BP-325E

Prepared by:
Therese Jennissen
Political and Social Affairs Division
December 1992

TABLE OF CONTENTS

INTRODUCTION

DEMOGRAPHIC OVERVIEW

AVAILABILITY AND ACCESS

   A.  Distribution of Physicians

   B.  Distribution of Other Health-Care Professionals

   C.   Distribution of Health Care Facilities

   D.   Under-Servicing of Health-Related Services

   E.   Under-Servicing of Special Needs Groups
      1.  Women
      2.  Children
      3.  Youth
      4.  Disabled Persons
      5.  Immigrants
      6.  Elderly People

UNIQUE HEALTH NEEDS IN SELECTED RURAL REGIONS

   A.   Farmers

   B.   People of Aboriginal Original

   C.   Maritime Fishermen

CONCLUDING REMARKS

INTRODUCTION

In Canada, the organization and delivery of hospital and medical services falls to the provinces and territories, each of which administers its own hospital and health insurance plan. The federal government, however, also plays an important role by conditionally granting the provinces a portion of the costs of medical care. To qualify for this grant under the Established Programs Financing Formula, the provinces' health insurance programs must be universal, comprehensive, accessible, portable, and publicly administered.

The concept of "health" has been evolving over recent decades in Canada. Before the mid-seventies, "health" largely meant freedom from disease; more recently it has taken on a broader and more comprehensive meaning. According to the Constitution of the World Health Organization (WHO), health is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy human needs and, on the other hand, to change or cope with the environment."(1) In Canada the Lalonde and Epp reports of 1974 and 1986 broadened the concept of health to include health promotion. Health promotion, a "process of enabling people to increase control over, and to improve, their health,"(2) focuses on the total environment of the population. From this perspective, health is no longer measured simply in terms of illness and death but rather it

becomes a state which individuals and communities alike strive to achieve, maintain or regain, and not something that comes about merely as a result of treating and curing illness and injuries. It is a basic dynamic force in our daily lives, influenced by our circumstances, our beliefs, our culture and our social, economic and physical environments.(3)

Thus health status is determined by a combination of factors, such as age, gender, race, lifestyle, heredity, income, housing, and type of employment. In Canada, geographic location (urban/rural) can be shown to be one important factor affecting the quality of health care. Although all residents of Canada theoretically have equal access to services under the Canada Health Act, it has become apparent that there are regions in Canada, mainly rural and northern regions, that are medically underserviced, and lacking in social services.(4)

The term "rural life" tends to evoke images of fresh air, natural foods, and robust, healthy people, who are often contrasted with stressed, unhealthy urbanites. In fact, studies suggest that rural residents on average have shorter life expectancies and lead less healthy lives than do residents of large urban centres.(5) Moreover, statistics indicate that rural residents over the age of 15 are more likely to suffer from long-term disabilities than their urban counterparts.(6) This can be only partly explained by the greater number of elderly people in rural areas. Various aspects of rural life influence health status.

This paper examines two important issues. The first is the availability of and access to good quality health care in rural areas, paying particular attention to needs of women, children, youth, disabled persons, immigrants and elderly people. The second is the health problems unique to certain groups in specified rural areas: farmers on the prairies, Indians and Metis on reserves, and fishermen in single-industry towns in the Maritimes.

DEMOGRAPHIC OVERVIEW

Canada has gradually evolved from being a rural to a largely urban society with almost 70% of the current population living in urban centres. Although almost 32% of the overall Canadian population lives in rural regions(7) there are major regional variations in rural-urban distribution as illustrated in Table 1. In The Northwest Territories and Atlantic Canada, for example, at least 45% of the population live in rural areas,(8) as do almost half of the population of Saskatchewan.

Source: Statistics Canada, Census 1991, Urban Areas Population and Dwelling Counts. Cat. No. 93-305, Ministry of Industry, Science & Technology, 1992.

AVAILABILITY AND ACCESS

The challenge of providing good quality health care close to home in a country as vast and sparsely populated as Canada is not new; Stories about the country doctor travelling miles on foot in a snow storm to save a patient's life are part of our folk culture. In spite of major scientific advancements and a health insurance system that has been developed over the past 50 years, the challenge remains.(9) A number of factors impede the availability of, and access to, good quality care for rural residents.

