David
J Godden MD FRCP (Edin and Glasg)
Helen M Richards PhD, MRCGP
Highlands
and Islands Health Research Institute
Address
for Correspondence
Professor
DJ Godden
Highlands
and Islands Health Research Institute
University
of Aberdeen, The Green House
Beechwood
Business Park North
Inverness
IV2 3ED, Scotland, UK.
Tel:
01463-667320
Fax:
01463-667310
E-mail:
djg@hihri.abdn.ac.uk
Abstract
Health
issues and the delivery of health care differ in many respects between remote
rural and urban areas. In Scotland,
rural health has received increased attention since political responsibility was
devolved from Westminster to the Scottish Executive.
Despite this, there are serious concerns about delivery of health care to
remote and rural Scotland, specifically the potential to match demand for
services with supply of health care, taking account of available budgets and
changes in the healthcare labour market. These
concerns apply to both primary and secondary care. This paper outlines the
potential contribution of research to the rural health debate, and describes
issues and constraints that must be considered by those undertaking health and
social research in rural settings.
Key
Words
Rural
Health, Deprivation, Recruitment, Retention, Health Care Provision, Research
Design
Introduction
According
to a recent Scottish Executive definition, rural Scotland accounts for 98% of
the Scottish landmass and is occupied by 18% of the population, approximately 1
million people
1
. Included within this are
many isolated remote and island communities. The existence of these rural and
remote communities gives a specific character to issues of health and health
care delivery in Scotland, distinct from that of the remainder of the United
Kingdom. In 1997, a series of
papers drew attention to a range of contemporary rural health issues
2;3
, described rural
residents perceptions of their health services
4
and discussed methods for
involving remote and rural communities in the health service planning process
5
.
A key theme that emerged was the need for more research into remote and
rural health. Since 1997,
devolution has led to an increased profile for health in the Scottish political
agenda and recognition of the remote and rural dimension has led to a number of
new initiatives. Despite this,
there is an impending crisis in health care delivery to remote areas, and the
need to understand the reasons for this, and to act to correct it, has become
increasingly acute. As will become
apparent, the very nature of remote communities can militate against conducting
research. An understanding of the
issues involved in conducting such research is essential to ensure generation of
meaningful/high quality evidence on which health care and social care planning
can be based.
Health
Issues in Remote and Rural Areas
What
are the characteristics of remote and rural areas in relation to health? Rural
areas tend to contain a high proportion of elderly people
6
and population projections
indicate that this pattern will be accentuated in the next decade.
In spite of the perception that it is healthier to live in the countryside,
it has been shown, in England, that the apparent health advantages associated
with rural areas largely disappear once levels of deprivation and affluence are
accounted for
7
. There are specific health
risks of rural communities such as zoonoses
8
and agricultural injuries
9
. An urban-rural gradient
for mental health problems has been reported in the UK, much of this accounted
for by differences in social adversity, stress and deprivation
10
. However, distinct from
rurality, remoteness may be associated with higher prevalence of psychiatric
disorder
11;12
. A high incidence of
suicide has been documented in the Highlands of Scotland
13
.
Recent additional pressures on rural communities, such as foot and mouth
disease, may have indirect human health consequences
14
. Excess mortality and
morbidity from road traffic accidents is a feature of rural communities
15;16
.
This probably reflects both an increased frequency of accidents and
poorer outcomes for accident victims, who may have longer delays in accessing
rescue services and reaching medical attention
16
.
Rural leisure pursuits are also associated with risk of injury or
illness, for example mountaineering and skiing accidents
17
, diving related accidents
and decompression illness
18
.
In addition to the demand on healthcare providers, these acute events may
be associated with high rescue and transportation costs, which impact on health
care provision.
Although
some health threats are specific to rural areas and there are differences in the
prevalence of some diseases, the main reason why rural health and health care
demands special attention relates to delivery of services and access for
patients. For cancer, there is evidence that distance from secondary care is
associated with delay in diagnosis and poorer outcomes
19;20
. In rural East Anglia,
asthma mortality increases with travel time from hospital
21
. Despite evidence on the
safety and efficacy of thrombolysis in acute myocardial infarction, provision of
this therapy in rural general practice is not universal
22
. Conversely, there may be
situations in which access to services is enhanced, the local configuration of
health services allowing for shorter waiting times than urban areas. Local
patterns of service delivery vary between rural areas. In the Highland Health
Board catchment, those areas where general practitioners have access to
inpatient beds demonstrate a reduction in district general hospital bed days for
general, geriatric and surgical patients, combined with an overall increase in
bed day use of 6-8% per 1000 patients
23
.
