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CHAPTER 1

What is rurality?
Nicolette Rousseau BA

BRITAIN is primarily a country of urban dwellers. For many, rural areas are seen as an idyll, the antithesis of the ills of urban life. The countryside is a place to 'get away from it all' - a weekend retreat, or somewhere where one might aspire to live. People have images of rolling landscapes or bleak moors, complete with smiling farmers leaning on farm gates. The country air is seen as recuperative, and the environment generally beneficial. McLaren in 1951 argued that city children should be encouraged to go hill walking; today young offenders are sometimes sent on hiking expeditions.
Jones and Eyles (1977), in An Introduction to Social
Geography, stated:
"This book is largely about urban society ... this does not unduly distort the real situation because we live in a predominantly urban society and most of our problems lie in the city."

Their view is reflected in the fact that recent interest in health inequalities has tended to be centred on the inner cities. Definitions of rurality in a health care context
Definitions of rurality have been neglected in health research. Definitions of deprivation attract frequent papers, with debate over the 'best' definition (Campbell et al., 1991;
Morris and Carstairs, 1991; Ben-Shlomo et al., 1992).
Researchers into deprivation and health generally choose to use one of two or three main indices of deprivation, such as that described by Townsend et al. (1986), or Jarman (1983;
1984), and seldom omit to specify the definition of deprivation which has been chosen. In contrast, where research has been carried out into rural issues in health, the definition of rurality has attracted less attention.
Definitions of rurality vary widely (Table 1) and in some papers no mention is made of how areas have been identified as 'rural'. This lack of consistency, and failure to state explicitly what is meant by 'rural', makes comparisons between different studies difficult.
The definition of rurality used to allocate rural practice payments to rural general practitioners has stimulated little debate compared to the use of Jarman's underprivileged area index to allocate 'deprivation payments'. This is despite the fact that for many family health services authorities, rural practice payments account for a significantly larger expenditure than deprivation payments. Little research has been done to assess where the additional costs of rural practice lie, and to what extent the rural practice payments target effectively practices experiencing the greatest costs.

Table 1 Definitions of rurality as used by health researchers
Index of rurality
Socio-economic classification
Population size/density

Population size + social characteristics Remoteness from urban centres
Subjective assessment

Bentham (1984)
Haynes (1991)
Carstairs and Morris (1991)
Phillimore and Reading (1992)

Phillimore and Reading (1992)
Williams and Lloyd (1990)
Haynes and Bentham (1982)
Ritchie et al. (1981)

There have been few attempts to include rurality in deprivation indices (Jarman, 1983, 1984; Townsend et al., 1986).
The most commonly used such index of rurality is that of
Cloke (1977; see Table 2).

Rurality
How to describe it?
These problems with a definition may appear strange when
'rural' and 'urban' are concepts that most people understand.
However, Moseley (1979) said that "There is no unambiguous way of defining 'rural areas'." This has not prevented people since then from striving to achieve an understanding of 'the rural', drawing on areas such as postmodernism to assist them in their search (Hoggart, 1988,
1990; Halfacree, 1993; Murdoch and Pratt, 1993; Philo,
1993); see also (Frankenberg, 1966; Pahl, 1966; Bell and
Newby, 1971).
As part of our study of rural health and health care we held discussion groups with patients and health professionals in which perceptions of rurality were discussed (McColl,
1993). Most people found it easy to categorize their homes as being in a rural or urban area. However, there was more difficulty at the boundary between urban and rural. One patient said:
"I know what rural means in terms of a village or hamlet but I am not sure where it stops being rural and becomes urban."
When questioned about what made them describe the area they lived in as rural or urban, people used varying and often quite sophisticated criteria. Though based around population size, they also took into account the general 'feel' of a settlement. For example, two comments from rural patients were: "I feel if you've got no facilities then you are definitely rural."
"It's your own perception of where you live."

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Table 2 Variables used in Cloke's index of rurality (after Cloke, 1977; Cloke and Edwards, 1986)

Variable name

Considered in 1971

Included in 1971

Considered in 1981

Population density
% Population age over 65
% Population men 15-45
% Population women age 15-45

/
/
/
/

/
/

/
/
/
/

Occupancy rate (household/dwelling)
Occupancy rate (persons per room)
Household amenities
Mobility (ownership of two cars)

/
/

Occupational structure (% agricultural) m/ Commuting out pattern

/

/
/

/
/

Population change (in past 10 years)
In-migration (% population resident