Statistics suggest that the prevalence of maladies, medical conditions and probability for medical conditions exist more intensely in rural areas, yet no noteworthy studies have been directed primarily to the sector. A group of residents and healthcare professionals in a rural Ontario community in Huron County are creating a centre to research healthcare issues in rural populations, the first community-driven rural research centre in Canada. Most of healthcare-related research conducted in Canada and elsewhere is based on results of surveys taken of test populations close to large urban medical centres of learning or practice, with projections of results for rural sector populations.
The research institute will have synergy in its chosen location, Seaforth Ontario, a town in the Municipality of Huron East. Among its community-driven initiatives in healthcare, Seaforth is home to a community-governed Family Health Team, a regional Community Care Access Centre, a medical clinic, a hospital allied with five others in the region, the award-winning Healthkick initiative that is focused on physician and medical professional recruitment, and a Registered Practical Nurse training extension program conducted by an Ontario community college. It has just completed construction of a 12,000 sq ft medical centre. It is also located in the initial study area – Huron, Perth, Grey and Bruce. Initial funding has been committed by a private foundation to attract a noted medical physician and researcher specializing in cardiovascular and ateriosclerotic issues. This business case outlines the genesis of the project, its achievable plans and aspirations, and its objectives to promote healthcare in a population and geographic sector (initially the counties of Huron, Perth, Grey and Bruce, then provincially and nationally) not well under study or documented. Benefits of the program are multi-faceted. Local rural physicians will be engaged in supportive and collegial modes and will benefit from opportunities to study issues they themselves identify in their practices. Pharmaceutical firms will benefit from test beds for medications in a regime of clients, prescribers and pharmacists who are eager to participate and easily monitored. The sponsoring and surrounding communities will benefit by active participation in community-driven research. The provincial health ministry will benefit by improved delivery of care to rural populations. Results of the community-driven research programs will be shared broadly and without reservation to all researchers, healthcare professionals and the public interested in rural health issues. Rural-based students and volunteers will benefit from training programs in medical investigation and analysis. The vision of the proponents is to make a measurable impact on the research affecting residents and the healthcare of residents in rural communities in Ontario and elsewhere. A comprehensive marketing plan tailored to rural areas is outlined to communicate the aims and purposes of the research programs to residents and the broader public to benefit researchers, physicians and public. Estimated costs for the first three years of operations are $1,718,000. Thirty-five per cent of this funding has been sought and committed.
It has become increasingly clear in recent years that clinical research addressing health issues specific to rural communities in Canada is insufficient. Funding for rural health research has not been a high priority in Canada even though about one third of Canadians, approximately 9 million people, live in rural areas and face significant and distinct challenges in health care (15.1). The death rates or prevalence of important chronic diseases such as ischemic heart disease, stroke, diabetes, some forms of cancer, and depression are considerably higher in rural communities than in the urban sector (Figs 1-4).
Source: Stats Canada, Canadian Community Health Survey 2001
Rural Ontario has the second highest death rates from cardiac causes in Canada, only after east coast provinces. The Huron-Perth-Grey-Bruce region has one of the highest cardiac death rates (15.2) within rural Ontario. Moreover, the prevalence of diabetes in the Grey-Bruce area is double (8.0%) that of the Middlesex-London (4.1%), a neighbouring urban area (15.3) (Fig 4).
There is a claim that “in Canada there is a two-tier health care system, not between rich and poor, but between rural and urban (15.4).” This situation is in part due to a failure of health policies to recognize the distinctive nature of the health care needs of rural communities, which in turn is due largely to insufficient research (15.5). This proposal suggests that it is important to build research capacity in rural areas to help highlight its distinctive health issues, and provide vital information to policy makers to effect rural-specific health policies. The Huron-Perth-Grey-Bruce region offers exceptional conditions to conduct clinical research, yet the area is fragmented and served by only a few isolated centres. The region combines ideal demographic and socio-economic profiles with high quality health care professionals. The total population in these counties shown in Table 1 is about 300,000 people of which about 38% are 50 or more years of age. (15.6).
Table 1. Population by county, Stats Canada 2002
County
Total
Male
Female
Huron
59,325
29,255
30,075
Grey
92,411
45,450
46,960
Perth
74,340
36,445
37,895
Bruce
65,349
32,345
32,905
Total
291,425
143,495
147,835
Proportionally, the Huron-Perth-Grey-Bruce area has the third largest group of seniors in Canada. The prevalence of chronic diseases associated with aging in these communities is high. The population enjoys socio-economic and political stability, conditions that are important for successful clinical research to yield high quality data. Existing health care centres offer an established network of highly qualified health care practitioners including physicians, nurse practitioners, and pharmacists who could collaborate on research projects. The proximity of this area to Toronto, Hamilton and London, hubs for medical research in Canada, creates a natural link between rural health centres and world-renowned clinical investigators favouring active clinical investigation. However, current collaboration on academic research projects with rural research outside these urban centres is virtually non-existent.
Recognizing the urgency of implementing local initiatives to confront a difficult health reality, members of the community in Huron County have created a rural research educational academic and teaching (GRREAT) centre, incorporated as the Gateway Rural Health Research Institute in Seaforth, Ontario (Fig. 6). The mission of the centre is to organize and coordinate complementing activities including operating community outreach programs, coordinating educational programs in rural health services and building a strong infrastructure for clinical research on rural health issues. A primary goal of the research institute is to encourage and support local investigators in all aspects of conducting research relevant to the rural population, from writing research proposals to preparing draft for publications.