A
major issue for rural health services is the widening gap between demand and
supply. Demand will increase with ageing of the population and with increasing
expectations of health care, which may be greater among incomers
24
. Provision of services is
increasingly problematic. Historically,
the local general practitioner was regarded as the primary focus for health care
delivery in remote areas and was expected to provide round the clock emergency
cover as well as routine primary care services. Reduction in the working hours
of junior doctors, rationalisation of out-of-hours cover by primary care
co-operatives in towns and cities, and an increased desire for part time working
has meant that remote practice has become unattractive to younger doctors
3
.
Similar pressures apply to other primary health care professionals such
as nurses and professions allied to medicine, and in remote hospitals where
emergency rota cover must be achieved.
There
is an urgent and recognised need to address the issue of healthcare provision
for remote and rural areas
25
. One element of the
approach is the enhancement of our understanding of the issues through health
and social research. In the
remainder of this paper, we will describe some of the proposed initiatives to
deal with remote and rural health in Scotland, and will outline methodological
challenges facing researchers working in this field.
Remote
and Rural Health Initiatives
Recognition
of the health problems of remote and rural areas is not new: in 1912, the Dewar
report
26
highlighted many
difficulties with service provision which led to the formation of the Highlands
and Islands Medical Scheme, a forerunner of the National Health Service.
More recently, in 1997, the Acute Services Review
25
focussed on issues of
surgical access in the Highlands and Islands.
This led to the establishment, in 2000, of the Remote and Rural Areas
Resource Initiative (RARARI www.rarari.org.uk)
which has a remit to promote new service development, education for health care
professionals and research into the entire spectrum of rural health issues.
During recent years, a number of service delivery problems have become
increasingly acute: for example, failure to recruit general practitioners and
allied professionals to remote practices, and debates over the most appropriate
models for delivery of hospital services. Policy makers have begun to address
these problems. Resource allocation
in NHS Scotland is now weighted by rurality
27
.
Specific educational requirements for remote and rural health
professionals are beginning to be recognised
28
.
The particular problems of medical staffing in rural areas are discussed
in the recent Scottish medical workforce review
29
. The Scottish Telemedicine Action Forum (STAF - www.show.scot.nhs.uk/telemedicine)
has been tasked with implementing telemedicine schemes which might be expected
to improve health care provision in remote areas. Consideration is now being
given to alternative models of service delivery, patterns of work and forms of
remuneration for health professionals in remote areas. Developments will require
to take account of new technologies such as the internet, telemedicine and
telephone based advice services such as NHS24 (www.nhs24.com
).
Research
in Remote and Rural Areas
The
research agenda for remote and rural areas is broad and includes epidemiological
studies, work on specific rural health problems, evaluation of the clinical,
economic and social consequences of new service configurations and development
and evaluation of new technologies. Rural health research has much in common with research in
other settings but there are features that require special consideration. These
include ethical issues, study design, particularly with regard to definitions
and statistical power, logistic difficulties, costs and generalisability of
findings. The location of the
researchers may also be important. In general, urban-based researchers are
rightly concerned with urban issues and therefore may lack insights into the
rural agenda, although there are examples of high quality rural health research
generated from urban-based research departments
19;20;30
.
Conversely, rural-based researchers are at risk of academic isolation,
lacking routine access to academic seminars, lectures and library facilities.
Equally importantly they may lack the informal interactions with others through
which collaboration may be forged.
Research
ethical considerations in remote communities relate primarily to difficulties in
preserving anonymity, relevant both to quantitative and qualitative studies.
Identification of research participants through conspicuous visits by
researchers, or even from anonymised datasets by identifiable characteristics,
may be relatively easy in the remote rural setting. Rigorous data collection and
storage procedures are essential and the use of locally based research staff may
be precluded by these concerns. In qualitative work, great care must be
exercised in ensuring that direct quotations cannot be linked to a particular
person.
A
number of study design factors are important.
There are inherent problems of defining rurality and
remoteness in a way that allows meaningful comparisons between studies.
Many possible definitions have been described, based on measures of
population sparsity, settlement size, or distance from a key public service such
as a school or hospital. However, a single, generally accepted definition of
rurality is not yet available and indeed may be unachievable. As has been
described by others 3,25, the widely used socioeconomic indicators
such as the Townsend index
31
and the Carstairs index
32
, which are based on
postcode sectors, are derived largely from, and are relevant to, the urban but
not the rural setting. Rural
communities tend to be heterogeneous and it is therefore difficult to reflect
the focal distribution of rural deprivation within a postcode sector. In
addition some of the criteria which make up these indices, such as housing
tenure, overcrowding and car ownership, do not necessarily correlate well with
low income and deprivation in the rural setting.
