The planning of rural health research: rurality and rural population issues

Rurality and rural population issues require special consideration when planning both qualitative and quantitative health research in rural areas. The objective of this article was to explore the issues that require attention when planning the research. This is the first of two articles and focus on issues that require consideration when undertaking rural health research. The diversity of study populations, the feasibility of a research topic, the selection of a research team, and the cultural traditions of Indigenous communities, are all aspects of rural health research planning that require attention. Procedures such as identifying the characteristics of the population, the selection of measures of rurality appropriate for the research topic, the use of local liaison persons, decisions on the use of 'insider' or 'outsider' researchers, and the identification of skills resources available, increase the quality of the research outcomes. These issues are relevant to both qualitative and quantitative research. Procedures are available to address issues of particular concern in developing appropriate methods for rural health research. While we have concentrated on Australian issues and solutions, rural localities in other countries may face similar issues. Attention to rurality and rural situations when planning rural health research, results in studies that support the continued improvement of health in rural communities.     

The growing importance of dental services in rural America

As the science of medicine progresses, associations between good oral health and improved health status are being documented. However, the data would suggest that individuals in America's rural communities are experiencing dramatic health problems because they are not receiving dental treatment. This article addresses the importance of dental services in rural communities and highlights the importance of cooperation among hospitals, individual clinical providers, community health care organizations, and governmental entities. It will also discuss why there is a shortage in these rural areas and how the shortage is affecting rural communities and will address some strategies for solving this crisis. This research on the availability of dental care in rural communities will provide a framework for community leaders, elected officials, and health care providers to collect and analyze data to support future decision making in response to community health care needs. Such decisions increase the quality and efficiency of health care services, thereby safeguarding the health status of the population. This study found that the capability for hospital-based dental care services is greater in urban communities, whereas rural communities have significantly less capability for hospital dental care. This would support the premise that the availability of dental services is inconsistent across the United States and that dental care resources could be allocated to provide a consistent level of services across the population. It also emphasizes the importance of building innovative partnerships among local, state, and national organizations to ensure that an appropriate level of dental care is available in rural America. The study has managerial implications on meeting the demand for dental care in rural communities and policy implications on future resource allocation.     

Complementary and alternative medicine in rural communities: current research and future directions

Contexts: The consumption of complementary and alternative medicine (CAM) in rural areas is a significant contemporary health care issue. An understanding of CAM use in rural health can provide a new perspective on health beliefs and practice as well as on some of the core service delivery issues facing rural health care generally. Purpose: This article presents the first review and synthesis of research findings on CAM use and practice in rural communities. Methods: A comprehensive search of literature from 1998 to 2010 in CINAHL, MEDLINE, AMED, and CSA Illumina (social sciences) was conducted. The search was confined to peer‐reviewed articles published in English reporting empirical research findings on the use or practice of CAM in rural settings. Findings: Research findings are grouped and examined according to 3 key themes: “prevalence of CAM use and practice,”“user profile and trends of CAM consumption,” and “potential drivers and barriers to CAM use and practice.” Conclusions: Evidence from recent research illustrates the substantial prevalence and complexity of CAM use in rural regions. A number of potential gaps in our understanding of CAM use and practice in rural settings are also identified.     

Health and poverty in rural Scotland

This paper presents findings from a study on rural disadvantage to explore the implications of disadvantage for the health of rural communities and the organisation and delivery of health care services in rural areas. Rural health research has been a neglected topic. Yet previous research has reported the importance local people and practitioners place on the provision and organisation of health services in rural areas.' The research reported in this paper further emphasises this point and, in addition, provides empirical data on local people and practitioners perceptions of health issues and health services in four areas of rural Scotland.     

