Rural Road to Health

Highlights from season 4 and find out what is planned for season 5 of the Rural Road to Health.

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Dr Roshni Jhan Ganguly, a family doctor and founder of Project SETU Foundation Trust. Dr Roshni identified that there was a gap between urban and rural healthcare. About 70% of India's population lives in villages where access to primary health care services may not be easily accessible. Project SETU was created to be the bridge that connects urban physicians with rural health care. Today we will talk to her about Project Setu and its mission.

Episode summary:

01.30 Dr Roshni tells us more about her professional background and interest in rural health

03.30 What is project SETU and why was it started?

10.30 What is the rural context like where she works?

15.45 What challenges are communities facing when needing to access healthcare services?

19.30 What kind of services does project SETU provide and what is the impact of those activities?

25.45 What challenges has she faced while doing this work?

29.00 What are some key lessons when engaging with communities?

35.00 How important is trust in the work that they do?

38.30 What are her hopes for Project SETU going forward?

Key Messages:

Family medicine is not confined to the four walls of a clinic. She thought why not really serve the people who really need it.

Project SETu Foundation Trust was born from the question - how do we build bridges rather than provide temporary solutions?. The vision is to bridge the gap between healthcare and hope, the urban expertise and rural needs, and between illness and wellness.

Project SETU evolved into a holistic community development organization where healthcare became the entry point but it was not the destination.

Villages in India are different, generally the population comprises of the state population and indigenous population. India has many different languages, cuisines and cultures. A typical village will have thatched houses, mud houses or brick houses. The cooking medium may be a stove which is fueled by cow dung. Women take care of the household and can be farmers. Male population is mostly farmers. There is also a migrating population which may be travelling to the cities for work. The population of the village can be about 50000 people.

ASHA workers (Accredited Social Health Activists) go door to door and check on people. They are community health workers funded by the government. They find out about the needs of the population and collaborate with local healthcare workers.

Community development is not easy and requires consistency, consistency requires resources.

Building trust takes time, deep rooted beliefs and behavior can not be changed overnight.

Project SETU initially does a needs assessment survey and get the community together to talke about health awareness and the community share their challenges. This is how they begin to build trust. Then they organize some health screening camps.

Project SETU collaborates with other organizations so that they can provide other training that the community needs such as training for farmers on organic farming.

Project SETU also finds out about the activities and products being produced in the community and helps to promote these more widely. In this way they support local economies.

During this process they build a local team with the village they are serving which then keep the services going and continue to connect the village to project SETU.

It was a challenge to get everyone together at the same time and in the same place.

Different political influences have been a challenge they have faced.

By engaging the community and supporting their livelihoods the community feels like they can trust what is being done.

It is important to understand the local language, customs and culture.

Sports, art, dance and music can be great enablers and a way to support young people develop and achieve their dreams.

Email: [email protected]

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Prof Alexandra Johnstone and Dr Daniel Crabtree are from Scotland. Prof Johnstone is Chair in Human Nutrition at the University of Aberdeen. She is currently leading on a UKRI Transforming Food Systems Grant focusing on Food Insecurity and Obesity. Dr Crabtree is a Research Fellow with the NIHR-funded Health Determinants Research Collaboration Aberdeen and has previously worked with the University of Aberdeen and the University of the Highlands and Islands.

Episode summary:

01.30 Alex and Dan share more about their background and their interest in rural communities

04.10 What are food environments and why do they matter?

10.20 How might rural food environments be different?

14.30 How is food insecurity being managed in Scotland and the UK?

18.00 How does inequity impact rural food environments?

20.30 How much is climate change impacting food security for the UK and globally?

26.10 What are some of the key issues when thinking about food insecurity and obesity?

33.00 What is the role of local retailers?

38.00 What impact does less access to healthy food have in rural and remote communities?

41.30 What are some key insights and policy recommendations from their work?

Key Messages:

Food environments are everything from the farm to the fork or from soil to sewage. It involves numerous stakeholders.

We have a huge proportion of people living with obesity, it has a higher prevalence in areas of social deprivation. It is not about blaming individuals but about how we can change the food environment to make it easier to make healthy choices.

BridgeAct was a project which developed an interactive toolkit for transforming food systems, it helps decision makers plan effective impact delivery strategies. It was tested by Aberdeen city council.

Food insecurity having the fear of not having enough food to feed your family over the next week.

Food security is more about imports and exports and having food available at a national level.

Remote and rural communities do encounter unique challenges when trying to access healthy and affordable food. This can include disruptions to long food supply chains, often this impacts island communities more often.

