Why are rural communities more vulnerable to Covid-19? – Expert Q&A

The latest Covid outbreak has so far centred on cities – but now with Northland and parts of Waikato at heightened alert levels, what are the risks for rural communities?

New University of Otago research has found vaccination is 11 per cent lower in rural areas. Compared with the total NZ population, Māori are more likely to live in small towns and rural areas.

The SMC asked experts about the Covid risks in rural areas. 

Dr Mataroria Lyndon (Ngāti Hine, Ngāti Whatua, Waikato), Senior Lecturer in Medical Education, University of Auckland, comments:

Why are rural communities more vulnerable to Covid-19?

“There are geographic barriers to accessing healthcare and services generally, including COVID testing and vaccinations. If COVID-19 spread within rural communities there would be greater challenges in accessing care, providing healthcare, and pressure on local health services too.”

How does access to health services differ from urban areas?

“There are differences in access to health services in some rural communities like the Far North where there are shortages of health professionals or ability to enrol with a GP. Geographic barriers or the distance needed to travel to health services is also a burden for rural communities. Outreach/mobile services for testing and vaccination is an important strategy in addressing some of the barriers rural communities face.”

What will be the issues when someone living rurally needs more specialised Covid-19 hospital care?

“They will likely need treatment at a secondary care hospital particularly if ICU level care is required. They will be further away from home and whānau support. More COVID cases in regional/rural hospitals could also impact on capacity for managing other health conditions.”

What unique challenges face rural Māori?

“There are barriers to accessing care (as outlined above), however, Māori are also likely to have more comorbidities, substandard housing, and less likely to be enrolled with a GP or access health services so are at greater risk from COVID-19 and severe disease.”

Conflict of interest statement: Dr Lyndon is co-founder and Clinical Director at Tend Health.

Katharina Blattner, Senior Lecturer, Rural Health, and Pacific Island Nation Liaison, Va’a o Tautai, University of Otago, and Rural Doctor (Rural Hospital Medicine and General Practice), Hauora Hokianga, Rawene Hospital, Northland, comments:

Why are rural communities more vulnerable to Covid-19?

“There is often higher socioeconomic deprivation (poorer, less education), poor housing , poorer health including co morbidities, long distances to access health care especially advanced or tertiary hospital care, limited health services in rural areas including very limited ambulance services, diagnostics, and limited connectivity. Also, there can often be a generally negative discourse from the rest of the country regarding rural communities – viewing rural areas as less of a priority. Only a limited body of research is available on rural health, it is a small new academic field – more research is needed.”

Why are vaccination rates lower in rural communities?

“A combination of: distance, being treated as the lowest priority – last in line – and access times for immunisation are often limited. For example, small local health teams are often providing the service along with all the other health services 24/7.

“Those working on the land and with commitments to dependent whānau can’t get to vaccination services at the time they need to, and there is no trusted person or service to explain and administer the vaccine. In contrast to other vaccines (eg tetanus, measles etc ), there is no possibility of opportunistic vaccination with COVID 24/7, as it is not held by local health services and due to the storage logistics of this vaccine. Connectivity is poor – no cell phone coverage, no internet – so making a booking is too hard / out of reach, and a final problem is distrust.”

What kinds of distances are some rural people needing to travel to get the vaccine?

“There is a long distance to services, the state of rural roads are very poor (in many places, including the Far North) so it takes longer. There is poor or no public transport in rural areas, as well as a higher cost of travel. Some people have no registered vehicle and no money for petrol.”

How does access to health services differ from urban areas?

“The rural context is all important in understanding that rural health services are not simply a ‘mini-version’ of the city health services set-up. Geographical distance and smallness demands different approach – small teams of clinicians (medical, nursing, allied health) work closely covering very broad scopes of practice at the primary-secondary interface, in community and rural hospital settings – over 24/7, 7 days a week.