Issues in rural adolescent mental health in Australia

The mental health of adolescents living in rural Australia has received little research attention. In this article, the extant literature on rural adolescent mental health in Australia is reviewed. Given the lack of literature on this topic, the review is centered on a vignette presented at the beginning of the article. The case represented by the vignette is that of a young Australian growing up in a rural area. The issues raised--including the nature of mental health issues for rural adolescents and barriers to seeking professional help--are then discussed in terms of the available literature. The article concludes with a future focus for research efforts in the area of rural adolescent mental health.     

Rural Public Health: Policy and Research Opportunities

Changes in the health care system, medicine, and technology as well as in the characteristics of rural communities raise issues that impact the responsiveness of the rural public health system to emerging threats to health. These issues, which are systemic in nature and primarily involve the infrastructure of public health, include the capacity of rural public health to manage population health, utilize information technology, monitor performance of the essential public health functions, develop leadership and the public health workforce, and promote the interaction and integration of public health and health care. This article provides an overview of policy and research implications, and it suggests that each of these issues contributes to the capacity of public health to effectively improve the outcomes of health in rural communities.     

Anonymity and confidentiality: rural teenagers' concerns when accessing sexual health services

CONTEXT: While confidentiality is recognised as a key aspect of successful health services aimed at young people, most research has looked at the concerns of those in urban centres. This paper reports on qualitative and quantitative data collected from general practitioners (GPs) and young people in a rural health district. OBJECTIVE: To assess the concerns of rural teenagers regarding anonymity and confidentiality when accessing sexual health services. DESIGN: The views of teenagers about using health services for issues of sexual health were sought through an in-school survey of 311 Year 9 and 119 Year 11 students. In addition, 18 single-sex focus groups discussions were conducted in North and East Devon. All GPs in the district were asked to complete a questionnaire. RESULTS: These reveal that the particular concerns of young people from small communities are more to do with the difficulties of remaining anonymous, which are related to visibility and lack of privacy in small communities. These problems were more pervasive among rural young people than those concerns more usually reported about confidential consultations.     

The health service needs of small rural communities

ABSTRACT: In recent years econometric models used in health service planning have tended to encourage the downgrading or closure of small rural hospitals with the effect of reducing access to services and transferring costs from health authorities to consumers. These changes have occurred despite mounting evidence that people in rural communities have specific health service needs which require special attention. This study aimed to identify the perceptions of community members, health professionals and administrators regarding the health service needs in their small rural communities as a basis for developing a more comprehensive model of rural health service planning. Focus groups were held in three selected towns in Gippsland, exploring participants' perceptions of the meaning of health, health service needs, impact of health services, and the best set-up for health services. Consistent with previous research, key findings include: a broad conceptualisation of health; the perceived overwhelming importance of doctors, hospitals and chemists; the economic and social importance of a rural hospital; and a preference for all health services being provided under the one roof, funding and program flexibility, and local involvement in health service planning and implementation.     

A framework for modeling the consumption of health services by the rural elderly

This paper reports on an ongoing research program which seeks to assess the implications of population aging for housing, services and transportation in rural communities in the Province of Ontario. Specifically, the focus is on the modeling of health and social service consumption by elderly (over 65) persons. Following a review of the literature on service provision to senior citizens in Ontario, a modeling framework conceptualizing the process of service utilization at both the aggregate (user and nonuser characteristics) and individual (decision-making) levels is introduced. Data on use of community support services drawn from a survey of elderly residents in two communities in Grey County, Ontario (Meaford, population 4380 in 1986, and Markdale, population 1226 in 1986) are used to illustrate the general features of the modeling framework. Particular attention is paid to the ability of the modeling framework to yield insights into the origins of notable variations in service use rates between men and women. Overall, the results are taken to be supportive of the usefulness of the modeling framework as a template for guiding empirical analysis of service utilization patterns. At the same time the case study testifies to the complex and dynamic nature of service provision issues in rural communities. The challenge of providing services effectively to an elderly rural population located in scattered villages and small towns will continue to tax the imagination and resources of responsible agencies.     