Food delivery services are more common in urban areas but in rural and remote areas they are often not available.

People living in rural and remote communities depend on cars and fuel to access supermarkets. The food can be more expensive but so can the cost of petrol. Public transport can be unreliable or non-existent.

Food that is produced in rural farming communities is often not consumed there but sent away for packaging and then potentially resold to them.

Surveys of people have shown that low prices on healthy and sustainable foods, particularly staples, would help families plan their food purchases allowing for better food budgeting and meal plans.

There is complexity around promoting healthy food, there is no uniform definition of what a healthy sustainable food would be.

When oil prices increase this has a huge impact on spending in rural and remote areas, not just for food purchases, but also the ability to get to work or take children to school.

Global warming impacts food production and our ability to have enough food to feed our populations. It impacts food systems and health systems and people's ability to stay well.

Vertical farms have controlled environmental conditions, they may not be the most environmentally friendly solutions as they require electricity, but they do allow communities to grow food all year round.

Investment in local food production may be a way to improve local food system resilience. Local communities of practice may also be useful for practices and strategies to guard against food shortages.

The ask for retailers is to offer a range of foods that are both healthy and environmentally sustainable, this would include fresh food but also frozen and tinned produce which has a longer shelf life.

The paradox of food insecurity and obesity, someone with a limited income to spend on food, they are more likely to make choices to buy the foods with the lowest cost. These tend to be foods high in fat, sugar and salt, this then drives rise in obesity.

Food costs have increased by 40% in the last five years. This means people rely on discounts and offers which are often for unhealthy foods.

If a community only has a small local convenience store, then you will struggle to access fresh nutritious food. The food there is also often much more expensive.

Rural and remote populations do not always have the option to choose a different retailer if they are not satisfied with what is available, however many accept that this is part of life in those communities. The local retailer also has an important role in those communities as they can often provide much needed spaces for social interactions.

Explored facilitators and barriers to accessing healthy food for older adults living in rural and remote areas. Barriers around price, distribution and access, however older adults may be less inclined to cook for themselves. Lunch clubs can be ways to improve social connection and nutrition.

In the tourist season on the islands this can lead to food shortages and requires a change to meal plans.

Price is the greatest barrier preventing healthy food purchasing. Policymakers could level the playing field and compel all supermarkets to price healthy foods in line with inflation to ensure more equitable access for all.

Legislation to prioritize healthy food promotion. Reducing ultraprocessed food and prohibiting them to be placed on the shelves at promotional prices.

Prioritize long term funding commitment for local initiative in rural and island communities.

Investment in community food preparation and storage facilities, this can help buffer impacts of shocks to local food systems.

Supporting communities of practice and making food supply chains more resilient.

Contact info for Prof Johnstone and Dr Crabtree

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Piotr Sadlocha is the president of the European LEADER Association for Rural Development.

LEADER is a European programme, with the aim to involve local actors in rural areas in the development of their own regions by forming Local Actions Groups (LAGs) and designing and implementing strategies. The LEADER programme already exists for almost 30 years.

Episode summary:

01.05 Piotr shares how he became more involved with rural communities02.00 What is the European Leader Association for Rural Development, LEADER and Local Action Groups (LAGs)? 08.30 What are some of the challenges facing rural communities in Europe? 14.00 What is the role of rural communities in wider society? 20.00 What steps could be taken to improve the relationship with rural areas within Europe?

Key Messages:

ELARD is a pan European organization, the membership is made up of more than 2600 Local Action Groups representing people living and working in rural areas.

LEADER takes a bottom up approach to rural development which started over 30 years ago. It was created to support rural development with the active engagement of communities and society through Local Action Groups. This project receives financial support from the European Union.

Local Actions Groups know what is a challenge in their area and take on different activities such as job creation, support for local business, creating walking and biking paths, supporting local education and developing local infrastructure.

One of the biggest challenges for rural Europe is depopulation. When there are fewer people there are less taxes collected and this usually means a lower budget for the local authority. However as there is usually a higher proportion of elderly people, spending for care tends to be higher.

The quality of life in rural areas can also represent a challenge. It is important to create a good quality of life if you want younger people to stay in these areas such as better education, employment opportunities and healthcare access.

There are often fewer opportunities for women in rural areas to return to work after having children. It is important to ensure that rural women are not disadvantaged.

Rural communities are important for food production and food security.

Many people in rural areas in eastern Europe are against the EU as they do not feel supported. They then vote against the EU as they do not see the benefits of being part of the EU.