   A. Distribution of Physicians

The uneven rural-urban distribution of physicians has been at the centre of discussion for a number of years.(10) Recently, the Canadian Medical Association (CMA) struck an advisory panel that examined the deficiencies in the provision of medical services in rural and medium-sized communities in Canada and proposed strategies to help correct them.(11) The panel found that approximately 10% of all physicians in Canada in 1986 practised in rural areas (with populations of less than 10,000), where slightly less than 25% of the Canadian population resided. When the data were broken down between family physicians general practitioners and specialists, it was clear that specialists were even more under-represented in rural regions.(12)

Rural regions encounter difficulties in recruiting and retaining physicians.(13) The decision to enter rural practice has both personal and professional dimensions. Physicians most interested in working in rural areas often come from rural backgrounds and are committed to working in this environment. Physicians' decisions to leave rural practice are usually influenced by non-monetary factors, such as a shortage of professional back-up, long hours of work, limited opportunities for further medical training, insufficient job opportunities for partners, and concerns over children's educational opportunities. Levels of satisfaction with rural work appear to rise with proximity to large urban centres.(14) Incentives to encourage and retain physicians in rural regions have been implemented by most provinces and new strategies are currently being discussed by the CMA.(15)

Another suggestion for dealing with the shortage of rural physicians is to make rural health a more important part of the curriculum in medical schools across Canada. The CMA argues that "the education of physicians for rural practice deserves special attention to ensure adequacy and appropriateness of learning experiences to meet the unique needs of rural Canada."(16)

Medical specialists are clearly under-represented in rural areas with, according to the CMA advisory panel, only 5% of the total number of Canadian specialists practising there.(17) In Ontario, only 2.5% of specialists practise in rural communities.(18) This situation is expected to become worse in the next 20 years, when two-thirds of retiring physicians will be specialists and one-third family physicians/general practitioners.(19) This shortage of specialists will undoubtedly have an impact on the rural community.

Some medical specialties are more commonly found in rural areas than others; the CMA advisory panel noted, for example, that general surgeons were the most common and pediatricians the least common.

Source: Canadian Medical Association. Report of the Advisory Panel on the Provision of Medical Services in Underserviced Regions. March 1992. p. 15.

   B. Distribution of Other Health-Care Professionals

Although the distribution of physicians appears to be the aspect of rural health most commonly discussed in the literature, the availability of and access to, other health care professionals are also of concern. The Saskatchewan Commission on Directions in Health Care, for example, found that there is a serious shortage of psychiatric nurses, physical and occupational therapists, and speech and language pathologists in rural areas of that province.(20)

There has been a movement, particularly in the United States, to hire nurse practitioners to help overcome the problem of inaccessible and fragmented health-care services in isolated, rural and under-served areas, but this has not proved to answer all the needs of rural regions.(21)

   C. Distribution of Health Care Facilities

The distribution of hospital services reflects the uneven supply of medical personnel. A major problem for people in rural regions is the distance they have to travel to reach medical facilities. As well as adding to the discomfort of the ill person, travelling requires time and money. In many small rural communities there are no hospitals and, though the larger rural centres may have hospitals with basic facilities, patients have to be transported to larger urban centres for specialized treatment. In Ontario, for example, larger rural communities have hospitals that provide essential services such as 24-hour emergency care, obstetrics, anaesthesia, and general surgery. Smaller hospitals may provide surgery and obstetric services but these provisions are dependent on anaesthetists, who are often difficult to recruit to rural areas.(22)

Unlike large urban centres, rural areas offer a limited choice of hospitals. This can become an issue if a hospital has made a decision not to provide certain services. In some provinces, for example, hospitals are operated by religious orders that do not provide abortion services and people seeking these services must travel to other centres.

   D. Under-Servicing of Health-Related Services

An important aspect of health promotion in Canada is the creation of the "healthy environment."(23)  The environment consists of "the buildings where we live, the air we breathe and the jobs we do, as well as the education, transportation and health systems."(24) Fully addressing the disparities in rural health within the context of the healthy environment involves going beyond medical care to include issues of poverty, unemployment, environmental health, workplace health and safety, child care facilities, and quality of housing.

