There is great disparity between rural and urban health status in Australia. Rural areas in Australia have been found to have high mortality rate and the main cause of this high death rate includes chronic obstructive pulmonary disease, motor vehicle accident, circulatory disease and chronic obstructive pulmonary disease. The higher death rate in rural population is also explained due to difference in access to health services and remote environment of rural groups. The accessibility barrier to health service indicates clear difference in health service usage between rural and urban population of Australia. Hence, poor health outcome and high death rate is seen in remote area (particularly in Aboriginal and Torres Strait Islander people who lives in remote areas). Public level action has been implemented for improving the access to health service in rural areas and to improve health status of the residing people (impact of rurality on health status (AIHW), 2017). However, the rural-urban health different will not be solved simply by improving the access to health services. Other social factors like stigma and discrimination needs to be considered that affect the rural group to plan effective health promotion activities for them. The essay analyzes the rural-urban health differential by means of recent Australian data and uses the Goffman’s theory of stigma to explain role of stigma in health disparities and methods to address stigmatization in people living in remote areas and also improve the health outcome of people apart from addressing accessibility to health service.
The difference in rural and urban health care depicts geographic characterization of public health. The past research on difference in urban and rural health care suggest factors such as difference in cost, health care access and utilization and geographic distribution of health service causing disparities in health. People residing in remote areas have been found to have higher health risk behavior, poor access to health services and health risk behavior compared to urban residents. Large disparity is seen in urban environment due to difference in socioeconomic status, psychological stressors and high level of crimes in cities. On the other hand, rural residents are less likely to engage in physical activity, they have poor diet and more prone to smoking compared to urban residents (Urban Versus Rural Health - Global Health University, 2017).Therefore, apart from physical environment, lifestyle of residents also increases disparities in health outcome globally.
The global data on health outcome also proves that health inequity and difference is mostly seen in rural areas. Mostly people with extreme poverty lives in rural areas and this comprise about 70% of the world population till the year 2015. The global, national and regional data collected on the health coverage in 174 countries shows rural-urban inequities and rural deficits in health coverage. Almost 56% rural residents worldwide do not have legal health coverage. Hence, in the context of health equity, it has been found that health of rural population is not improving. The gap in health outcome is seen due to staff access deficit, employment deficit, extra health care cost and high maternal mortality ratio in this group. Although half of the world population resides in rural areas, however only 23% health staffs are deployed in these areas (Lancet, 2017).
In the context of Australian population also, rural and remote population of Australia has been found to suffer from severe health outcome compared to metropolitan counterparts. Due to increase in diagnosis of severe disease, the hospitalization rate is high. This consequently contributes to higher mortality rate and lower life expectancy than expected. This also has relation with income inequality experienced by the people of rural Australia. Low income also has an impact on health and well-being of rural and remote Australian population (Lancet. (2017).
While considering the population who lives in remote or rural areas, it has been found that Indigenous Australians mostly live in remote or rural areas. They are 12 times more likely to live in rural areas compared to rest of the population (Indigenous health (AIHW). (2017). The WHO report clearly indicates the vast disparities in health of Australia’s indigenous Aboriginals and other population. Firstly, they lag behind in health outcome due to unemployment and high imprisonment rate. Aboriginal and Torres Strait Islander people were three times more likely to unemployed compared to non-indigenous Australians (4102.0 - Australian Social Trends, 2014, 2017). The average life expectance among male is 60 years whereas the average life expectancy among female is 68 years. This life expectancy is about 17 years lower for rest of the population. The aboriginal groups, the most disadvantaged people in Australia comprise about 2.5% of the total population and they mainly suffer from diseases like pneumonia, diabetes, cardiovascular disease and others. The likelihood of contracting different diseases is also higher in indigenous population compared to non-indigenous population (WHO | Australia’s disturbing health disparities set Aboriginals apart, 2017).
Figure 1: Difference in likelihood of disease in indigenous and non-indigenous Australians. Source: (Indigenous health (AIHW, 2017).
