A Look at Rural Health Through the Ecological Model
- rachelnazarko
- Feb 25
- 6 min read
Updated: Mar 7
Where people live has an impact on their health status and health care needs.
The definition of 'rural' can refer to a geographical concept, a location of boundaries on a map, a social representation, a community interest, a culture or a way of life (Kilty, 2007). According to Statistics Canada, 'population centers' have a population of at least 1000 people and a density of 400 people per square kilometer. All areas outside outside 'population centers' are considered rural (Stats Can, 2021). Depending on how it is defined estimates are that anywhere from 20-30% of Canada's population live in rural areas (Williams & Kulig, 2011).
Significant differences exist between urban and rural populations in terms of health status, health behaviours, health service use, costs and outcomes (Canadian Institute for Health Information). In general, rural residents are more likely to experience injuries, chronic conditions, and higher mortality rates (DesMeules, et al. 2011). These disparities should be of particular concern considering the number of rural Canadians.
The ecological model provides a useful framework to examine these challenges. This post will explore how the various factors affecting rural health in Canada can be viewed through the layers or this model.
Understanding the Ecological Model
"The ecological perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem. It highlights people’s interactions with their physical and sociocultural environments"(Rural Health Information Hub).
The ecological model of health highlights that health outcomes are influenced by several interconnected factors. These include:
Individual factors, which influence health and behavior such as genetics, age, education, knowledge, attitudes, beliefs, and personality.
Interpersonal/Relational factors, such as social connections and family characteristics which can provide support or create barriers to healthy behavior.
Community factors, such as formal or informal social norms, resources and service systems, and infrastructure that can limit or enhance healthy behaviors.
Societal factors, including local, state, and federal policies and laws that regulate or support health actions and practices for disease prevention including early detection, control, and management (Rural Health Information Hub)
The ecological perspective is a useful framework for understanding the range of factors that influence health and well-being. It is a model that can assist in providing a complete perspective of the factors that affect specific health behaviors, including the social determinants of health. Because of this, ecological frameworks can be used to integrate components of other theories and models, thus ensuring the design of a comprehensive health promotion or disease prevention program or policy approach (Rural Health Information Hub).
In rural areas, the ecological model can shed light on how these factors interact. For example, while urban dwellers often have better access to healthcare services, rural residents may struggle with geographic isolation, insufficient healthcare resources, and inconsistent health policies (Hale, Grzybowski, & Ramdin, 2021).
Individual Factors
Individual factors—like age, gender, socioeconomic status, and health attitudes and behaviors—are critical in shaping health outcomes. In rural Canada, these characteristics often contribute to notable health disparities. For example, seniors in rural communities may face unique health challenges and access barriers compared to their urban peers, including higher rates of chronic diseases such as diabetes and heart disease (DesMeules, et al., 2011).
Educational levels also significantly impact health literacy, which is essential for effectively navigating the healthcare system. In Canada, rural areas report higher levels of people with lower income and less formal education (DesMeules, et al., 2011).
Personal attitude and culture around health and lifestyle can play an important role in health outcomes, both on an individual and a community level (Hale, Grzybowski, & Ramdin, 2021).
Interpersonal Factors
The second layer of the ecological model focuses on interpersonal relationships, encompassing family, friends, and social networks. Strong social support can enhance health outcomes.
Rural residents are more likely to report a strong sense of belonging. Healthcare providers in these communities play significant roles beyond their clinical duties. They often serve as trusted advisors and sources of community support. This can strengthen relationships, but it might also introduce biases. For example, a patient may hesitate to share information with a provider who is also their neighbor (Kilty, 2007).
Community Factors
Community characteristics heavily influence health in rural areas. Interestingly, residents of rural areas report a stronger sense of community and yet they experience worsened health status. This is likely due to factors like access to healthcare resources, transportation options, and the quality of the built environment (DesMeules, et al., 2011). Rural areas frequently face a shortage of healthcare professionals, leading to long wait times and limited medical services (Kilty, 2007).
Transportation is another significant hurdle. A rural resident is likely to have to travel long distances to get diagnostic testing, see a specialist, or reach a healthcare facility, which can deter earlier medical intervention. Furthermore, the built environment—like infrastructure quality and housing conditions—affects health directly (Williams & Kulig, 2011).
Societal Factors
On a broader scale, societal factors encompass policies, cultural norms, and economic conditions that guide rural health. Government policies related to healthcare funding and delivery can significantly affect how resources are allocated between urban and rural areas.