The provision of social services, education, and job training influence people's quality of life, and ultimately their health. Rural communities often lack the services of counsellors, therapists, social workers, and child care workers. This problem is exacerbated by a lack of information and support in a number of areas such as sex education for children and youth, information on the adverse effects of drugs, alcohol and smoking, education about childbirth, breastfeeding and infant care, healthy eating, parenting, and the prevention of violence in the home.

   E. Under-Servicing of Special Needs Groups

Many people have needs for special services in addition to basic health care. These needs, which can be acute (emergencies) or long-term (chronic diseases), are often not easily met in rural environments. Six categories of people with unique and specialized health care needs are examined below. They include: women, children, adolescents, immigrants, disabled people, and the elderly.

      1. Women

On average, women in Canada live longer than men but they suffer from more ill health and are more frequent users of the health care system.(25) Women's contact with the system is often related to their reproductive health. They may require special services to deal with problems to do with menstruation, unintended pregnancies, infertility, sexually transmitted diseases, birth control, childbirth, new reproductive technologies, and menopause. However, gynaecological/obstetrical services are often not readily available to women in rural regions. The rise of female cancers, particularly breast and ovarian cancer, raises the issue of the availability of cancer treatment facilities in rural regions.(26) Rural women may thus be forced to travel (at considerable expense and discomfort) to urban centres where the required facilities are available.

Violence against women is a serious problem in both rural and urban Canada.(27)  Rural women face additional problems of isolation, absence of privacy, and in some cases, limited mobility. One rural women explains, "You have no idea how important 1-800 numbers are in these areas....Most help is long distance, so the call will be on the husband's telephone bill at the end of the month." Moreover, telephone party lines invade the privacy of women: "It's pretty damn intimidating to call for support. It's not rare to hear someone listening to my calls or for someone to pick up the phone and join the conversation."(28)

Farm women who leave abusive situations often do so at great economic cost. Unlike many of their urban counterparts, farm women's work is usually directly linked to that of their spouses, and their job experience is on the farm.(29) In other words, when farm women leave an abusive situation they also leave their jobs, a fact that can make leaving more difficult. One woman told the panel of the Task Force on Violence against Women that "her husband becomes most abusive at harvest time. Because she has an economic interest in getting the harvest off, she puts up with the abuse."(30)

The shortages of women's shelters in Canada is more pronounced in rural areas, and women may have to travel vast distances to reach one.(31) The House of Commons sub-committee on the Status of Women heard in 1991 that some women in Saskatchewan had to travel 500 miles to reach a 16-bed shelter.(32)

Women may not be able to leave abusive situations because they do not have any money, they do not have access to vehicles, buses and trains do not travel through many small rural centres, and the nearest telephone may be miles away.

      2. Children

Most Canadian children are physically healthy and do not require the services of medical specialists. In cases where a child is seriously ill, the rural family, particularly if living in an isolated community, faces serious problems. Required services may be difficult to reach, compelling the sick child to travel long distances and spend long periods away from home and family while undergoing treatment. Distance may make it impossible for parents (or siblings) to stay with the child, or even to pay regular visits. In some cases, one parent may stay with the child while the other remains in the family home with the other children. Either situation causes serious stress on the family and on the ill child who may feel alienated, lonely, homesick and afraid--conditions not conducive to convalescence.

Health promotion and education tend to be underdeveloped in many rural communities.(33) Like all children, those living in rural areas could benefit from early exposure to health promotion information on matters such as healthy diets healthy sexuality, fitness, positive human relations, the dangers of drug abuse, alcohol abuse, smoking, and violence.

Abused children in rural areas face some of the same frustrations as rural abused women; namely, geographic isolation and lack of information, mobility, and support services.

