Community Health Nursing Rural health

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Zagazig University - Faculty of Nursing
Community Health Nursing Rural health

Rural health

Outlines

 Introduction
 Definitions
 Forms of agricultural work
 General conditions and problems of life in rural areas
 Rural population at risk
 Rural health services
 Preventive services
 Curative services
 Outreach program
 Role of rural nurse
 Barriers to health care in rural areas
 Health services priorities of rural communities

Learning objectives


By the end of this lecture, the student will be able to:

 Define rural population
 Explore forms of agricultural work
 Determine general conditions and problems of life in rural areas
 Identify rural population at risk
 Differentiate rural health services
 Illustrate role of rural nurse
 Conclude barriers to health care in rural areas
 Revise health services priorities of rural communities

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Introduction
Agriculture employs half of the world labor force and an estimated 1.3
billion workers are active in agricultural production worldwide. Although the
proportion of the workforce engaged in agriculture is under 10% in the more
developed regions, the proportion is almost 60% concentrated in developing
countries. The proportion of women and children in agricultural employment
is also increasing. Women now account for 20 to 30 % of total agricultural
waged employment. Egypt is an agricultural based country. Its development
primarily depends upon rural resources.

Agriculture contributes approximately 14% of the Gross domestic product

(GDP) and absorbs about 31% of workforce. About 53% of population lives
in rural areas where directly or indirectly their livelihood depends upon
agricultural sector. Despite its positive and significant contributions to food
security/supply, economy, employment, export earnings, ecological balance,
yet the agriculture of the country faces many threats and challenges which, in
turn, affects rural development initiatives. Around the world, the health status
of people in rural areas is generally worse than in urban areas. Nursing in a
rural environment is shaped by its context. If rural nurses are to be effective
practitioners it is necessary for them to be saturated with contextual
knowledge and possess the competencies required to practice rurally.

Individuals in rural areas often have poor access to health care because of
poor accessibility and availability of standard healthcare system and socio-
cultural factors affecting their perception of health compared to the urban
population. There is a growing need to create rural communities which are
healthy and at par with health care facilities in urban areas. Therefore,
prioritizing rural health is imperative and will be a dire necessity for the
future.

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Rural health
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.

 Rural health: Is the interdisciplinary study of health and health care

system in the context of rural environment or location.

 Definitions
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 center,
settlement patterns, labor market influences, and postal codes.

 The rural: Is the community where agriculture is the chief occupation of

the population (the majority of people work in farming).
 Rural population: Are those live and/or work in rural areas. To many
people, the dominant characteristic of rural areas is low population
density.
According to Central Agency for Public Mobilization and Statistics
(CAPMAS), rural population in Egypt in the year 2021 was about 59
million, and about 28% of the total employees worked in agriculture sector.

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Characteristics of a rural community are:

1. Communities are smaller in size and sparsely populated (i.e. the
density of population is less).
2. The population shows homogeneity of language, culture, customs and
traditions… etc.
3. The main occupation is agriculture.
4. People live in close contact with nature as most of their daily activities
revolve around the natural environment.
5. People are social and culture is simple.

 There are a number of specific working situations which vary from

country to country:
a. Highly-mechanized agriculture in plantations.
b. Traditional methods in small-scale subsistence agriculture.

 Agriculture Activities covers not only farming (the practice of cultivating

the land or raising stock), but many other associated operations such as:
1. Irrigation 2. Pest management 3. Crop processing and packaging
4. Poultry 5. Fishery 6. Grain storage
7. Manure and the associated domestic tasks (carrying water or fuelwood)

General conditions and factors affect health in rural areas:

1. Demographic
 High proportion of children and elderly people.
 Disproportionate low number of young adult males.
 Women and children participate to a great extent in the workforce.
2. Socioeconomic
 Decrease in the agricultural land available with the continuous and
progressive increase in the size of population.
 Soil loss and desertification.
 Migration of farmers.
 High fertility rate lead to big family size and low income.

