Key Research Issues

Rural Canada makes up 90% of our land and approximately 18.5% of our population. Our health is influenced by where we live. It has been shown that people living in rural areas have poorer health than those living in urban areas. However, everyone has a right to be as healthy as they can be. This is called health equity.  

 Health equity means that everyone has a fair and just opportunity to be as healthy as possible. – Robert Wood Johnson Foundation 

Research helps us understand why health differences exist and find solutions. Research can be defined as:

 the process that asks questions, finds answers in a systematic way, analyses the results of each study, judges their quality and meaning, integrates the results of different studies, investigates the applicability of the results to (rural health and rural practice), and disseminates the results both to professionals and to the public in order to promote awareness, knowledge and change. – Strasser 2001

At present, most health research is done in urban settings. Unfortunately, solutions that work well for the city do not always work for rural environments. The realities and needs of rural people are distinct, and rural health systems and practices are different.  Conducting rural health research in rural communities will identify the best solutions for the local areas.  

Examples of rural health research topics include: 

• the rural health context and rural health practice  
• health of rural residents, main health issues (morbidity), and reasons for death (mortality) 
• rural health services for rural people as a large group (population health) and individuals (primary health care) 
• issues related to health providers working in rural areas, including the care they provide and how to attract and retain them 
• specific clinical tasks and topics in rural health 

The findings of rural health research will help to create programs, policies, and practices that improve the health of rural people. Research in rural areas also creates important data and builds research abilities that can be fed back into the community to generate more research down the road. 

When conducting rural health research, it is important to define what we mean by “rural”. The definition should include the geographic area that we want to investigate, the rural population, and the distance to urban centres.  

Most people think of rural as non-urban; but it is more complicated than that. How we define “rural” matters as it can lead to different research results. For example, one study has shown that the rural population number varies by as much as 16% depending on how rural was defined. Unfortunately, there is no commonly agreed upon definition of rural. 

Some popular definitions use distance and density to define rural. One way to do this is to use the Statistics Canada definition of Metropolitan Influenced Zone (MIZ). This approach divides communities based on their access to urban centres (strong, moderate, weak, no MIZ). Strong MIZ communities are typically closer to urban centres and have a higher population. Also, residents in strong MIZ communities travel to urban centres for recreation, banking, entertainment, and at least 30% of those employed work in the city. In weak MIZ communities, less than 5% of those with jobs work in the city.

Choosing an appropriate definition of ‘rural’ for research allows to better understand research findings. It also allows researchers to compare data from different communities and over time. 

High quality rural health research requires considerable knowledge, skills, and understanding of local context. The rural context has some special challenges for researchers.  

Rural health-care providers have an important role to play in rural health research. In rural practice, the close relationships with patients and other rural health providers happen naturally. This makes it easier to see gaps in care and explore ways to help the patient.

Erin Albrecht, a pharmacists in Manning is passionate about research and even won an award for her work!

However, rural health research has its challenges. With smaller populations, it can be difficult to find people that are willing to participate. Interested people also must meet certain criteria before they can become research participants. Some rural residents may feel reluctant to participate because of privacy concerns. They may worry that the community could find out about their health condition or their personal opinions about a health-care issue. This can be even more difficult when the researcher lives and works in the same community.  

One solution is to have an outside person assist with data collection. The downside is that an external person may not have a good understanding of the local issues, or the trust of the participants. On the other hand, this makes it easier for them to be neutral. Researchers can use different ways of collecting data to protect the participant’s privacy. For example, anonymous surveys can be used as these do not contain names or other identifying information. Researchers can also complete individual interviews on the phone instead of in-person or in a group setting. These methods can help participants to express their views and concerns more freely. 

Another issue is whether local health professionals have the time, skills and resources to do research in their communities. To build their research skills and find resources, they can connect with the Alberta Strategy for Patient-Oriented Research (SPOR) Support Unit. The SPOR service centre helps researchers with questions about methods, data analysis, and communication of findings.  

It is also important to create opportunities for rural residents to participate in research as co-creators, not just as research participants. As co-creators, community members identify research questions that are most meaningful, help with data collection, and interpret the findings based on their understanding of the community. This approach makes research relevant to the community, and rural residents are more likely to accept and value the findings.  

Lastly, it is important that researchers honor the time and expertise of community residents that participated in the research. Researchers need to find useful and practical ways to tell the community what was learned. Likely, the research will identify both strengths and challenges facing communities and residents. Researchers need to be open about these findings and think about how this information may affect the people and communities they are working with. Good researchers support communities to focus on creating solutions that build on their strength in order to make improvements. 