      3. Youth

Adolescence is a period during which children are developing into adults. These transition years involve pronounced physiological changes, such as rapid growth and sexual maturation as well as emotional development and identity formation. For many young people this period of life is stressful; adolescents may be concerned about poor body image, which can lead to eating disorders such as anorexia nervosa and bulimia and problems with sexual identity, sexuality, school work, family relationships and interpersonal relationships. Particularly frightening has been the dramatic increase in the number of youth suicides over the past 20 years, especially among 15-19 years old males.(34)

Unsafe sexual activity can result in unwanted pregnancy and/or sexually transmitted diseases (STDs), including HIV/AIDS and chlamydia. Although the devastating effects of AIDS are well established, studies suggest that adolescents are not modifying their behaviour to protect themselves against this disease.(35) Chlamydia is the most common sexually transmitted disease amongst youth; rates of infection have been rapidly rising over the past years, particularly in the 15-19 year old age group. Since chlamydia is usually asymptomatic, it is particularly dangerous; like other STDs, it can lead to pelvic inflammatory disease (PID), which can put fertility at risk.

A number of adolescents use alcohol and drugs; studies indicate that in recent years more women than men between the ages of 15 and 19 are smoking.(36) The negative health effects of drug and alcohol abuse and smoking are well documented, yet this information has not made a major impact on adolescent behaviour.

Some of the problems facing adolescents can be circumvented with education and adequate support services, including drug and alcohol abuse counselling, birth control information, STD clinics, social workers, family counsellors, and nurses. In rural regions, however, these services are rare, if not absent altogether.

      4. Disabled Persons

Rural areas have a disproportionately high proportion of long-term disabled people compared to the urban population.(37) There are two types of problems that disabled people are more likely to encounter in rural, rather than urban settings: a lack of specific needed facilities and a lack of access to the standard services.

Disabled people often require specialized services such as surgery, physiotherapy, dialysis, chemotherapy and counselling. These specialized services may not be available in smaller rural centres, so that the disabled person must travel to reach them. If the person is a child, an elderly person, severely disabled or seriously ill, travelling becomes even more complex because the assistance of another person may be required.

Disabled persons living in rural areas encounter the additional problem of access to services that are generally available to other people. Ramps, elevators, sloping curbs, automatically opening doors, grab bars in washrooms, and washrooms that can accommodate wheel chairs are only starting to be introduced into such areas. Moreover, special transportation for the disabled person is usually not available in rural areas, making the rural disabled person more dependent on family and friends for medical appointments, social engagements, and work.

      5. Immigrants

Inadequacies in health services and informational material in rural areas are more pronounced for recent immigrants, especially immigrant women, since women have more contact with the health care system. Some problems are "lack of information about services, insensitivity on the part of health care personnel because of cultural practices, and problems associated with services designed for a mainstream population."(38) In some cultures, for example, women are used to delivering their babies in their own homes with the help of a midwife, yet midwives in rural Canada are almost non-existent.

An immigrant woman may not able to communicate her problem effectively and as a result receive inappropriate diagnosis or treatment for a medical problem. Language training centres are not as available in rural communities and women generally have less access to them than do immigrant men.(39)

      6. Elderly People

Seniors (those 65 years and older) in Canada are over-represented in rural regions. In 1991 close to one third of Canada's seniors lived in rural areas and small towns.(40) Seniors are also the largest consumers of health care.

A number of health problems are particularly prevalent among elderly Canadians, including depression, dementia (including Alzheimer's Disease), osteoporosis, malnutrition, and loss of bodily functions (sight, hearing, mobility, continence). All of these may require specialized medical care and support services. Travelling long distances to reach required services is particularly challenging for seniors with mobility problems.

The majority of senior Canadians live independently and studies repeatedly show that independence is a crucial factor in seniors' housing choices.(41) The capacity to live independently, however, depends upon a number of factors, including health, financial status, and the availability of support services, which include professional services, such as medical or personal care. Over the years, a number of support services have been developed to help seniors but many of these services - meals for seniors, special transportation, homecare, visiting homemakers, social and recreational programs, and counselling and information - are available only in larger urban centres.

Although most rural residents, particularly those who live in isolated communities, experience difficulties with access to services and information, residents of specific regions and workers in specific occupations face additional or unique health concerns. Some of these concerns for three samples of the rural population are highlighted below.

   A. Farmers

According to the 1986 census, approximately 3.8% of the Canadian labour force were employed in the agriculture industry.(42) Although there are many different types of farming (e.g., cattle, fruit, vegetable, dairy, grain, mixed), each with its own specific health and safety risks, some health concerns are common to most farmers, farm families and farm labourers.(43)

Farming is a hazardous occupation; farmers, farm workers and farm families(44) are routinely exposed to health hazards from use of chemicals (pesticides, insecticides, fertilizers), dangerous machinery, infectious diseases, noise, and stress.

