There is a range of reasons why COVID-19 prevention programmes may be more challenging to implement in rural areas:
Access to handwashing facilities with soap and water - In rural areas there is often a lack of access to adequate handwashing facilities at home and in healthcare facilities, schools, workplaces and in public areas. An estimated 45% of the rural population globally don’t have access to a basic handwashing facility with soap and water at home; this disparity further increases to 81% in low-income countries. The figure below shows the disparity in the availability of handwashing facilities between rural and urban contexts in several countries.
Urban populations are also much more likely than rural populations to have soap available within the household as shown in the figure below. The reduced availability of both soap and handwashing facilities requires that response initiatives invest heavily in products and infrastructure in order to enable good practice.
Image: Kumar, S. et al. 2017
Reliable water access - This is essential to ensure adequate handwashing and cleaning. In rural areas, access to basic water supplies is lower than in urban areas, with 81% of the population having access to basic water supplies in rural areas, compared to 97% in urban areas. Only 60% of people living in rural areas have access to a water supply on their premises (compared to 87% in urban areas). Water is also less available when needed in rural areas (only 74% of people living in rural areas have water available when needed compared to 88% in urban areas). Water availability in rural areas can be further limited by unreliable supplies from poor water point functionality and variable water quantity. Unreliable water supplies can increase the risk of transmission by reducing water available for handwashing, and increase the time spent queuing for water. Water availability is likely to vary over time, being more restricted in a long dry season or after extreme weather events. These extreme events continue to happen during COVID-19 and often affect rural populations severely. For example, in Bangladesh, after cyclone Amphan in May 2020, water supplies were damaged restricting access to safe water further. Flooding in the same region in July 2020 also reduced access to safe water. We also know that unreliable water supplies have created challenges during other outbreaks. For example, in a cholera-prone region of DR Congo, the inconsistent availability of water led to increased cholera transmission. It is possible that movement restrictions may have more severe impacts on the ability of rural populations to collect water from communal water points. Moreover, water access can also be a potential source of transmission if physical distancing is not practised at communal water points.
Reduced literacy level - People in rural areas may have reduced access to formal education and as a consequence may have lower rates of literacy. This means that printed materials or messaging about COVID-19 will be less suitable for these audiences.
Reduced access to communication channels - People living in rural areas have historically been less able to access mass media like television and radio. This has been due to blackspots within broadcasting coverage, economic factors, and access to technologies. However, there are indications that this is changing throughout Africa and Asia and more people are gaining access. Radio in particular is now more able to reach people in rural areas of Sub-Saharan Africa. Similarly, people in rural areas are less likely to have access to mobile phones and the internet and this can further restrict communication with populations at this time. Given these challenges, one of the most common ways of engaging rural populations in public health promotion activities has been to organise community meetings or gatherings. However, this now presents a risk of increasing COVID-19 transmission.
Perception of risk - Given that COVID-19 cases typically originate in urban areas and that, as a consequence, news headlines and response activities typically focus on the COVID-19 situation in urban areas, it is possible that rural populations may consider that they are not at risk from COVID-19. In rural areas, it may be useful to identify opportunities to share the stories and experiences of COVID-19 cases living in these areas so that rural populations realise that they too are at risk.