In Poland there is a large difference in investment between rural and urban areas. In some rural areas the investment is 10x less per person than in urban areas.

Why is there such a large difference in investment between rural and urban areas in the EU?

Rural people often use less money so they do not travel around Europe and make use of the opportunity of social mobility across EU countries as often.

To maintain European values and democracy it is important to give citizens the power to participate in decision making, particularly around questions related to their communities and lives.

Learn more about ELARD: https://elard.eu/

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Professor Tanya Ovenden-Hope is Professor of Education and Dean of Place and Social Purpose at Plymouth Marjon University in the UK.

Tanya has spent many years exploring social inequity and educational disparity with a particular focus on the challenges for coastal, rural and small schools. More recently she also led on the Pretty Poverty report which looks at how current government measures underestimate rural and coastal poverty in Cornwall. We discussed both of these topics in more detail.

Episode Summary:

01.30 Tanya tells us about her professional background and how she became interested in rural education and rural inequity

09.20 What are the challenges for rural, coastal, and small schools?

17.50 Education as a social determinant of health and how we speak about these topics

31.10 How did the idea for the Pretty Poverty report happen?

46.05 What were the key findings of the Pretty Poverty Report and why does the IMD not accurately capture rural and coastal deprivation?

Key Messages:

In many rural and coastal areas in the UK affluence lives next to poverty, and this observation got her thinking about what the impact of this was in the educational setting.

The concept of educational isolation resonated with countries around the world as a place-based problem. It identified three compounding factors of place which were causing challenges for schools: geographical remoteness, socio-economic deprivation, and cultural isolation.

If you are a child from a persistently disadvantaged background going to school in a coastal area, you will do less well than a child from a persistently disadvantaged background going to school in a rural area, who will do less well than a child from a persistently disadvantaged background who goes to school in an urban area, who will do less well than a persistently disadvantaged child who goes to school in London.

Lack of Child and Adolescent Mental health services is impacting on child attendance at school. Schools lack funding to support the needs of children with additional educational needs.

Schools in coastal and rural areas receive thousands of pounds less per student which compounds the cycle of poorer outcomes.

In policy we have equality, but equality does not mean equity.

The cost of getting a child to school is higher for rural and coastal areas often requiring the use of private transport as public transport is not available or not reliable.

Social mobility in the South West is poor, students are not progressing to higher education.

The lack of infrastructure, large employers and higher qualification jobs is impacting on what young people aspire to or if they return to the area after their degree.

The Pretty Poverty report was part of a larger project that came out of conversations with the Cornwall Dioceses. The IDM did not seem to represent what they were seeing in Cornwall or the rural experience. It was part of the Cornwall Rurality Matters project.

Went to six selected areas identified using a triangulated approach which avoided the issue of spatial aggregation.

The research asked: what is it like to live in an area of Cornwall which is classified as deprived but the IMD and explore the measure that identified that area as deprived and why other similar areas were not being classified as deprived?

There is a new index of deprivation which was launched in 2025 the IOD (Index of Deprivation), this new index is not more sensitive to rurality. Some minimal adjustments around housing and transport, but still not enough to recognize rural deprivation.

The Community Needs Index - this uses "neighbourhood trust, perceived as a sign of affluence. In the Pretty Poverty report this is represented as community resilience. In rural areas that is not a sign of affluence but a sign of absolute need. You rely on your family, friends and neighbours to access your basic needs due to the lack of things like public transport or digital connectivity.

We value statistics more than we value qualitative and narrative data which can really show what it is like to live in a certain place.

The Office of National Statistics does not report on areas with 5000 people or less, why is that and what could this mean for policy? It makes small communities invisible in the data.

There were six key findings in the Pretty Poverty report: transport dependency, housing displacement, employment precarity, healthcare withdrawal, educational isolation and community resilience.

If services are not being used they get reduced, but when they are reduced they are used less, making it a vicious cycle.

Transportation is a key barrier to employment, healthcare and education. Two thirds of rural residents live in transport deserts.

Healthcare withdrawal - service centralizations are compounding access challenges. People felt that the move to digital access was excluding them from healthcare access due to digital connectivity challenges, this was the feedback from all demographics, from young people to elderly. This move is a very urban-centric policy. Cornwall's connectivity is over 30% worse than other areas of England.

Distances were seen as a barrier to specialist care, Cornwall has one hospital and many people travelled to Devon for care.

There is a high concentration of special needs children in small schools, 29% compared to the 3% which is the national average. The schools are struggling as they have fewer teachers and less funding than larger or urban schools.