Mounting evidence in the scientific literature indicates that exposure to farming chemicals may lead to greater risks of certain cancers (e.g., cancer of the stomach, testes, and brain).(45) Chemicals have also been implicated in neurological diseases, skin disorders, and reproductive health problems in both men and women (e.g., disrupted sperm production, menstrual irregularity, spontaneous abortion, stillbirth, neonatal death, infant mortality and congenital anomalies).(46) People on farms often suffer from lung disease (e.g., "farmer's lung" from exposure to mouldy hay, "silo filler's" lung from exposure to oxides of nitrogen from unventilated silos, and asthma), infectious diseases (e.g., leptospirosis, salmonella, brucellosis, tularaemia, Q fever, ornithosis, toxoplasmosis) carried by several animals, hearing loss due to exposure to noisy machinery, and musculo-skeletal diseases related to repetitive motion and adverse ergonomic conditions.(47)

Work-related accidents are also common in farming; the tractor is a central agent in farm accidents but other machines such as grain augers, balers, combines and power shafts are also implicated.(48) An estimated 150 to 200 people die from farm-related accidents each year in Canada,(49) and accidents to children are increasing at alarming rates.(50)

Farm work, especially grain, fruit and vegetable farming, is regulated largely by weather; when crops are ready and the weather permits, farmers work extended hours. During these seasonal peaks most members of the farm family may be required to help. If there are small children in the home, child care becomes an urgent need. The children are sometimes required to look after themselves or must accompany their parents in tractors, combines, and trucks.(51) This very dangerous situation has caused deaths and injuries and has become the issue of a grass roots movement amongst Saskatchewan and Alberta farm women, who are calling for rural child care services.(52)

Although stress is not unique to the farming industry, it has become a big problem there because of increasing economic pressures from low market prices, high interest rates, and drought. The economic pressures confronting prairie farmers have created incredible uncertainty in the lives of farm families,(53) and the stress is felt by all family members, including children.

   B. People of Aboriginal Origin

The federal government has jurisdictional responsibility for Canada's Indian and Inuit populations. When it comes to health and social services, the federal government is responsible for those populations living on reserves; however, there is ongoing discussion about transferring this authority to band councils.(54) For status Indians and Inuit not living on reserves, the federal government provides access to the provincial medicare systems and supplemental programs and covers provincial health insurance premiums and user fees.

Through the Department of Health and Welfare, the federal government provides "non-insured" health benefits to Indians and Inuit living both on and off reserves. These services include medical transportation of patients, drugs, glasses, orthopaedic appliances and supplies and dental services.(55)

Approximately 3% of the Canadian population is of aboriginal origin (Indian, Metis, Inuit).(56) These people have traditionally been concentrated in rural regions (on reserves or in small communities); however, they are increasingly moving to urban centres in search of employment. According to the 1986 census, slightly less than three-quarters of the Canadian population of aboriginal origin are now living outside reserves.(57) Their educational levels and labour market participation are closer to that of the total Canadian population than to that of their on-reserve counterparts, but they still have higher rates of unemployment, lower levels of education, lower income patterns and poorer health than the rest of Canadian society.(58)

The poor health status of Canadians of aboriginal origin is most marked in the Indian population living on reserves.(59) Like unemployment, illiteracy and poor housing, the lack of availability of, and access to, health information and services are linked to poverty. Populations living on reserves have higher mortality and morbidity rates than the total Canadian population; their life expectancies are estimated to be ten years less than the national average.(60) Residents of reserves have higher rates of diabetes, respiratory and infectious diseases, anaemia, gall bladder disease, lung disease, hearing impairments, vision, dental, and mental health problems, alcohol and drug dependence, and violence.(61) In a study conducted by the Ontario Native Women's Association, 84% of respondents (45% of whom lived on reserves, and 62% of whom lived in communities of under 2,000 people) reported family violence in their communities.(62) Abused women on reserves face the same problems of isolation and transportation as other abused rural women.(63)

On reserves, infant mortality and postnatal mortality rates are respectively 60% and 100% higher than those for Canada as a whole.(64) Moreover, the incidence of suicide is more common among aboriginal populations on reserves, as is the incidence of all violent deaths and disabilities. Young people are at higher risk for contracting sexually transmitted diseases (especially chlamydia and gonorrhoea), including HIV infections.(65) There is also the growing problem of teenage pregnancies.

