I Am (Rural) Woman

I learned it was ‘Women's Health Week’ in Australia the first week of September, almost a week after the occasion. It came and went without the recognition it deserved. Women are just over half of the Australian population, including across regional to very remote areas of Australia [1], yet Women's Health remains a problem drawing patchy attention.

Women (and girls) from regional to very remote (or rural) areas are internationally recognised as a priority population, and women in rural areas play a crucial role in strengthening their communities [2, 3]. Women are the stalwart backbone of their communities, often also holding responsibility and care for everyone around them. I was asked to write about ‘Women and Rural Health’, but the topic is enormous. Where do we set our focus?

Women's rights and women's health rights are once again being challenged, diminished and removed in nations around the world. In Australia, there are numerous policies, strategies and initiatives in place to address gaps in healthcare for women and for those living in rural communities, from the federal government to the local health systems and even the non-government agencies within the states and territories. The Australian Government's Minister for Women has identified Health as one of five priority areas. Priority area 4 of the Strategy for Gender Equality states that, ‘Over many decades in Australia and around the world, women's control over their health has been challenged. … A lack of support for women's health not only affects their everyday wellbeing, it also impacts how they participate and thrive at work. …and (women) in regional, remote and rural communities also face additional barriers due to religious or cultural values and beliefs, language and communication challenges or a lack of access [4].’

The federal Minister for Health has produced a Women's Health Strategy that recognises ‘that women's experiences of mental and physical illness are different from men's [and this] is essential for developing services that are effective in addressing the health needs of women and girls in Australia’ [5]. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has also responded with a strategy to address the ‘barriers that create a financial, logistical and emotional burden on women and their families’ and it will continue to ‘advocate for, and support initiatives that help support the equitable delivery of services’ [6].

The rules of play are being laid out, but there remains a clear gap in access to healthcare and a shortage of appropriate health providers to meet the unique health needs of women, especially in rural Australia.

In Australia, women significantly outnumber men in the health workforce—no matter the discipline, classification, or location (78% Australia-wide, 80% in rural areas) [7]. Women also outnumber men in the tertiary education and research workforce (59% Australia-wide, 62% in rural areas). The number of women involved in rural health and rural education and research is a great strength and one response to this health gap. So, how are women contributing to rural health? And how are rural health and women's health issues being addressed and represented?

When I was first approached to write about ‘Women and Rural Health’, I contacted a number of women who are rural health educators and researchers. I communicated with women across the country and across the academic spectrum (from Early Career Academics to Professors). Unsurprisingly, their ideas about the topic were broad and varied. Their reflections presented evidence of women as leaders in the rural and remote context, experts in various research methodologies, and members of a range of health, academic, and industry-related disciplines who walk the line between necessary generalism and realised specialisation.

For every positive, these rural women also shared the numerous challenges they face. Although the proportion of women who apply for and are funded as Chief Investigator-A with an NHMRC grant is increasing each year [8], few of these projects are focused on rural health or women's health [9, 10]. The ‘Daversity’ problem, where ‘men look after other men’ and existing ‘networks routinely lock women out (of research funding)’, still reaches into rural health spaces [11]. Everyone I spoke to was challenged by barriers to attaining grants, joining research teams, receiving professional development and getting simple recognition, all while also navigating within the realities of the personal, professional and geographical contexts in which they live and work. Yet these women are increasingly taking the lead. While the foundational conversations about rural health (and rural health research) may have been pioneered by men, the next generation is stepping up and women are taking the field.

One end where goals are accumulating is the dissemination of the rural health research work being done by women. I explored the activity of the Australian Journal of Rural Health (AJRH) and specifically, the activity of women as authors. The AJRH is the journal of the National Rural Health Alliance. The Alliance ‘provides a united voice for people and health professionals living and working in rural communities and advocates for sustainable and affordable health services’ and represents ‘health professional organisations, health service providers, health educators, the Aboriginal and Torres Strait Islander health sector and students’ [12].

Details of 261 articles were extracted from a Medline search for AJRH publications in 2004, 2014 and 2024. Three-quarters of the published papers had a woman listed as an author (74% of which had five or fewer authors); two-thirds had a man on the author list. Sixty percent of the publications were by women as first author (n = 156), and these have increased over the last 20 years (34, 42 and 80 publications). First authorship is commonly attributed to the person responsible for the work. Women were listed as the last author for 100 of the 261 articles, another example of leadership in their fields, as last authorship is commonly reserved for the supervisors, project leaders, or senior contributors. Seventy-six (29%) of the articles published were from teams that had women as first and last authors. Articles were being published in four broad categories: Evaluation of Service Delivery, Workforce, Reviews/Audit and Other. When considering the primary topics of the published activity, most of the publications with women as the first author were general healthcare service evaluations, followed by research activity related to workforce training, recruitment and education (Figure 1). This is all worthy of celebration.

The strength of research activity addressing workforce matters aligns with the priorities of the University Departments of Rural Health, the Federation of Rural Australian Medical Educators (FRAME), and the Office of the National Rural Health Commissioner. These common priorities include building a future rural and remote health workforce and supporting continuing professional development [13-15]. The varied research and activity related to rural healthcare services and delivery of healthcare acknowledge the diverse populations that live in rural communities and their health needs.

Despite all of this excellent work happening on the rural health pitch, only nine of the 156 articles with a woman as first author explicitly addressed matters of women's health. Admittedly, the health of rural women is one concern among many; there are also Aboriginal and Torres Strait Islander women, women of culturally and linguistically diverse communities, women within the LGBTQIA+ community, aging women, young women, women with chronic disease, women needing acute care, pregnant women and women seeking to terminate pregnancy and so many others. All of these women, including rural and remote women, need and deserve access to appropriate and equitable healthcare.

It is important to recognise that rural health and women's health are enormous topics and that there is a lot already being done. Despite the persistent and perpetual challenges, goals are being kicked, but the game is far from over. There are clear gaps and opportunities for action and response in the field of ‘Women and Rural Health’.

So, what holds us back? Sometimes it may be that we do not know where to start or do not have the resources to act. Sometimes we can be overwhelmed by the magnitude and the complexity of the issues rural women face or we get knocked back when we propose to address these wicked problems. Sometimes it is because we (rural women) have been told we need to help others before we help ourselves. Whatever the reasons, the reality is we all have agency and how we use our agency may depend on our positionality. We do not all have to lead the fray. Maybe we are slicing oranges for the under-6's half-time break, we could be barracking from the stands for those on the field, we might be joining the team and then calling the play, or we could be the referee, coach or team manager. We can all ‘rise up’ together and do our part to inform and create change for ‘Women and Rural Health’.

This was an invited Editorial on the topic of ‘Women and Rural Health’ by Emily Saurman, a migrant to Australia who is originally from Ojibwe country. Emily is an Associate Editor of the Australian Journal of Rural Health and a ‘rural woman’. Emily was responsible for all contributions to this work including the direction, analysis, and writing of this Editorial. Emily acknowledges her rural and remote academic colleagues who shared ideas and stories with her, informing the production of the manuscript. Emily is a generalist rural and remote health service researcher and evaluator with particular expertise in matters of access, methodologies, and research ethics. Emily has spent her career living in rural and remote Australia and working with community to address and improve the health and wellbeing of rural and remote Australians.