“The more rural-remote, and the further from big-city services, the more blurred is the boundary between primary care and secondary care. Rural clinicians have to manage anything that comes through the door 24/7 at least initially and with small spaces, limited assistance and limited diagnostics (eg they may not have an on-site lab or X-ray), plus there is not easy access to ambulance or retrieval services.

“The situation is worsened by the erosion of rural health services over decades. Rural health services are the end of the drip line. The rural GP shortage is serious. With respect to medical services, in general only 2 specialties work in rural areas:  General Practitioners and Rural Hospital Medicine specialists. Shortages in both areas have been well-documented over decades. The rural nursing shortage is even worse.

“The guidance from the primary care sector, including the College of GPs (RNZCGP), is often not relevant for health professionals in rural areas. For example, they are advised to consult virtually only, but this is not an option as they provide 24/7 care including providing all urgent/emergency care – so they need to attend to patients!”

What will be the issues when someone living rurally needs more specialised Covid-19 hospital care?

“The absence of access to advanced respiratory care in rural health centres and rural hospitals – except for immediate emergency treatment – is a problem. As above, there are no anaesthetists, anaesthetic nurses, or ICU specialists in rural areas. There is no equipment, and only limited diagnostics, eg no lab, no X-ray.

“The transfer to secondary or tertiary care is often not easy to arrange / access is poor. St Johns Ambulance’s national protocols are not aligned to local ones – and there is often no local context knowledge. It is difficult to get an ambulance rurally – there are long wait times, and no one available to accompany the transfer – there’s often only one nurse on duty at night in rural areas, so that nurse can’t be sent on transfer. There are small spaces that are multi-purpose, and limited rooms /equipment.

“In order to get a patient transferred from a rural area, they first have to be ’accepted’ by a specialist at base/tertiary hospital.  When calling a specialist about a sick rural patient in a COVID pandemic situation, it is likely that patients right in front of the specialist – at the tertiary centre ED/ICU – would get priority. There are no clear policies around the transfer of these potential patients. Also, organising a helicopter retrieval takes a lot of resources, and may not be granted.” 

What unique challenges face rural Māori? 

“Rural Māori have the lowest socioeconomic status. Other challenges are poor connectivity, co-morbidities, and institutional racism making it harder to navigate the system.”

No conflict of interest declared.

Fiona Doolan-Noble, Senior Research Fellow in Rural Health, University of Otago, comments:

“The Covid-19 pandemic has repeatedly exposed fault lines within society and a health system based on the value that public services are available to everyone. Culturally-based health inequalities being a clear example. Rural is potentially another. The questions asked here are focused on deficits rather than strengths – however, the multiple assets within rural communities and how these are activated during a pandemic is worthy of consideration.”

Why are rural communities more vulnerable to Covid-19?

“Rural people have been left out of most research on the impacts of the COVID-19 pandemic so any understanding is limited. Rural residents are more likely to be older and to have a chronic health condition exacerbating the effects of COVID-19.”

Why are vaccination rates lower in rural communities? 

“It isn’t just distance – it is also the condition of the roads, road slips, gravel roads. Also due to higher levels of people on lower incomes, not everyone in rural areas owns a means of transport, neither does everyone have access to the internet.”

How does access to health services differ from urban areas?

“Specialist services are much harder to access. In May last year the Ministry of Health assessed the capacity of ventilators and ICU beds, which shows the lack of access to specialist care in rural regions. Rural areas have both lower access to timely specialist care, and fewer intensive care beds per capita.

“The rural GP shortage is serious, but it isn’t just the shortage – it is the increase in workload and complexity linked to the older rural population, and their associated multi-morbidity. Nurses are very much at the frontline and therefore at high risk.

“Generally, rural and remote services are generally made up of smaller teams than urban services. Consequently, small gaps in the workforce are felt more intensely. For example, if absence increases due to sickness or isolation requirements, these teams will be at more risk of fatigued related to vaccine roll out programmes.

