What is "rural"?

"Many studies compare rural with urban areas with respect to physician availability....

"However, there are almost as many definitions of 'rural' as there are researchers. To make a bad situation worse, it is not uncommon for authors to use the term rural without specifying what it refers to. Bosak and Perlman (1982) have reviewed 178 rural mental health and sociology articles and found that 43% of them do not include a formal definition of rural. Similarly, Ricketts and Johnson- Webb (1997) have reviewed articles on physician practice locations and physician recruitment and retention issues published in the Journal of Rural Health between 1993 and 1995 and have found wide variations in how rural was defined. Johnson-Webb et al. (1997) have noted that in the US, policy-makers in federal, state and local governments have not reached a consensus on what rural means. Inconsistent definitions often exist within an agency, such as the Health Care Financial Administration, which uses different designations of rural for different legislation-mandated programs. Furthermore, the concepts of rural and urban are not constant. Bollman and Biggs (1992), for instance, have documented the changing definitions of rural and urban as used by the Canadian Censuses of Population over time.

"In its report, the Advisory Panel on the Provision of Medical Services in Underserviced Regions (1992) of the Canadian Medical Association defines rural communities as those with a population of 10,000 or less. This definition appears to be similar to the definition of 'rural and small town Canada' used by Statistics Canada (Mendelson and Bollman, 1998). 'Rural and small town Canada' refers to the population living outside the commuting zones of larger urban centres - especially outside Census Metropolitan Areas (with population of 100,000 or more) and Census Agglomerations (with core population of 10,000 - 99,999). Statistics Canada (1997; see also Table 2.2 and Chapter 3) classifies areas into five categories: urban core (Census Metropolitan Area/Census Agglomeration), urban fringe (urban areas within CMA/CA boundaries but not contiguous with the urban core), rural fringe of CMAs/CAs, urban outside CMAs/CAs, and rural. In their study, Sanmartin and Snidal (1993) define rural physicians as doctors living in areas with a '0' as the second digit in the postal code. An agreement between the Ontario Ministry of Health and the Ontario Medical Association defines communities that have fewer than 10,000 people and are at least 80 km from an urban centre with 50,000 population or more as 'specified' or 'isolated' communities (Rourke, 1997). This is often used as a definition of rural in health services planning in Ontario. Leduc (1997) has proposed the General Practice Rurality Index.

"Each of these definitions has its attractiveness and limitations. As an illustration, Wilkins (1993) has discussed the potential of using the postal codes of the addresses of patients and health care providers in the spatial analysis of health services provision. On the other hand, the shortcomings of the Canada Post definition of rural (i.e., areas with a '0' as the second digit in the 6-digit postal code) have been noted by Wootton (1996)...

"In the US, the two most common designations used in health care delivery for classifying rural populations are the county-based 'metropolitan' and 'non-metropolitan' designations employed by the Office of Management and Budget and the 'urban' and 'rural' designations used by the Bureau of the Census. 'Non-metropolitan' counties are those counties without a city of 50,000 or more residents, or counties without an urbanized area of 50,000 or more and without a total population of 100,000 or more. 'Rural' populations are those living outside of urbanized areas in towns of fewer than 2,500 persons or in open country (US Department of Health and Human Services, 1992). The problem with these definitions is that a sizable percentage of people in census-defined rural areas live in Office of Management and Budget-defined metropolitan areas, and, conversely, a considerable percentage of metropolitan residents live in census-defined rural areas (Goldsmith et al., 1998). In order to overcome the problems of using the conventional definitions of rural, Weinert and Boik (1995) have designed the Montana State University Rural Index. This index assigns a value (degree of rurality) to each household on the urban/rural continuum using only two variables, population of the county of residence and distance to emergency care. In addition, Fickenscher and Lagerwey-Voorman (1992) have differentiated four types of rural areas: Adjacent rural areas, urbanized rural areas, countryside rural areas and frontier areas.

"Leduc is right when he opines that '(a) widely accepted and validated definition of 'rural' in the context of medical practice has not yet been developed in Canada'. Perhaps, as Halfacree (1993) has suggested, the search for a single, all-purpose definition of rural is neither desirable nor feasible. How rural should be defined depends on the task at hand. The problems facing researchers and health services planners is the inability to compare studies and findings with respect to physician availability in rural areas since the term is not used in a consistent manner. Thus, rural as a geographic unit of analysis is quite restricted in its utility. As it appears in most studies, the concept is either implicit or not consistently defined. Also, because 'rural' covers a vast territory and is not sufficiently differentiated to reflect varying degrees of rurality, it tends to mask intra-regional variations in physician availability and population dispersion. However, a rural-urban comparison can be effective in highlighting or underscoring gross unevenness in physician distribution within a jurisdiction. Its imprecision notwithstanding, the term 'rural' is unlikely to disappear from everyday parlance or from policy and planning discourse since it is such a convenient label and is so ingrained in our consciousness.

From: Roger Pitblado and Raymond Pong (1999). Geographic Distribution of Physicians in Canada. Sudbury, Ontario: Centre for Rural and Northern Health Research, Laurentian University.