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3. Housing
 Poor building materials.
 Lack of internal planning and sanitary principles.
 Potential for outbreak of fire and ignition sources.
 Livestock and poultry housed in the same dwelling as the farmer.
4. Water and sewage/waste disposal
 Lack / Inadequate rural water supply system.
 Poor bathing and washing facilities.
 Use of rivers and canals as disposal facilities.
 Dung mixed with garbage as manure.
5. Nutrition
 Poor nutritional habits and micronutrient deficiency.
 High metabolic requirements due to high metabolic expenditure in
agricultural activities.
 Excessive use of Fertilizers and Pesticides lead to unsanitary food
supply.
6. Education
 Poor and inadequate education.
 Scarce teaching facilities and high absentee rate.
 Bad health habits & behaviors, and faulty traditional beliefs.
7. Transportation and communication
 Geographic isolation.
 Poor state of country roads.
 Lack of transportation facilities.
 Lack of marketing and medical care.

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The common problems in rural communities

1. Health problems
A. High morbidity: The rural people suffer from endemic diseases:
 Communicable diseases (infectious and parasitic diseases e.g. hepatitis c,
and schistosomiasis)
 Waterborne diseases (Infection commonly results during bathing,
washing, or drinking) e.g. typhoid, dysentery or diarrhea.
 Chronic diseases include heart disease, hypertension, diabetes &dental
caries or edentulism (loss of all teeth) as rural diets contain more fats and
calories.
 Chronic respiratory disease e.g. asthma, emphysema or COPD due to
long term exposure to grain dusts.
 Plant& animal allergens and zoonosis (diseases transmitted from
animals to people as rabies, plague &bovine tuberculosis.
 Nutritional deficiency diseases such as iron deficiency anemia.
 Accidents &Injuries: due to environmental condition (e.g. temperature
extremes, unpredictable circumstances, types of crops produced, and
types of machinery used.

B. High mortality:
Due to higher morbidity and less satisfactory health services, mortality is
relatively higher, especially infants and children before 5 years. Also, due to
reluctance of the people to make benefits of available health services, and
seek medical care.
 COPD & cancer mortality is high in rural areas as a result of later stage
of diagnosis.
2. Inadequate or unsatisfactory health services: Due to limited resources
and inconvenient system of work influencing the efficiency of services.

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3. Socio economic problems: Low socio economic level in any rural

community due to limited economic resource, increasing overpopulation
problem, with big Family size and low income, due to high fertility, and
low work capacity and productivity.
4. Education and culture problem:
 High illiteracy rate (more in females).
 Faulty health-related habits of the public.
 Faulty traditional, inherited deeply rooted beliefs.

Rural population at risk:

1. Women:
 Girls may be destined for a heavy work load, poor diet, early marriage
and many closely spaced pregnancies.
 Anemia is particularly common among women.
 Malnourished women are likely to have low birth-weight babies,
many of whom die in infancy.
2. Children:


 Low education and health level.

 Poor families' children may be at risk of debilitating or fatal diseases
brought on by unsanitary conditions and inadequate care and feeding.
 Infection can push children from a state of marginal undernourishment
to one of acute malnutrition.
 The children may also have to work long hours at menial jobs to
supplement the family's income.
3. Elderly:
Elderly are population of special concern for rural community health
nurses. The elderly have increased chronic disease as diabetes and
functional impairment. Rural elders rarely have close access to the

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health care that they need. Oncologist, cardiologists, neurologists, and

other specialists do not typically practice in rural communities.
4. The mentally ill people:

 Mental health services are limited.
 Health care providers need to ensure confidentiality and attempt to
reduce the stigma for mental illness for these clients.
 There are numerous risks associated with farming. The community
health nurse must help this population to identify possible hazards and
practice injury prevention.
5. Farm workers:
 Agricultural workers are at risk of exposure to hazards every day as
endemic diseases (infectious, parasitic, and nutritional diseases).
 Heavy machinery such as tractors, forklifts, and combine harvesters
can cause serious injuries.
 Toxic pesticides and other chemicals are common place on farms.

6. Chronic disease patients:

 Persons with heart disease, diabetes, and cancer often do not focus
on prevention early enough to make significant differences in health
outcomes.
 Rural residents may ignore their early cardio vascular symptoms and
give little heed to preventive intervention such as exercise and low
fat diets.

