Below we highlight some factors which may affect the management of COVID-19 in rural areas:

Reduced health care access - People in rural areas may have to travel further to access healthcare and are less likely to have access to acute hospital care or specialised health care staff. The lack of access to healthcare may result in those people who are ill with COVID-19 being cared for at home. Healthcare facilities in rural areas are also more likely to lack access to adequate personal protective equipment (PPE) and water (an estimated 1 in 4 health facilities lack basic water services) which would make it difficult for health workers to practice proper and frequent handwashing as recommended to maintain effective infection prevention control (IPC) and curb the spread of the virus. In health care settings where water is scarce, the increasing demand for water may result in water being reused, which can increase the cross-transmission of COVID-19 and other hospital-associated infections.

Access to COVID-19 testing - Limited access to health care may compound limited access to COVID-19 testing. In high-income countries, rural areas have struggled to expand COVID-19 testing at the scale and speed which is necessary. This may be more pronounced in low- and middle-income countries where rural areas already have limited access to health services and where remote regions are harder to reach. This may mean that initial cases in rural areas go undetected, leading to further transmission and causing the overall burden of COVID-19 in rural areas to be underestimated. This situation may make detecting and managing COVID-19 cases in rural areas more challenging. In many countries there have been efforts to improve testing capacity and processing times. This has included decentralisation testing facilities and pool testing of multiple samples.

Older populations - There are many factors that increase the risk of severe health consequences from COVID-19 (discussion of these are addressed elsewhere). One difference between urban and rural areas relates to demographics, as rural areas typically have a higher proportion of older people than urban areas. This is because younger populations often move to urban areas to seek education and employment. We know that COVID-19 is more likely to have severe health consequences on older people, as many are likely to have other health co-morbidities, and so proportionally rural areas may face a more severe strain on their health systems and may see higher mortality rates. However low- and middle-income countries typically have younger populations overall which may result in COVID-19 causing less mortality than in high-income settings.

Modes of socialising and communicating - In rural areas, large gatherings such as religious events, funeral events, celebrations, market days, or gatherings at workplaces and schools are still key parts of community life and may be more common than other forms of social connection and communication (e.g. the use of mobile phones to communicate). This may facilitate transmission in ways that are different to transmission patterns in urban areas. In many countries, governments have imposed restrictions on gatherings but these may be harder to enforce in rural areas.

Vulnerability to secondary impacts - Rural populations are particularly vulnerable to the secondary impacts of COVID-19 because of existing inequalities between urban and rural regions. For example, people in rural areas are commonly less wealthy than in urban areas and people in rural areas are more likely to be employed within the informal sector or as seasonal agricultural workers. The combination of these factors means that families in rural areas may be particularly vulnerable to the economic impacts of COVID-19. For example, families may face food security challenges due to direct loss of income or a reduction in remittances coming from family members in other regions. Rural areas may be more vulnerable to food shortages due to travel restrictions and the impact of COVID-19 on supply chains. Rural areas may also experience shortage in the supplies of other key items such as soap, sanitizer, masks, chlorine and gloves.

Editor's Note
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Authors: Katrina Charles, Li Ann Ong and Robert Hope
Review: Balwant Godara, Peter Winch, Kondwani Chidzwizisano, Boluwatito Awe
Last update: 04.08.2020