Transformation of a rural community for active living

The current economic recession is challenging all communities to protect and promote the health and well-being of children and families. Rural communities are often more vulnerable than their more urban counterparts because of limited resources and services. Successful models are needed in rural communities that demonstrate the benefits of linking programs, services, and policies that promote active living to improve population health. This article reports the lessons learned by the Martinsville-Henry County Coalition for Health and Wellness and Activate initiative as a rural model for active living and provides recommendations for other rural communities.     

AHRQ series paper 4: assessing harms when comparing medical interventions: AHRQ and the effective health-care program

Comparative effectiveness reviews (CERs) are systematic reviews that evaluate evidence on alternative interventions to help clinicians, policy makers, and patients make informed treatment choices. Reviews should assess harms and benefits to provide balanced assessments of alternative interventions. Identifying important harms of treatment and quantifying the magnitude of any risks require CER authors to consider a broad range of data sources, including randomized controlled trials (RCTs) and observational studies. This may require evaluation of unpublished data in addition to published reports. Appropriate synthesis of harms data must also consider issues related to evaluation of rare or uncommon events, assessments of equivalence or noninferiority, and use of indirect comparisons. This article presents guidance for evaluating harms when conducting and reporting CERs. We include suggestions for prioritizing harms to be evaluated, use of terminology related to reporting of harms, selection of sources of evidence on harms, assessment of risk of bias (quality) of harms reporting, synthesis of evidence on harms, and reporting of evidence on harms.     

AIDS survey methodology with black Americans

Unique substantive and methodological issues are involved in conducting survey research on sexual and HIV risk related behaviors among Americans of African descent. Problem conceptualization, sampling, design of instruments, mode of data collection, interviewer/respondent characteristics, community resistance, and data analysis and interpretation are discussed. The lack of survey research on sensitive health issues is noted. Possible methods for addressing these issues are drawn from the experiences of the authors in conducting national research on the general and at risk Black community populations. It is concluded that attention to these issues can substantially improve the quality of research on AIDS related behaviors on Black communities. Finally, it is suggested that behavioral theories and sophisticated methodological and analytic approaches, sensitive to the special cultural dimensions of racial/ethnic life in the United States, would contribute substantially to the scientific armamentarium needed to successfully meet the challenge of the AIDS epidemic.     

Biopsychosocial imperatives from the rural perspective

Rural health issues are examined within a biopsychosocial framework by addressing three questions: what is meant by ‘rural’? what are rural health needs? what factors must be considered in understanding and addressing these needs?Probably the single most important characteristic distinguishing rural from urban areas is low population density. This factor is particularly important in terms of its impact on (1) communication and transportation patterns, (2) one's ‘sense of community’ and (3) the availability of specialized services and complex organizations and institutions.For statistical purposes two different definitional dichotomies exist: rural-urban and metropolitan-nonmetropolitan. Although the rural and nonmetropolitan populations are not conterminous, approximately the same percentage of the nation's population is included in each of the two categories. A serious misconception is that of equating agriculture with rurality. While most farmers live and work in rural areas only a small fraction of rural Americans are engaged in agriculture.In terms of health needs, infant mortality tends to be higher in nonmetropolitan than in metropolitan areas; and limitation of activity due to chronic conditions is more likely to occur among the nonmetropolitan than the metropolitan population. Similarly, the percent of people who perceive their health as either ‘fair’ or ‘poor’ is higher for the nonmetropolitan population. On the other hand, the incidence of acute conditions and disability days per person per year are lower for the nonmetropolitan population than for the metropolitan population. Limited data on mental health suggest that the halcyon picture of country life may be grossly distorted.Understanding and addressing rural health needs involves a close look at the social, economic and medical systems operating in rural America. Income and employment levels, and their interrelationship to nutrition, housing and transportation generally find rural areas at a disadvantage. Although attitudes and values between rural and urban populations differ, it is all too easy to exaggerate these differences. The areas of sharpest differences have to do with issues of morality, religion and political philosophy. Problems in the availability and accessibility of medical services—especially specialized services—continue to plague rural areas.Recently, the most important dynamic in rural areas has been the rapid population growth associated with urban-to-rural migration. Another important characteristic of rural America is its diversity. Greater diversity likely exists among rural areas than among urban areas. For example, some rural areas have medical systems that are as sophisticated as those found in most urban areas.Failing to recognize and appreciate the diversity within the rural sector may be the greatest impediment to designing and implementing effective public policies for dealing with rural health needs. Considerable research, recent books, the creation of statewide offices of rural health and the work of national organizations have been helpful in alleviating the misunderstanding which surrounds rural America, its health care needs and the ways to best address those needs.     