Cultural perceptions about health and help-seeking behaviors are also crucial influences. In some rural communities, stigma associated with mental health issues and fear of lack of confidentiality can prevent individuals from seeking necessary care (Kilty, 2007)
Addressing Rural Health Disparities
Currently, there is no comprehensive national - or even provincial - rural health care strategy to address the needs of rural populations (Wilson et. al., 2020)
Addressing the distinct challenges of rural health requires a comprehensive approach that integrates all levels of the ecological model. Solutions should be diverse and can include targeting individual behaviors and local attitudes around health and also look towards optimizing community resources, including the training and recruitment of health professionals, and advocating for impactful policy changes.
A core personal value on ‘healthy lifestyle’ is one of the themes relating to positive health outcomes (Hale, Grzybowski, & Ramdin, 2021). In rural communities an interesting phenomenon can occur wherein the inherent qualities of individuals that lead them to be healthy can in turn positively influence the overall health of the community. This positive feedback loop happens when enough people in a community share healthy values. The collective mindset influences the development of infrastructure and programs through fundraising, volunteering, and the election of like-minded officials. This in turn attracts more similar people who contribute to maintaining the culture, and in time the overall health of the community improves. Within the ecological model this phenomenon suggests that, although the relationships between levels of influence are reciprocal, the mindset of the individual can be a key determinant of the health of the community (Hale, Grzybowski, & Ramdin, 2021).
As outlined above, there is evidence to indicate that local level attitudes and initiatives may improve health; but the larger system of healthcare also needs to be addressed in order to see widespread change in rural health disparities. Changing the landscape of rural health is a large and dynamic problem but some notable recommendations include: focused research on rural communities; creating community specific healthcare plans and polices that represent diverse needs through the social accountability model; and improving access to healthcare by both strengthening local services with the recruitment and retention of professionals and increasing access to regional health services by improving transport and delivery methods (Wilson, et al., 2020, & Kornelsen, J. et al., 2021). Each one of these recommendations presents multifaceted challenges, but as a person living with a lifetime of rural experience, I agree that this is the way forward.
The ecological model is an effective tool for understanding rural health in Canada. By acknowledging the interconnectedness of individual, interpersonal, community, and societal factors, we can develop effective strategies to tackle the unique obstacles rural populations face.
References
Canadian Institute for Health Information. Rural health care in Canada. https://www.cihi.ca/en/topics/rural-health-care-in-canada
DesMeules, M., Pong, R.W., Read Guernsey, J. Wang, F., Luo, W., Dressler, M.P. (2011) Chapter 2: Rural Health Status and Detirmanants in Canada. In Williams, A.M. & Kulig, J.C. (Eds.) Health in rural Canada. UBC Press. https://www.ubcpress.ca/asset/9079/1/9780774821728.pdf
Hale. I. Grzybowski, S., Ramdin, Z. (2021). What makes a healthy rural community?. Canadian Journal of Rural Medicine 26(2):p 61-68, DOI: 10.4103/CJRM.CJRM_22_20 https://journals.lww.com/cjrm/fulltext/2021/26020/what_makes_a_healthy_rural_community_.6.aspx
Johnston CS, Belanger E, Wong K, et al. How can rural community-engaged health services planning achieve sustainable healthcare system changes? BMJ Open 2021;11:e047165. doi:10.1136/ bmjopen-2020-047165
Kilty, H.L. (2007). Rural Health: A Qualitative Research Approach to Understanding Best Practices for Rural Health Service Delivery in a Public Health Setting. Haldimand-Norfolk Health Unit https://hnhu.org/wp-content/uploads/Rural_Health_Report_2007_low_res.pdf
Kornelsen, J., Carthew, C., Míguez, K. et al. Rural citizen-patient priorities for healthcare in British Columbia, Canada: findings from a mixed methods study. BMC Health Serv Res 21, 987 (2021). https://doi.org/10.1186/s12913-021-06933-z
Rural Health Information Hub. Ecological Models.
Williams, A.M. & Kulig, J.C. (2011). Chapter 1; Health and Place in Rural Canada. In Williams, A.M. & Kulig, J.C. (Eds.) Health in rural Canada. pp. UBC Press. https://www.ubcpress.ca/asset/9079/1/9780774821728.pdf
Wilson, C. R., Rourke, J., Oandansan, I.F., Bosco, C. (2020) On behalf of the Rural Road Map Implementation Committee. Progress made on access to rural health care in Canada. Canadian Family Physicican. 66 (1) pp. 31-36. PMCID: PMC7012120
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