Rural health services

These are basic health services that are delivered by rural health
infrastructure, providing primary health care including preventive and
curative services. These services can be provided through rural health
centers and units.

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 Rural health center: An outpatient care facility that provides rural health
services such as primary care and routine laboratory services to rural and
often underserved communities.
 Rural health unit: An office takes charge of the effective and
economical implementation of health related services and programs.
Develop plans and strategies in the prevention and occurrence of diseases.

 Rural health services

Despite the substantial differences between developing and developed
countries, the key themes in rural health are the same around the world.
Access is the major rural health issue. Even in countries where the majority
of the population lives in rural areas, the resources are concentrated in the
cities. All countries have difficulties with transport and communication, and
they all face the challenge of shortages of doctors and other health
professionals in rural and remote areas. Rural health centers and units
provide:

 Preventive services  Curative services  Outreach program

 Preventative and positive rural health:

Counter to the curative approach that continues to dominate health policy
around the world, there is a growing swing toward more preventative
approaches in a slow response to calls by the WHO since the mid-1980s.

Preventative approaches aim to ‘design out’ (to a degree) certain

preventable and expensive health problems by tackling their major risk
factors. Responses include health services such as vaccination and antenatal
care designed to avoid the occurrence of some conditions and others focused
on early detection and early intervention in order to try to minimize the
health impact of disease as:

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 Environmental sanitation: Inspection and supervision of the

environment.
Health office functions
 Health education of the public  Registration of births, deaths and
infectious diseases
 Health office services  Compulsory active immunization
 Environmental sanitation
 Maternal and child health services
 Control measures for infected
 School health services cases and contacts

 Physical check-up: Periodical medical examination

 Survey studies

 Curative services:
 Out-patient clinic with referral system.
 Pharmacy for providing prescribed drugs.
 Some basic laboratory investigations.
 First aid and emergency services.
 In-patient service with limited number of beds (20-30) of big rural
centers for minor surgical and medical cases.

 Outreach Program:
Outreach is an activity of providing services to populations who might
not otherwise have access to those services. Key component of outreach is
that the groups providing it are not stationary, but mobile. In addition to
delivering services, outreach has an educational role, and raising the
awareness of existing services.

Out-reach program is a community-based grant program aimed towards

promoting rural health care services by enhancing health care delivery to
rural underserved populations in the local community or region.
 Types of outreach:
1. Domiciliary (undertaken at individual homes).
2. Detached (undertaken in public environments and targeting
individuals), such as streets, cafe, clubs, or railway stations.

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3. Peripatetic (undertaken at public or private environments and targeting

organizations rather than individuals), such as schools, prisons.

 Forms of Outreach Program:

A. Home visits:
Regular home visits are arranged for all houses of the area, with priority
for those having vulnerable groups.
B. Immunization campaigns:
Through coverage or completion of multi-dose vaccine of a particular
immunization.

C. Mobile units:
Through equipped mobile units and health system that provides primary
health care for some isolated communities which are deprived of adequate
health services, or small villages or communities where convenient health
services may not be available.
The role of rural services in prevention and control of diarrheal diseases
of children:

A. Preventive role:
1. Health promotion of infants and young children, especially adequate
nutrition.
 Nutrition education of mothers, for scheme of feeding and weaning.
 Providing dietary supplementation.
2. Protection of infants and young children against infection, especially the
respiratory infection.
3. Monitoring the environment: Sanitary environment is basic preventive
measure of infection.
4. Health education of mother for adequate nutrition and prevention of
infection.

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B. Control Role:
1. Health appraisal of infants and young children for:
 Nutritional status, to screen and manage cases of malnutrition and
deficiency.
 Systemic infection e.g. otitis media and bronchitis to be managed.
 Protozoal infection: Examining stool for cysts, and treatment of
infected.
2. Curative services, for management of diarrheal disease.
3. Health education of mother to seek medical care of child early.