Strong social capacity or community resilience is a positive in rural and coastal communities, however we need to recognise that this is a response to disadvantage. If we removed community care we might start to see the need that is underneath this.

Community assets should compliment not substitute formal services.

The Pretty Poverty Report: https://cornwallreports.co.uk/wp-content/uploads/2025/09/The-Pretty-Poverty-Report.pdf

Coastal Schools and Educational Isolation: https://www.plymouth.ac.uk/research/education/university-practice-partnerships/research-in-practice/coastal-schools-and-educational-isolation

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Martin Robertson, a lived experience expert and Faye Watson, a Public and Community Engagement Consultant, speak about the project they are leading to start conversations about dementia in farming communities in Scotland.

Mind Our Farmers

Episode Summary:

01.10 Martin and Faye introduce themselves

03.12 What is the Mind Our Farmers Project?

05.10 Why is this project important for farming communities?

07.25 Why are rates of dementia higher among farmers?

10.00 What is the experience of being a farmer with dementia?

15.30 What partnerships are they exploring for the project?

19.30 What is it like after a diagnosis of dementia, what support services are needed?

28.55 What is the role of community?

Key Messages:

Farmers often lead quite isolated lives and often will only meet in places like the local Mart.

Mind Our Farmers is a project funded by the Inspire Fund from Alzheimers UK and is about opening up conversations about dementia with farming communities in Scotland.

They are interested in what the challenges are and what resources are needed.

Farmers often don't see anyone apart from their immediate family, social isolation, farming chemicals, and noise in the work environment are potential risk factors for dementia.

Farmers often do not talk about their health.

There is a lack of research around dementia and farming. A review paper from Bangor University identified that farmers experience more than half of the known risk factors for dementia.

Farmers work much longer than most people and often do not retire, many symptoms can be missed or overlooked.

There are over 100 different types of dementia, this often involves your brain slowing down and forgetting, this can be dangerous around machinery.

Sometimes farmers have to give up farming when their wife is diagnosed with dementia, there is a lack of support in that situation.

They are hoping to have young farmers involved to start intergenerational conversations about dementia.

From the community advisory group the message was that they need practical advice around managing the farm during and after diagnosis.

There are challenges for tenancy farmers as there is no social housing available in local areas.

There is a lot of interest in the project and they are exploring different partnerships.

Less than 50% of people get appropriate post diagnostic support, the reality is that you get two phone calls and leaflets dumped on you.

In Scotland there is free personal care available, however access to this is not available in rural and remote areas. Home care workers do not get paid for traveling and travel distances can be vast, so it is difficult to get care workers to work in these settings as they would lose money.

To get a diagnosis you have to go to a hospital with an MRI machine for a brain scan, this can be a long distance away.

GP surgeries can also be 5 or more miles away and may not have public transport access.

Once you have a diagnosis of dementia you are placed on a palliative care pathway.

Many people want to be at home at the end of life, unfortunately many people get stuck in hospital at the end of life as no support is available locally.

Community has an important role in supporting people with dementia, but small communities can also be a source of stigma.

• RSABI website: https://www.rsabi.org.uk/
• Farmstrong Scotland website: https://www.farmstrongscotland.org.uk/
• Review by Jen Roberts and colleagues at Bangor University who is on our community advisory group to contextualise our work to Wales: https://pure.bangor.ac.uk/ws/portalfiles/portal/79308988/1-s2.0-S0743016725001500-main.pdf
• Paper from team at University of Iowa assessing whether agricultural workers are at greater risk of dementia: https://pmc.ncbi.nlm.nih.gov/articles/PMC8849525/
• First project in the UK that was funded to look at farming and dementia, that was back in 2016: https://www.plymouth.ac.uk/research/centre-for-research-in-environment-and-society-ceres/farming-dementia-and-networks-of-care

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Prof Ioanna Tsiligianni is a rural doctor, Professore in General Practice and Public Health at the University of Crete and the President-elect of WONCA Europe. She talks about her experiences in rural practice in rural Crete, her reserach interests and her plans for her term as WONCA president.

Episode Summary:

01.14 Ioanna tells us about her professional background and how she became interested in rural health

03.45 Why was rural practice a great experience?

05.15 How is primary care organized in Greece and the Greek islands?

10.40 What is it like working on an Island like Crete?

12.30 How is island practice different from practice on the mainland?

19.00 What are your research interests?

28.30 What is she hoping to do as president elect and then president of WONCA Europe?

32.20 What are some key challenges for family medicine in Europe?

34.00 What could we do to improve the health of our communities but also our primary care professionals?

Key Messages:

She has worked in a rural area for 16 years and this was the best experience of her life.