Rural health research is important. The views and experiences of rural people give a different perspective on health and health care. By using the right tools and engaging with rural residents, researchers can be a valuable voice for rural communities. 

We have all been impacted by the COVID-19 pandemic in one way or another. Emerging data from the United States has shown that rural residents face unique risks related to COVID-19. For example, one study showed that 50% of rural residents are at high risk for hospitalization and serious illness if they are infected with COVID‐19 due to advanced age and pre-existing health conditions. It was also estimated that rural residents will generate around 10% more hospitalizations for COVID‐19 per capita than urban residents given equal infection rates. This is of particular concern because rural residents may live far from a hospital and rural regions have a disproportionately small percentage of ICU beds, ventilators, and respiratory treatments.

As we have been witnessing the science and research evolve in front of our very eyes, the pandemic has revealed some big gaps in current approaches to health research. Tackling these challenges will help to better understand how COVID-19 affects different populations. From there, scientists can develop new treatments, and governments can create policies to help protect vulnerable groups. 

Rural residents under-represented in COVID-19 research 

Research studies have already begun the process of exploring the behaviour of the COVID-19 virus in various regions and the effects of the virus on people and societies. Unfortunately, the bulk of this research has concentrated on nations and cities and rural populations have been largely left out of the research. One study conducted in rural regions of the American West found that the effects of the COVID-19 pandemic on rural populations have been severe. In particular, there have been significant negative impacts on rural well-being including employment, overall life satisfaction, mental health, and economic outlook.  

Ongoing research and timely data collection on rural people and the impacts they are experiencing is key to a full recovery from this pandemic. Data is needed for evidence-informed policies that support the wellbeing of a large and diverse rural population. 

Historically, women were excluded from clinical trials largely because of the potential for pregnancy during the research. This approach to science resulted in only understanding disease and treatment in male bodies, which meant diagnosis and treatment in women was suboptimal.  

Women living in rural areas are even further under-represented in health research. Research shows that there are no significant differences between rural and urban residents in their willingness to participate; however, rural residents were more likely to perceive limited access to research sites and lack of awareness of available opportunities.

There have been significant efforts to increase the recruitment and participation of women in health research studies and minimize the risks associated with potential pregnancy. However, pregnant women are still excluded from most research because they are both vulnerable and ‘scientifically complex’. This means that research about the use of drugs and other treatments in pregnancy is severely limited, although pregnant women are still vulnerable to infections and diseases like COVID-19. 

A recent review of the research studies examining COVID-19 treatments showed that 75-80% excluded pregnant women. Key findings of this study were:

1. The exclusion of pregnant women as research participants was not well justified as many of the treatments being evaluated have no or low safety concerns during pregnancy.  
2. Inclusion of pregnant women in clinical treatment trials is urgently needed to identify effective COVID-19 treatment for this population. 

Fair inclusion of pregnant women in research could be achieved by conducting separate trials for this group early on. It is also critical for health researchers to further develop the science around medicine use in pregnant women. 

The University of Calgary is conducting a research study on women that were pregnant during COVID-19. The research team aimed to enroll 1,200 pregnant women across Canada to ask them about their health, worries for their baby, and how life changes during the pandemic have affected them. More than 11,000 women across Canada responded!

While the enrollment for this study is now closed, you can find updates on the study findings on the research website.

The University of Calgary runs a unique program that trains patients to become health researchers – the Patient and Community Engagement Research (PaCER) program. The idea of PaCER was born when a group of seniors expressed discomfort with the negative image of aging research. They wanted to challenge the researchers’ assumptions that aging was defined by burdens. Instead, they wanted to do their own research and focus on resilience.

This approach was so successful – leading to better research, new methods, several presentations, publications, and even a book – that the approach soon expanded into other areas of study and PaCER was born. 

 “It’s so exciting to see how a collective patient voice is helping to transform community-based support for Albertans with arthritis.” –Jean Miller, patient researcher, PaCER

Through this certificate program, patients learn about different research approaches. They also have an opportunity to do a practicum and conduct their own research project. Once PaCERs have completed their training, they can become involved in various health research projects. The program recognizes that patients have unique lived experience through their patient journey and that their perspectives can help improve the health-care system. PaCER allows patients to have a stronger voice in health care and health policy. Click here to access a list of publications about the various projects they have conducted to transform the role of patients in health care and the health culture through engagement research. 

RhPAP engages in and supports research related to the education, attraction, and retention of health providers that practice in rural areas. By collaborating with partners on research projects and initiatives across Alberta, RhPAP aims to develop innovative programs and policy towards improved rural health services and outcomes. 