The above discussion related to the urban-rural health difference globally and in Australia suggest that poorer health outcome in this group is seen not just due to remoteness and accessibility issues. It also occurs due to social risk present in the environment. Some of them include environmental risk, poor social behavior, stigmatization in this group due to poor educational and employment related attainment. The discussion utilizes the sociological concept and theories relayed to stigma to explain the reasons for health inequity in people residing in remote areas particularly indigenous Australians and take relevant actions in this area. This is a form of sociological imagination to understand the importance of sociology on stigma and its relevance in daily life. The analysis of different sociological theories related to stigma will help to understand the relationship between people’s personal experience and its impact on wider section of society (such as health service) (Housley et al., 2014). The understanding of theory related to stigma and its social outcome will be an effective step to understand why rural-urban health difference cannot be addressed by improving accessibility to health service alone.
Social stigma is related to the people’s experience of disapproval in society due to the origin of the person or social position in the society. Stigma is a social construction resulting from people’s perception about mental disorder, diseases, ethnicity, relationship and other social factors. Emile Durkheim was the earliest sociologist to give idea about stigma. He regarded it as a means of spoiling identity. It is based on the perception of certain traits that is thought to be deviant of social norms in society (Erikson, 2014). Erving Goffman added to the social theory of stigma by stating that three types of stigma is seen in society and these includes stigma associated with mental illness, physical deformation and stigma related to race, ethnicity and ideology. He explains that society plays a role in categorizing person and creating gap between virtual social identify and actual social identity. According to him, people can have three types of relation with stigma, either they are stigmatized or they bear the stigma. The third category is those person who sympathize with stigmatized individual (Bos et al., 2013). Therefore, on the whole, stigma is social phenomenon which arises from social relationships in society and imbued with power relations.
The Goffman’s theory of stigma has also been utilized as a concept in a sociological research to understand stigma in rural to urban migrants in China. They are marginalized group and the researcher used the Goffman’s concept to understand stigma and its inferiors social status group. According to the Goffman’s theory, stigma is a discrediting social interaction leading to social devaluation and discrimination of a person or a group. As Goffman’s theory had explained difference relationship of stigma with people, the research aimed to explore the stigmatization in rural to urban migrants by investigating the perception of both the stigmatizer and the stigmatized. The overall analysis of the result showed that rural and urban migrants are stigmatized by urban residents due to their discredited place of origin, risk of diseases and crime, physical appearance and poor financial status. The stigma arise in this group of Chinese population due to social categorization of people into superior and inferior groups. The migrants were found to be resilience against stigma and urban residents legitimated stigmatization of migrants according to the hokou system. This resul reflects stigma being influence by social context and social relationship (Guan & Liu, 2014). Similar analysis is also needed to understand the perception and consequence of stigma in rural residents living in Australia.
The sociological concepts of stigma indicates stigma as a social construct occurring when people engage in front stage and back stage behavior. This is understood from the labeling theory of stigma, which explains how people’s behavior gives another person negative or positive label. Negative labels are given to those persons who are thought to be deviance of standard cultural norms and stigma is also one of those negative labels that changes a person’s social identity (Link & Phelan, 2013). In the context of addressing population health inequalities also, it is necessary to focus on removing stigma in society because stigma is also a fundamental cause of health inequality. Due to the pervasive nature of stigma, it disrupts multiple life domain of an individual such as social relationship and coping behavior and consequently have an impact on health. Stigma is also a source of social disadvantage for certain sections of society, which might be the driver for morbidity and mortality rate (Hatzenbuehler, Phelan, & Link, 2013). Hence, certain ethnic group and people living in remote area are vulnerable to multiple risk factor and multiple disease outcome. Therefore, health policies and interventions must address the social factor of health inequity too. Greater attention is needed for stigma as social determinant of population health and linking stigma related pathway to health inequity. This would serve to improve health and well-being among the deprives section of the society (Link & Hatzenbuehler, 2016).