She knew everyone in her community very well and it felt like a big family of 2500 people.

The feeling of being in a rural area is unique.

There are 5000 GPs across Greece and 3000 pulmonologists, there is a large number of specialists, for this reason primary care is undervalued.

In rural areas by law all medical graduates have to serve for one year in rural areas, so communities often expect the doctors to leave to go specialize.

Enormous challenges for three main reasons: 1) low numbers of primary care specialists, 2) Greece has huge geographical differences, there are 400 inhabited islands, and 3) in rural areas the majority of the younger population leave for urban areas while the elderly population remains.

On the Greek islands the population triples or quadruples in the summer which impacts availability of medical care for about five months of the year. On Crete an additional 3 million people arrive during summer. The population of Crete is 700 000.

Much of the day to day work focuses on chronic disease management and public health activities.

Crete has developed a rural research network.

On the islands during the summer you have to deal with permanent inhabitants as well as emergency visits of children and tourists, this means a huge overload for doctors on the islands as no additional capacity is available.

On the mainland in rural areas there is a problem of access and fragmentation of care as it is difficult to refer to specialists and a growing elderly population.

She was a single GP practice for 16 years so she needed to do everything herself as there were no additional staff.

Researched medication use in a rural area which found that patients were hoarding and exchanging medication between themselves.

As a GP in a rural area you have the obligation to raise the issues in scientific articles of the rural patients. She tries to include the rural patient voice in her work. This is important for influencing policy.

Her research also focuses on respiratory diseases, Greece is the first in Europe in regards to tobacco use with 38% prevalence in the populations. There are many undiagnosed cases of COPD.

She took the initiative to identify COPD in the community by writing in the local paper about symptoms to look out for and encouraging the local priest to speak about COPD to the community. This helped to encourage people to come to the doctor and identify COPD earlier so that it can be managed.

As WONCA Europe president-elect she is hoping to improve education and research opportunities for family doctors in Europe. This will hopefully help family doctors feel less isolated and provide them with easy access to patient education materials.

Family medicine is still not recognized as a specialty in Europe, this needs to be addressed.

We need to have the flexibility to spend more or less time with patients depending on what is needed with the patient and family at the centre.

You need to listen to your community as each community is unique.

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This episode was recorded at the 21st WONCA World Rural Health Conference in Wellington.

Three rural clinicians share their perspective on their rural health career in three different countries. They share what they like and don't like about rural practice as well as what they do for their wellbeing.

Dr Amber Wheatley - British Virgin Islands

Dr Shuja Mohamed - Sri Lanka

Dr Muna Mandula - New Zealand

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Dr Sarah Lesperance & Dr Sarah Chalmers have been trying to understand the factors that influence the leaderships styles and journeys of diverse medical leaders. Initially they were exploring women's experiences and this has now expanded to look at diversity in rural health leadership more broadly and the development of a framework.

This episode was recorded following their workshop at the 21st WONCA World Rural Health Conference. They invite listeners to be part of thier research and framework development by sharing thier leadership stories.

Contact infromation:

Dr Sarah Lesperance

Dr Sarah Chalmers

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Rural Health Compass

GRACE -Global Rural Health Action, Collaboration and Excellence, is a new initiative led by the WONCA Working Party on Rural Practice (Rural WONCA). It aims to identify, recognise and connect organisations worldwide that demonstrate exceptional commitment to rural health, creating a formal global network of centres of excellence.

This initiative was launched at the 21st WONCA World Rural Health Conference in April. In this episode you will hear more about the aims of this initiative from Rural WONCA Chair and from five of the GRACE partner organization representatives. Thsi episode was recorded at the conference.

Speakers:

1. Pratyush Kumar - Chair Rural WONCA
2. Claire Quilliam - University of Melbourne, Australia
3. Lungile Hobe-Nxumalo - RuDASA, South Africa
4. Gavin Parker - Society of Rural Physicians of Canada
5. Roshni Jhan Ganguly - Project Setu Foundation Trust, India
6. Anders Svensson, Norwegian Centre for Rural Medicine, Arctic University of Norway

Learn more about the launch of GRACE here: https://www.globalfamilydoctor.com/News/RuralWONCAAssemblyAdvancingtheGRACEInitiative.aspx

If your organization would like to become part of GRACE you can contact Pratyush at: [email protected]

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Rural Health Compass