Rural nurse role

Rural nurse is a generalist who practices professional nursing in
communities with relatively low populations that are geographically and
often culturally isolated. Commitment to provide care at the individual,
family, and community level is central to the role of a rural nurse. A strong
and varied experience base is crucial in rural nursing, as the population the
nurse care for ranges from infants to elderly (every stage of life). The nurse
may give prenatal care to a 25 yrs old woman, then treats an 80 yrs old for a
bladder infection, or teach a recent stroke victim how to get in & out of the
shower.
Core competencies/ Skills of rural nurse:
1. Physical assessment and emergency / trauma management skills.
2. Skilled in all areas of nursing (surgical, obstetric …etc.).
3. Critical care skills.
4. Management skills.
5. An aptitude for teaching.
6. In-depth awareness of cultural norms and values of the region in which
one is practicing.
7. A wide knowledge of resources within the community.
8. Ability to adapt to the resources that are available.

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9. Ability to use innovative and creative solutions.

[Link] the close interaction they have with the individuals, families,
and communities they serve.
Barriers to health care in rural areas:
 Lack of health care providers and services.
 Distance to obtain services.
 Lack of personal / public transportation.
 Lack of telehealth services.
 Unavailable outreach services.
 Inability to pay for care.
 Inadequate provider attitudes and understanding about rural
populations.
 Language barriers (caregivers not linguistically competent).
 Care and services not culturally appropriate.
Health services priorities of rural communities:
 Access to care
 Cancer (screening, early intervention, oncology services)
 Diabetes (prevention, screening, tertiary care)
 Maternal / infant and children services
 Mental illness and behavioral health services
 Nutrition / obesity
 Tobacco use
 Community based programs
 Public health infrastructure
 Immunizations and infectious diseases
 Injury and violence prevention
 Environmental and occupational heath
 Emergency medical care services infrastructure
 Long term care / assistive living facilities

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The role of community health nurse:

1. Provide care: Through direct nursing care in the home visiting, and
provide care in outpatient and clinics in school areas.
2. Facilitates health promotion for the aggregate.
3. Prepare medical equipment and medicines as needed and according
her scope.
4. Acts as advocate for the community in assisting with communication
and feedback.
5. Optimizes client use of and access to health care services.
6. Functions as a referral agent to client and community.
7. Acts as liaison between community and their health care providers.
8. Becomes a health resource for aggregate.
9. Participate in screening tests according her scope and identifies health
problem early.
10. Apply all steps of nursing process, assessment, diagnosis planning;
implementation and evaluation to achieve optimum level of health
promotion and early case finding.
11. Acts as educator for aggregates and whole community through home
visiting, school, out –patient to give health information needed about
anything.
12. Acts as a counselor to teach individuals how to depend on themselves
during solve their problems.
13. Organizes social support system for individual and families.
14. Facilitates communication process between families and communities
through acts as coordinator and collaborator role.
15. Acts as a researcher to investigate any new phenomenon or health
problem on a scientific basis.
16. Evaluates programs serving the rural residents.

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References

Bacha, U. (2022). Rural Health. (1st ed.). United Kingdom. P.p. 21-30.
Health Resources and Services Administration (HRSA). (2020). Rural
Health Care Services Outreach Program. Retrieved from
[Link]
Nies, M.A and McEwen, M. (2018). COMMUNITY /PUBLIC HEALTH
NURSING: Promoting the Health of population. (7th ed.). United
States of America: Elservier.
Novotny, J.m., Lippman, D.T., Sanders, N.K., and Fitzpatrick, J.J.
(2003). 101 Careers in Nursing. USA: Springer Publishing Company,
Inc. P.p. 162-166.
Rhodes, T. (1996). Outreach Work with Drug Users: Principles and
Practice. Council of Europe. Printed in Germany. P.p. 25-26. [Cited
2015 Apr 17], retrieved from
[Link]
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Stanhope, M., and Lancaster, J. (2014). Public Health Nursing:
Population-Centered Health Care in the Community. (8th ed.). USA:
Mosby. P. 441.
World Health Organization (WHO). (2001). Occupational health A
manual for primary health care workers, Regional Office for the
Eastern Mediterranean Cairo. P.p. 147-149.

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