RhPAP has funded and supported over 30 published studies on rural health:

• Building on Success: A study of Rural Alberta Communities’ Success Strategies in Attracting and Retaining Health Professionals (2019)
• Alberta Family Physician Electronic Endoscopy Study (2018)
• Challenges and Opportunities in Rural Preceptorship (2016-2018)
• Scope of Practice of Family Medicine Graduates who Completed a Rural Versus Urban Program (2018)
• Well-being of Family Medicine Graduates (2017)
• Implications of Not Matching to a First-choice Discipline: a Family Medicine Perspective (2017)
• Perceived Preparedness for Rural Practice: Does Rural Background Matter? (2013)
• The Alberta Primary Care Endoscopy (APC-Endo) Study (2013)
• Rural Physicians’ Skills Enrichment Program: A Cohort Control Study of Retention in Alberta (2012)
• Locum Practice by Recent Family Medicine Graduates (2010)
• Family Medicine Graduates’ Perceptions of Intimidation, Harassment, and Discrimination During Residency Training (2011)
• Physician Retention in Rural Alberta: Key Community Factors (2010)
• Outcomes of 1949 Endoscopic Procedures Performed by a Canadian Rural Family Physician (2009)
• Why Would I Choose a Career in Family Medicine? (2007)
• What is Medicine? Recruiting High-school Students into Family Medicine (2006)
• The Pandemic from Within: Two Surveys of Physician Burnout in Canada (2006)
• Additional Skills Training for Rural Physicians. Alberta’s Rural Physician Action Plan (2006)
• Acute Myocardial Infarction: Quality of Care in Rural Alberta (2006)
• General Emergency Medicine Skills for Rural Doctors (2006)
• Preparedness for Rural Community Leadership and its Impact on Practice Location of Family Medicine Graduates (2005)
• Do Students from Rural Backgrounds Engage in Rural Family Practice More Than Their Urban-Raised Peers? (2004)
• Introducing Personal Digital Assistants to Family Physician Teachers (2003)
• Does a Rural Educational Experience Influence Students’ Likelihood of Rural Practice? Impact of Student Background and Gender (2002)
• Rural Surgical Programs in Western Canada (2002)
• A Study of Alberta Physician Burnout (2002)
• Location of Family Medicine Graduates’ Practices: What Factors Influence Albertan’s Choices? (2001)
• Rural-Urban and Gender Differences in Procedures Performed by Family Practice Residency Graduates (2001)
• Alberta’s Rural Physician Action Plan: An Integrated Approach to Education, Recruitment and Retention (1998)
• Outcome of Thrombolysis in Patients with Acute Myocardial Infarction in Rural Alberta (1997)

Rural health professionals have an important role in conducting and applying research to improve the health of individuals, families, and rural communities. Often, research capacity in rural communities is low. This means that there is limited research created by rural researchers that is relevant to their community and can help to create better rural practice, programs and policies.  

 Research capacity strengthening is the process by which individuals, institutions and societies develop abilities – individually and collectively – to perform research.

There are several reasons for this including:  

• Rural practitioners may not have the time to do research because they are busy caring for patients  
• Rural practitioners may not have the knowledge and skills to feel comfortable to do research; they may not have mentors or collaborators to help them with the research 
• There might be no infrastructure to do research (such as computer programs to collect and analyze data) 
• There might be a lack of funding and support in the work environment that makes doing research difficult 

There are many strategies to strengthen research capacity in rural communities. Creating a research culture and environment that allows researchers to be successful is the first and most challenging step. Rural policies and programs need to consider local researcher training, funding, and infrastructure to support local health providers to conduct research. Local researchers also benefit from mentoring and collaboration opportunities with urban research centres and from professional development opportunities that focus on rural health issues and research skills.  

The Memorial University of Newfoundland introduced a research training program for rural physicians to enhance their research capacity. The program also removed barriers commonly experienced by rural health researchers (lack of mentoring, collaborative opportunities, infrastructure, resources). The program effectively  increased physicians’ research knowledge and skills. Physicians’ research productivity also increased, measured as publications, grants and presentations of research-related work at conferences.

Another great example is the work being done at the Interior Health Authority in British Columbia. They have used a number of strategies to build research capacity in rural communities, including:  

• Brown bag lunch seminars to share research results related to rural health 
• Research skills workshop series for rural practitioners 
• Literature reviews and summaries on priority topic areas 
• Research collaborations/partnerships with academic researchers, health authorities, and research networks 
• Annual rural research conference