The
sparseness of rural populations renders recruitment of adequate numbers to
achieve statistical power more difficult than in centres of high population
density. For research carried out in rural primary care where general practice
list sizes are comparatively small, more general practices need to be involved
to attain adequate numbers of patients or health care professionals.
This leads to recruitment difficulties and to greater confounding effects
of variation between practices. The
wide geographical scatter of subjects may lead to important cluster effects in
studies, which must be considered at the design stage.
Logistical
difficulties are particularly important where local data collection is required.
For example, the population density of the Scottish Highlands in the year
2000 was only 8 persons per square kilometre (General Register Office for
Scotland). This necessitates prolonged travelling time for the researcher if
subjects are to be studied close to home, or for the subjects if they are
required to visit a central location. The
latter may have an impact on participation rates. Similarly, where
epidemiological data on the health consequences of leisure pursuits such as
skiing and diving are sought, the mobility and transient nature of the at
risk population adds to difficulty in data collection.
Research
costs are heavily influenced by the expense of rural travel. As an example, we
estimated the travel costs for an Inverness-based researcher to carry out a
series of 1000 home interviews in a randomly selected population sample derived
from Highland Region and the Western Isles at 19,000.
This calculation is based on standard academic mileage rates and current
public transport costs. Use of
locally based research assistants reduces these costs, but local appropriately
skilled people are not always available and even if they are, it may, as
described earlier, be inappropriate to use local researchers for reasons of
confidentiality.
Generalisability
of research findings is a goal that many research funders and policy makers
rightly identify as important. However,
health services research in rural areas, particularly that which concerns models
of service delivery, is often context specific and therefore limited in its
wider application. This lack of generalisability is in itself a powerful
argument for rurally-based research. Anecdotally, there is also an unwritten,
but nevertheless well understood view in rural areas, held by the general
population and healthcare professionals, that the findings of locally performed
research should be locally applicable and researchers must be particularly
sensitive to this concern.
Opportunities
for research in rural areas
While
recognising the above concerns, there are major opportunities for research in
remote and rural areas. Recent events have focussed political attention on the
health and well-being of rural communities, and have highlighted the particular
problems faced by such communities. Issues of health care organisation and
delivery are being reconsidered, new models are being advocated and it is
essential to investigate the clinical and economic impact of these models.
Existing informal healthcare networks in rural and remote areas may allow
scope for much needed primary care/secondary care collaboration in research. One
methodological advantage of more scattered communities is that it may be
possible to carry out studies of interventions with less risk of contamination
between centres. Whereas patients and health care professionals in some urban
areas may feel that they have been over-researched, this is less likely to have
occurred in rural practices where they may be more willing to participate,
especially if the research has local relevance.
Conclusion
As
in other settings, rural and remote healthcare provision should have a firm
evidence base. It has been cogently argued however that the relevant evidence
base for rural healthcare practice is still largely absent and that we need to
have a broad perspective on clinical effectiveness
33
. Research to define and
measure best practice in the remote and rural setting therefore remains an
exciting and important challenge
34
. Such research should address clinical needs and effectiveness, cost
effectiveness and resource requirements. Barriers to carrying out high quality
research exist at methodological and practical levels but there are some
advantages of working in the rural setting. In Australia, USA and Canada,
progress has already been made in developing administrative and academic
agencies that have a specific rural focus. In the UK, the Institute of Rural
Health in Wales (www.rural-health.ac.uk)
is addressing a number of research issues in rural health. In Scotland, the
research and development strategy for primary care recognises that researchers
working in rural and remote areas are disadvantaged by lack of infrastructure
35
.
This difficulty is in part addressed by research networks, which provide
a educational and discussion forum for those working in practice e.g Highlands,
Islands and Grampian Research Network (www.highren.net
). The Scottish School of Primary Care (www.sspc.uk.com)
now provides a central coordinating role for primary care research in Scotland
and the Chief Scientist Office (www.show.scot.nhs.uk/cso
) has supported general practitioners through the research practice scheme.
The Highlands and Islands Health Research Institute (www.abdn.ac.uk/hihri)
is a new academic department whose major focus is remote and rural health
research and which is now linking to other international groups with similar
interests. It is important that
these researchers and potential sponsors of research should have insight into
the particular features of the rural and remote environment in which they intend
to work. This should ensure the development of a sound evidence base for future
health care provision.
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