The causes of the poor health status of aboriginal people living on reserves are complex and result from "centuries of oppression, of the domination of one society by another."(66) Poor conditions of housing, high illiteracy rates, high unemployment, and poverty are also relevant.(67) In addition, there is a shortage of health education materials and of health educators, nutritionists, therapists, and mental health workers who can communicate with residents of reserves. In Canada, most health information is disseminated by televised public service announcements or by printed materials, neither of which may be appropriate for remote communities or communities with high rates of illiteracy.(68)

A role for traditional aboriginal medicine in the health care system has been an issue for aboriginal peoples for many years.(69) Currently the government of Saskatchewan is attempting to incorporate traditional aboriginal medicine into a redesigned Saskatchewan health care system. The Saskatchewan Commission on Directions in Health Care states that:

Within the culture of the Indian population, the medicine man provides a special service that touches on the meaning of life and on the relationships between an individual and the realities which are beyond him or her. It is a very personal service which cannot be defined within constrictive parameters because it will vary with persons and with circumstances. However, it must be recognized as important, and it must be seen as complementing the scientific and clinical approaches used by the formal health care system in our society.(70)

In recent years, efforts have been made to encourage Canadians of aboriginal origin to attend medical schools. In 1990, however, there were only an estimated 17 native doctors in Canada, most of them practising in Ontario, Manitoba and Alberta.(71)

   C. Maritime Fishermen

Two important facets of the lives of fishermen and their families undoubtedly have major implications for their health status. First, it is clear that fishing in Canada (east coast, west coast and inland) is replete with serious health hazards.(72) Each year fishermen are lost at sea, or drowned, but "unless there is a multiple drowning or the loss of a boat, it does not receive much comment."(73) As well, fishing is a highly developed industry that uses complex machinery (e.g., winches) with the potential to cause serious accidents.(74) Fishermen are injured on boats each year in Canada and there is continuing discussion about how health and safety education and regulations can help alleviate this problem.(75)

The second factor is poverty. Since fishing provides seasonal employment, low incomes are part of the fisherman's life, and Maritime fishermen and their families are regularly dependent on unemployment insurance to supplement their incomes.(76) Even with unemployment benefits, "as many as one in three full-time fishermen and their households live below the rural poverty line."(77) The direct relationship between poverty and health has been well documented; poverty is regularly accompanied by malnutrition and disease.(78) In regions where poverty exists there is a strong need for increased medical facilities and social support services.

CONCLUDING REMARKS

Clearly there are barriers to good quality health care in rural and remote communities in Canada. Availability of and access to medical services are often perceived as the major problems, but, although these are important, many other complex factors influence the health status of rural Canadians. In many cases these barriers to health have their origins in larger systemic problems in society; rural residents are confronted with particular hazards to their health and safety. Moreover, the general socio-economic climate for employment, income, and the environment has important implications for the health of rural Canadians. Solving these problems will undoubtedly require a range of comprehensive and multi-faceted social strategies.

(1) World Health Organization, International Conference on Primary Health Care, World Health Organization, Geneva, 1978.

(34) National Task Force on Suicide in Canada, Report: Suicide in Canada, 1987, p. 30.

(50) Task Force on Health and Safety in Agriculture (1985), p. 27.

(51) Annual Farm Safety Hike Program, 1991 Report, Edmonton, Alberta; Information sheet on Alberta Rural Childcare Pilot Project Committee.

(54) Health and Welfare Canada, Annual Report, 1990-1991, p. 18-19. The precise provincial/territorial-federal division of power over aboriginal health care is not entirely clear. Although the federal government has responsibility for Indians on reserves, health and social services are not specifically addressed in legislation. The provinces' traditional refusal to extent their jurisdiction to reserves gradually resulted in the federal government's role of funding health services on reserves.

(55) Jack Woodward, Native Law, Carswell, Toronto, 1989, p. 388.