To date recognition of the role and contribution the non-regulated health workforce, lay health navigators, kaiawhina, have made to support the vaccination programme and contact tracing in rural areas has not been fully acknowledged.”

What are the risks or concerns where a farmer tests positive and has to isolate?

“There is a key issue with workforce numbers available within the agricultural and horticultural workforce. For farmers this means more reliance on family members to undertake the work during the pandemic. Inability to take time off from the farm is a recognised factor in mental health and wellbeing within the sector.

“At the end of the day, COVID-19 is yet another uncertainty in the uncertain world of farming, adding to the recent stressors of the Mycoplasma bovis eradication programme, new water regulations and the ute tax, which themselves are additional to the routine stressors farmers face – commodity prices, the weather and increasing regulation. Furthermore, COVID-19 is disrupting not only access to qualified workforce but also supply and demand within the food sector in complex ways.”  

No conflict of interest.

Dr Jesse Whitehead, Research Fellow, Te Rūnanga Tātari Tatauranga – National Institute of Demographic and Economic Analysis, University of Waikato, comments:

Why are rural communities more vulnerable to Covid-19?

“Many rural communities have a higher proportion of population groups that are at risk of severe outcomes from Covid-19 infection. This includes Māori, older people, poorer people, those living with underlying health conditions – all populations who are more likely to become hospitalised, require ICU, or die as a result of Covid-19 infection.”

Why are vaccination rates lower in rural communities? 

“Although there are multiple factors at play, one key component in lower Covid-19 vaccination rates for rural areas is likely to be the accessibility of vaccination services. Rural residents are required to travel further to their nearest vaccination service – a median of 10mins in rural and 20mins in remote areas, compared to 3mins in cities. Priority populations, including Māori, older people, socioeconomically constrained people, and also residents of rural areas have had worse access to Covid-19 vaccination services.

“In some parts of the West Coast and Central North Island communities would have to drive 1.5 – 2 hours to their closest clinic. It’s also worth remembering that these measures are drive times that are compounded by socioeconomic deprivation in areas where there is often scant public transportation. Furthermore, many rural vaccination services run at reduced opening hours – which may not align with the schedules of working rural people.”

No conflict of interest. Note that Jesse Whitehead is an author of the University of Otago research just released.

Associate Professor Garry Nixon, Department of General Practice and Rural Health, University of Otago, and rural doctor at Dunstan hospital, Clyde, comments:

Why are rural communities more vulnerable to Covid-19?

“Relative to other geographic categories, rural towns have: 1) Older age structure  2) Lower socioeconomic status  3) Higher levels of dependency 4) Higher proportion of Māori, and 5) Poorer access to health services.  All these factors increase their vulnerability to Covid.

“The experience in the US, and other countries, has been that while the cities bore the brunt of the first wave, subsequent waves had a greater impact in rural areas. Rural areas had both higher infection rates and higher case fatality rates.”

Why are vaccination rates lower in rural communities? 

“This will be multifactorial but access to vaccination is an obvious factor. There may also be a sense that COVID-19 is still a distant problem not affecting them.

“Lower vaccination rates have also been noted in rural areas overseas. In the US only 46 % of rural residents are vaccinated compared to 60% of urban residents.”

How does access to health services differ from urban areas? 

“Rural communities are more reliant on primary care and small generalist and hospitals. Generalist doctors nurses and others provide a lot of the services in rural areas that in the cities are provided by larger hospitals. The one small healthcare team is often trying to do everything in a rural community.  In order to access specialist emergency and other care rural patients have to travel to the city.

“There is a severe and chronic shortage of doctors and other health professionals in rural areas including nurses. Many rural health services are reliant on locums. The shortages are not new but their impact will be exacerbated by the pandemic.

“Rural health services are not geared up, or resourced, to manage large numbers of visitors and many have struggled to cope with city dwellers shifting to rural areas to sit out lockdowns.”

