation (Audet et al., 1995).
Finally, access to health services has received the most attention from researchers, planners, and decision makers, perhaps because in Canada—where healthcare is supposed to be universal—one-fourth to one-third the population, according to the definition of “rural” (du Plessis et al., 2001), faces a situation of inequality (Health Canada, 2002). The shortage of and difficulty in retaining primary care providers (physicians, specialists, dentists, and nurses), the closing of small hospitals and, conversely, the tendency to hospitalize, financial barriers (cost of travel to services), and cultural differences between health service providers and users have all been identified as major issues of concern in Canadian rural communities (McKie et al., 1992; Black et al., 1995; Ng et al., 1997; Pitblado and Pong, 1997; MacLeod et al., 1998; Pitblado et al., 1999; James, 2001; Bushy, 2002; Health Canada, 2002; Pollet and Harris, 2002).
Although valuable and useful, research conducted in rural Canada leads to a fragmented view of the population's health, as it focuses on specific and sometimes single health problems, determinants, databases, or rural areas. Indeed, the concept of health is often reduced to a few biomedical characteristics that reflect only a portion of a multidimensional health model that also includes socioeconomic and demographic characteristics, the healthcare system, the physical environment, etc. (Marmot and Wilkinson, 1999). The same is true of health determinants which are often considered separately and rarely associated to population health status. Most studies also reveal a tendency to rely on a single source of information, whether a survey or administrative database (e.g., deaths, census, etc.), to the detriment of other sources. Yet a team in Ontario has shown that many unused provincial and national sources and databases in Canada could help researchers document the many facets of rural health (Pitblado et al., 1999; Pong et al., 2002). Finally, our review shows that study areas are often geographically limited to a specific region or several rural areas at best, producing results that cannot necessarily be transposed to other contexts. As Pitblado et al. (1999) note, “Until recently, Canadian research on rural health issues has been piecemeal in nature and limited to small-scale projects. To make matters worse, despite the wealth of health-related data at the federal, provincial, and territorial levels, most data collected or released are frequently not presented in a manner that supports meaningful rural health research and analysis” (Health Canada, 2002, pp. 164–165). Behind this geographic limitation lies an even greater shortcoming: the lack of attention to the definition of “rural” and, subsequently, to diversity among rural areas.
With this study, we wish to counterbalance the usual fragmented approach to rural health in Canada and adopt a more global perspective. First, this means focusing on population health status, which is the ultimate goal of both the healthcare system and the population itself. This also means referring to a multidimensional concept of health that includes not only population health status but also its major determinants, which are grouped here into three large categories. Last, this means looking at all of Québec—its urban and rural areas—as a whole, as well as the diversity of rural areas. Québec has a mix of urban and rural areas typical to most industrialized countries.
Two questions guide us through this study of rural health in Québec: 1—are there significant differences between urban and rural areas, as a whole? and 2—are there significant differences within rural areas? In other words, is it better or worse for health to live in the country rather than cities or in certain parts of the country? These questions will be posed first in terms of population health status, and then in terms of its major determinants: the demographic and socioeconomic characteristics of the population, lifestyles, and the healthcare system.
The purpose of this study is to challenge the negative view of many observers regarding rural areas when they target specific health determinants or specific health status indicators. More importantly, our purpose is to underscore the distinctive features of health in rural Québec communities and highlight issues that should retain the attention of researchers, planners, and decision makers.
Section snippets
Data and methods
To develop our global perspective, it is important to first define “rural” and specify our spatial analysis grid. Adopting such a perspective also means using many data sources, health indicators, and statistical techniques, which are described in sequence. Finally, the analysis strategy is presented.
Results
Health status varies little between urban and rural residents in Québec (Table 1). At birth, rural residents have a life expectancy and a healthy life expectancy of half a year and a year and a half less than their urban counterparts, although these values (particularly for life expectancy) drop slightly from strong MIZ to weak or no MIZ. Differences are more pronounced in men than in women (Fig. 1). Total mortality mirrors such variations, as do disability and poor health perception, although
Discussion
This study adopted a global perspective to underscore the distinctive features of health in rural communities of Québec. Population health status and three major groups of health determinants were considered. On this basis, rural areas were compared with urban areas as a whole. Rural areas were also subdivided into three zones, from the area bordering urban centers to the remote hinterland, and these zones were compared. Ultimately, does people's health differ between the city and country and
Conclusion
From these results, it appears that living in Québec's rural areas is not as big a health risk as some literature might suggest. While there are differences in people's health between the city and country and within the country, these differences are small when overall population health status is considered. What really distinguishes the city from the country and areas within the country is the presence of specific health conditions and health determinants.
These conditions and determinants
Acknowledgements
This study is an initiative of Association pour la santé publique du Québec (ASPQ) and would not have been possible without the financial support of MSSS. We would like to thank Renald Bujold, ASPQ President, for having initiated this study and the following people for having facilitated it: Guy Raymond and André Charest of MSSS for extracting data from various records, Renaud Dugas of Institut de la Statistique du Québec for facilitating access to certain databases, and Jean-Guy Bourbonnière
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