Health Care Needs of the Growing Latino Population in Rural America: Focus Group Findings in One Midwestern State

Latinos represent nearly 13% of the U.S. population, surpassing African-Americans as the nation's largest racial/ethnic group. Many rural midwestern communities are seeing unprecedented growth in their Latino populations, creating new challenges and pressures for health and social service providers. This study is based on four focus groups conducted in three rural communities to examine concerns with health care services and access to care. Focus group analysis found several key barriers to health care access, including cost of health care services and frustration with the complexity of the U.S. health care system, as well as language and cultural issues that adversely affect patient-provider relationships. In addition, a number of impediments related to employer-sponsored health coverage were identified, including prohibitive premium costs as well as concerns about occupational injuries and access to care during work hours. The growth of the Latino population in the rural Midwest will require changes in existing health and social service systems to serve as a bridge to new systems in this country. We recommend several policy options including premium subsidies for low-wage jobs, community-based enrollment specialists for public programs, and continued research and data collection to monitor change and progress.     

“People are struggling in this area:” a qualitative study of women’s perspectives of telehealth in rural South Carolina

ABSTRACT

Rural communities face disparities and barriers to health care access that may be addressed through telehealth programs; yet little research is available detailing rural women’s attitudes toward telehealth. Researchers partnered with a women’s reproductive health organization to conduct formative audience research to understand rural women’s perspectives of telehealth in their communities. Qualitative research was conducted to improve understandings of women’s perceptions of telehealth in rural South Carolina. In-depth interviews with 52 women aged 18–44 years were conducted in five rural counties in South Carolina during June – August 2015. Analytical techniques from grounded theory methodology were used throughout data collection and analysis. Participants believed a telehealth intervention would benefit the community by addressing reproductive health barriers, such as cost, transportation, and long wait times at local health care facilities. Participants’ concerns included issues of confidentiality in a small town, discomfort with mediated communication, privacy, and the importance of relationship-centered care, including patient-provider communication and approachability of health care providers. Findings provide insight to design and implement telehealth interventions to improve women’s health in rural communities.     

Cancer treatment in rural areas

The inability to deliver cancer prevention and treatment to the rural population poses a significant barrier in the national effort to reduce cancer mortality. Since 25 percent of the U.S. population lives in rural areas and few rural areas are readily accessible to cancer centers or Community Clinical Oncology Programs (CCOPs), the prospects for accomplishing the National Cancer Institute (NCI) Goals for the Year 2000 are limited unless substantive changes occur in rural cancer care delivery. This article reviews the problem of cancer risk and care in rural areas and describes one effort to deliver state-of-the-art cancer treatment to rural patients in Virginia. It describes the needs and barriers to access in rural Virginia, the structural elements of the Rural Cancer Outreach Program, and the health policy issues that result when subspecialty care is exported to disadvantaged areas.     

Determinants of rural women's health: a qualitative study in Southwest Ontario.