What will be the issues when someone living rurally needs more specialised Covid-19 hospital care?

“Patients with very severe COVID require advanced respiratory support. This will necessitate transfer to urban hospitals with these capabilities. Transporting highly infectious patients needing respiratory support is complex and resource intensive. There is already considerable pressure on inter-hospital transfer services from rural to urban. If the number of cases is high the inter-hospital transfer services may struggle to cope with the demand.

“Many small rural hospitals lack the negative pressure rooms and space to isolate COVID-19 from other patients. Rural hospital lack ‘surge capacity’ – that is they don’t undertake a lot of elective procedures that they can cancel in order to create space and free up staff. They are drive by acute demand.  Rural health care teams are small and interconnected with the risk the entire team may need to go into isolation when one team member gets infected.”

What are the risks or concerns where a farmer tests positive and has to isolate?

“Delta brings down the whole household not individuals, which in this situation is the entire workforce of an essential business with jobs that can’t wait, as they often involve animal welfare. Rural people have to travel to access services and food.”  

Given that many rural and semi-rural areas rely on septic tanks to treat wastewater, how reliable is wastewater testing in rural areas? What are alternative strategies for surveillance?

“This is not my area of expertise. But yes, obviously wastewater surveillance won’t work in communities without shared wastewater systems. I am unsure, even when they exist in smaller communities, that they are being monitored. The public health experts may have other ideas but there may be no alternative in these communities other than testing individuals.”

No conflict of interest. Note that Garry Nixon is an author of the University of Otago research just released.

Dr Kyle Eggleton, Associate Dean – Rural Health, Department of General Practice and Primary Health Care, University of Auckland, comments:

Why are rural communities more vulnerable to Covid-19?

“As colleagues from the University of Otago have demonstrated, rural areas have lower rates of vaccination than urban areas. Partly this is explained by geographical distance, for example their analysis showed that the further a person was away from an urban setting the more likely they are to not to have had a vaccination.

Why are vaccination rates lower in rural communities?

“Vaccination centres have been set up in a number of rural locations, but these are still moderate-sized towns. A good portion of the rural population lives away from towns and travel to these rural locations for vaccinations is still problematic. In the early days of the vaccination roll-out the Ministry of Health set very stringent criteria on the requirements for health providers to deliver vaccinations. Guidelines included instructions on how many health workers or assistants a provider needed to have in a vaccination centre and this, along with the initial requirements around very cold refrigeration of the vaccination made it very difficult for rural providers to operate innovative ways of delivering vaccinations.

“In addition, the small number of people in each rural location and the time it takes to set up a clinic and then move onto the next location mean that you are not going to get the efficiencies or economies of scale seen in urban settings. Those providers, that have successfully vaccinated large portions of their population had to essentially buck against and resist the bureaucracy of the MoH and DHBs. Only now are we starting to see innovation which means that rural health providers have had a delayed start to vaccination as innovation is required to overcome the tyranny of distance.”  

What unique challenges face rural Māori?

“However, a focus on geographic isolation, or lack of access to health care only accounts for a portion of the barriers facing rural areas. As you have pointed out Māori have lower rates of immunisation due to a number of reasons – such as bias operating in the health system, a failure to adequately finance or allow rural Māori health providers to undertake their own programmes, and historical mistrust of the health system due to racism and ongoing inequity.

“These concepts bring into play what I refer to as the compounding inequities that explain rural inequities. In other words we have layers of inequities – Māori health inequities, such as I have described, socioeconomic inequities which I will describe later, access issues to health care, and infrastructure inequalities (i.e. limited broadband access or cellphone coverage or poorer roading that enables people to make a booking for a vaccination).”

What unique challenges face people on low incomes?