Labelling and stigma are derived from interrelated sociological perspective. However, Goffman’s theory does not focus on social process of labeling, rather its explains the consequences of stigmatizing process for an individual. He stresses that different label given to an individual as part of stigma has the power to spoil the identity of the sufferer. In the context of addressing rural-urban health inequity, it is also necessary to consider how health of rural residents deteriorates due to experience of stigmatization (Bos et al., 2013). Aboriginal and Torres Strait Islander people are most likely to experience stigma due to their exposure to racism issue. This makes them vulnerable to psychological distress, depression, poor quality of life and substance abuse. Racism is also a form of stigma and this creates many form of disadvantage in Aboriginal and Torres Islander’s life. For instance, racism contributes to inequitable access to health care resource (education, housing and employment), unequal exposure to risk factors (poor nutrition), poor mental health dues stress, increased engagement in unhealthy activities, physical injury and poor motivation in life (Markwick et al., 2014). Therefore, overall ill health experience increases in indigenous Australians living in remote areas.
The epidemiological data related to rural-urban health difference in Australia revealed that gap in health outcome is seen due to employment deficits, educational deficit, environmental barriers and accessibility issues. In relation to the rural population of Australia, the likelihood of diseases and mortality rate is higher than the urban population. Apart from accessibility issues, health disparity in this population group is also seen because of the experience of stigma in these group. Disease related stigma was highly associated with poor health seeking behavior in people. This is proved by a survey data in which 42% people with diagnosis of disease felt ashamed of their symptoms and was embarrassed to seek help from health professionals. This reflects the perception of the stigmatized individual and their role in contributing to gap in health outcome. This was mostly seen for mental health problems and diagnosis of depression in people (Effects of Stigma | IBHP, 2017). Therefore, people avoid seeking mental health service not because of remoteness of locatton, symptomatology and disability, but because of causal attributions of stigma. Major intervention and public health program has focused on addressing accessibility issues to improve health outcome. However, the perception of stigmatized individual from survey reveal that this action will not reap any benefits unless thoughts and behavior related to stigma is not addressed in this group.
By comparing the sociological concept of Goffman’s stigma theory and contribution of stigma in creating health disparities, it has been found that apart of social perception and social relationship, structural factors prevents controlling the widening gap in rural-urban health disparities. This is because health services have not focused on stigma as a determinant of health and focus is on improving accessibility issues. However, even of accessibility issues are addressed, people are not likely to visit the health care facility unless they changes their perception about mental illness. This is related to stigma occurring due to nature of disease. On the other hand stigma also occurs due to stigmatization from urban residents. Therefore, community level intervention is needed to reduce the difference in health outcome between rural and urban residents of Australia. This can be done by means of phsycoeducational intervention to changes beliefs and attitude about mental illness and depression in people. Action in multiple setting is needed so that those with power make judicious decision for the health and well-being of urban residents. Periodic assessment of experiences of discrimination at population level also needs to be identified to target health interventions in the right areas and reduce the negative categorization of people in the society of the basis of power relation (Reavley & Jorm, 2014).
The main arguments raised in the essay was based on the premise that rural-urban health differences in Australia cannot be addressed by improving health service accessibility issues. The main argument raised against this was that experience of stigma also plays an important role in contributing to health disparities and research in this area is needed to improve heath outcome. The epidemiological data on urban and rural population worldwide and in Australia revealed that extreme difference in health outcome exists and rural residents are more likely to have disease than urban residents. However, with support from Goffman’s theory of stigma, it was discussed that different level of stigma exist in society and this also contributes to health difference in rural and urban population. For instance, indigenous Australians health issue is exacerbated by racism experience which is also a form of stigma. Secondly, disease related stigma in rural groups minimize the health seeking behavior of people. Hence, it reflects the main concepts raised by the Goffman’s theory. Therefore, intervention to widen the health outcome gap should focus on addressing stigmatization too to promote positive health outcome in rural residents.
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