CONTEXT: The influences of gender and geography are increasingly being acknowledged as central to a comprehensive understanding of health. Since little research on rural women's health has been conducted, an in-depth qualitative approach is necessary to gain a better initial understanding of this population. PURPOSE: To explore the determinants of health and their influence on rural women's health. METHODS: From November 2004 to September 2005, 9 focus groups and 3 individual interviews were conducted in 7 rural southwestern Ontario communities. Sixty-five rural residents aged 26 years and older participated in the study. Semi-structured interview questions were used to elicit participants' perceptions regarding determinants of rural women's health. FINDINGS: Four Health Canada determinants (employment, gender, health services, and social environments) and 3 new determinants (rural change, rural culture, and rural pride) emerged as key to rural women's health. CONCLUSIONS: Although health determinants affect both urban and rural people, this qualitative study revealed that rural women experience health determinants in unique ways and that rural residents may indeed have determinants of their health that are particular to them. More research is needed to explore the nature and effects of determinants of health for rural residents in general, and rural women in particular.     

我国农村居民自评健康状况与报告行为实证研究

目的:对我国农村居民的自评健康以及自评健康报告行为进行测量,检验自评健康指标的可靠性与稳健性。方法:采用多阶段整群抽样法抽取了3省1 800户农户进行入户调查,共有5 849名农村居民纳入分析。使用世界价值观调查表中的自评健康状况问题,EQ-5D量表以及中国一般人群健康效用值积分体系,分别测量农村居民的自评健康状况和潜在健康状况,并利用两者的系统测量误差反映报告行为。采用卡方检验与方差分析检验不同特征农村居民的自评健康与报告行为的差异性。结果:农村地区女性、65岁及以上老年人群、小学及以下低学历水平、离退休、无业或失业、低收入水平、患有多种慢性病人群中,自评健康状况为"好"的比例相比其他人群更低,这部分农村居民的自评健康状况报告行为也更加悲观。结论:我国农村居民自评健康状况与报告行为变化趋势一致。自评健康指标在测量健康水平上具有较高的可靠性与稳健性。罹患合并症的慢性病患者是慢性病健康管理的重点人群。老年人群需要得到更多支持与关注。低收入水平对报告行为的负效应强于其他收入水平。健康行为与自评健康和报告行为的关系有待进一步挖掘。     

Meeting the needs of rural populations through interdisciplinary partnerships

This article describes the organization and outcomes of a Rural Health Outreach Initiative (RHOI) designed to increase collaboration between the medical education and health care delivery sectors to improve the quality of health care delivery and health outcomes in rural communities. Two inter-related partnership strategies were utilized in rural communities to address the health and social service needs of rural populations. The partnerships were created through the efforts of a rural health professions education program located in a community-based medical school. The two partnership models were implemented at the same time and target the same rural populations. Both strategies relied upon interdisciplinary collaborations to achieve their goals and outcomes. One strategy involved the creation of partnerships among rural medical students and the projects they initiate, using the model of community oriented primary care (COPC). The second strategy involved the establishment of partnerships by a variety of rural, community-based entities that resulted from a three-year Health Resources and Services Administration Rural Health Outreach grant that supported a "mini-grant" program. This article summarizes the process and results of these innovative collaborations that occurred at two levels: (1) between health and service institutions representing multiple disciplines and (2) between academic institutions and local communities. Specific attention is given to projects that resulted from the work of the partnerships that address the needs of older adults residing in the rural communities. The two strategies are compared and implications for the success of similar efforts are discussed.     

Investigating the health of rural communities: toward framework development

How healthy are the residents of rural Canada? How healthy are Canada's rural communities? Members of an interdisciplinary research team at the Brandon University Rural Development Institute, Manitoba, Canada, formed a partnership with rural stakeholders in an attempt to strengthen and build capacity in rural communities. One component of this research was the development of a framework to assist residents of rural communities to assess the health and sustainability of their community. Through dialogue with partners and review of the literature, a preliminary framework can be generated. This article formed the first step in the creation of such a framework. The article begins with common term and concept development, extends to a critical analysis of framework literature and culminates with consideration of steps to be taken next in the establishment of a framework and indicators that are both meaningful and useful for rural residents and their communities.