“In regards to socioeconomic inequities, rural populations are more deprived in general than urban settings – meaning that filling up the car with petrol to travel to a vaccination centre in a town 30 min away is going to be a problem. Some patients will have to travel about an hour to get to a vaccination clinic. In addition there is a relationship between working in a lower paid job and having reduced power/ability to negotiate with an employer to take time off for medical reasons i.e. vaccination.

“Agricultural work, which obviously predominates in rural areas, have longer unsociable hours that don’t fit nicely into the schedule of a vaccination clinic. Imagine for example a forestry worker who gets up at 4:00AM in the morning to travel to a forest and then returns at night. If you have a look at the opening times of vaccination clinics and GPs there are very few open after hours.”

How does access to health services differ from urban areas?

“The rural health workforce is stressed although probably as not as stressed as the urban GP workforce at present. Recent work that we have undertaken at the University of Auckland has shown that COVID has caused higher levels of stress in urban GPs compared to rural GPs. The 2019 RNZCGP workforce survey showed that the rural GP workforce was older, that there is a higher reliance on overseas trained doctors in rural areas and was a workforce more reliant on short term employees. Shortages in getting to see a doctor of course means that care might be impacted. The workforce shortage likely extends to other professions although there is limited data available.”

What will be the issues when someone living rurally needs more specialised Covid-19 hospital care?

“In regards to needing more specialised care, of course there are no ICU beds in rural hospitals. Some rural hospitals have the ability to ventilate someone for short periods of time in an emergency but are not  generally set up with negative pressure rooms in their emergency room. Likewise large rural general practices would struggle safely managing someone presenting short of breath due to COVID.

“The more likely scenario that we will see in rural areas, based on overseas experiences, is an increasing burden of managing unwell people in the community who are not sick enough to go to hospital or who are sick, but there is not enough space for them in hospital.

“In overseas situations GPs have managed this burden by monitoring people at home. This requires access to cheap portable oxygen monitors to monitor a person’s oxygen levels, as well as having the ability to initiate modern treatments in the early stage of a mild-moderate infection such as mono-clonal antibodies that require intravenous injection. Rural GPs have not been provided oxygen saturation monitors nor are they in a position to start delivering mono-clonal antibody therapy. Delays in access to care will be more pronounced in rural settings and are likely to impact on mortality and morbidity.”

What are the risks or concerns where a farmer tests positive and has to isolate?

“The risks for farmers are that of course they will be unable to maintain looking after their farm/herd. This has implications for animal welfare, but of course the viability of the farm. There will be a heavy reliance on neighbouring farmers to help out, which will add to the stress already experienced by farmers. Agricultural workers (mostly employees) generally have higher rates of mental health problems than other occupational groups.”

Given that many rural areas rely on septic tanks, what are alternative surveillance strategies?

“Only large rural towns have wastewater plants, and small locations are reliant on septic tanks. There are no other mass surveillance approaches that I can think of beyond extending saliva monitoring out into broader occupational groups, although this is likely to miss small employers and businesses that are often seen in rural settings.” 

No conflict of interest declared.

Professor Nigel French, Research Director for the School of Veterinary Science, Massey University:

Why are rural communities more vulnerable to Covid-19?

“Rural communities are more vulnerable for many reasons – see the SMC expert reaction on rural Covid from the pandemic’s start. But now we have a vaccination programme underway, this has heightened the disparity in access to health services between urban and rural areas – as evident in the lower vaccination rates.”

What are the possible impacts, including on farming households?

“If chains of transmission were to reach into rural communities, particularly the unvaccinated, the consequences could be very serious. Not only the risk of serious illness and the need for hospitalisation in vulnerable communities with poor access to healthcare, but also the effects on the workforce and farming families of testing positive and the need for isolation. Livestock, for example, need to be cared for daily – they need feeding, watering and in the case of dairy animals, milking. Smaller operations in particular may struggle to cover for staff that are sick or required to isolate for prolonged periods. Improving vaccination rates in rural areas by providing greater access is critical for reducing this risk to both human and animal welfare.”

No conflict of interest declared.