The research centre will be built on a strategy that involves promoting the centre in the community, creating a network of investigators across the region, training of research staff, preparing grant applications for funding, and establishing long-term partnerships with regional academic centres such as McMaster University (Hamilton), the University of Western Ontario (London) and York University and the University of Toronto (Toronto). Some of the measures of success of the centre will be the number of investigators participating, quality and number of research papers publisheds, number of enquiries generated by publications, enquiries to participate, funded programs committed, funded programs underway, numbers of patients participating and academic collaborations.
Initial research projects will focus on determining the health status of disadvantaged rural sub-populations including patients without access to continuous comprehensive health care or “orphan” patients. In Huron County alone there are approximately 12,000 residents without a family doctor1 or about 20% of the total population (Fig 5) (15.6). To our knowledge, there is no publication reporting on the actual health status of orphan patients. Review of local conditions suggests that their medical status is grim. The focus of research on the sector will be on cardiovascular health (heart disease and stroke), diabetes, as well as associated risk factors such as hypertension, hyperlipidemia and obesity. In addition, an important research priority will be to ascertain the status of mental health of women in the area. In United States, the rate of depression in rural women is double that of urban women (15.7,15.8).
A centre for clinical research in the Huron-Perth-Grey-Bruce area will benefit all stakeholders including the community at large, patients, investigators, and academic centres. The community will benefit from research activity that can lead to rural friendly health policies. The centre will be a source of employment for local residents. Patients will have access to assessment of health status and will be able to participate in novel therapies and prevention programs. For physicians, conducting clinical research is a rewarding experience that can contribute to a satisfying medical practice in a rural setting. The centre can help to recruit and retain doctors or other health care workers. Collaborating academic centres will have access to an immediate network of qualified community-based investigators.
The principal challenges will be to overcome funding limitations, investigators’ lack of time for research, and cultural attitudes toward clinical research. Rural research has not been a priority for funding but this will change as communities take the initiative and build research capacity to document needs and requests for funding. Physicians’ lack of time is a main reason for not engaging in clinical research. The centre will minimize their time commitment by providing the support they need to become productive rural investigators. Local cultural attitudes toward clinical research are a potential barrier to clinical research in a rural setting. Mistrust in the process of clinical research may cause some resistance to participation; however, this can be overcome by intense public education on the importance of clinical research to solve community health problems.
The strongest aspect of this project is that Gateway is a community-generated initiative operating in a rural setting.2 The community has taken ownership and responsibility for identifying and solving its own most pressing health problems. The research centre will empower local investigators to engage in clinical research and establish productive collaborations with remote academic centres to generate high-quality data. Data generated will be used to characterize health issues, guide further research, and more importantly, influence policy makers on establishing policies tailored to the health needs of rural communities.
Some graphical statistics on incidences on critical medical conditions initiating enquiry into the creation of Gateway follow.
Stats Canada, Canadian Community Health Survey 2001
Stats Canada, Canadian Community Health Survey 2005
Gateway’s long-term goal over three to five years is to establish an independent, community-based centre in Seaforth, Ontario dedicated to the investigation of health issues affecting rural communities in the Huron-Perth-Grey-Bruce region. The centre will support rural investigators in all aspects of clinical investigation including preparing research proposals, applying for funding, implementing studies, collecting and analysing data, and publishing results. Although the focus of the initial research activity will be on heart disease, stroke and diabetes, the centre will consider support of any research initiative considered relevant to the rural population.
Gateway plans to become a recognized centre of excellence for clinical research that generates new knowledge necessary to develop and implement policies designed to improve the health status of Canadians living in rural areas.
The initial goal (1 to 2 years) is to implement a strategy that involves:
1. Creating a network of clinical investigators (physicians, nurses, pharmacists, dieticians, physiotherapists).
2. Obtaining certification for clinical investigators and research coordinators.
3. Establishing partnerships with academic centres and industry to participate in large research projects.
4. Writing grants application to Heart and Stroke Foundation of Ontario and other agencies.
5. Promoting Gateway in the community
6. Implementing initial research projects:
* Health status of orphan-patient population in underserved sub-populations
* State of cardiovascular health in a rural population
* Diabetes intervention program
An outline of each of these goals and the strategy for achievement follows.
1. Network of clinical investigators
In Huron, Perth, Grey and Bruce counties, there are 17 community hospitals, 14 internists, 228 physicians and approximately 54 private family practices in addition to 24 newly-formed family health teams. There are also several community-based programs providing basic services including 6 Community Care Access Centres. CCACs engage health professionals including nurses, physiotherapists, pharmacists and dieticians who actively provide basic health care to rural residents. There are also 38 long term care residential facilities with 2,600 residents.
Gateway will contact selected professionals of the various health care organizations and formally invite them to participate in the centre as clinical investigators. This work will require (a) development of appropriate written material and visual aids, (b) making presentations to potential investigators, and (c) organizing and conducting investigators meetings to discuss research priorities and new research initiatives and obtain feedback on overall research goals. Efforts are underway to recruit at least two internists and an investigator (physician, nurse, pharmacist, or dietician). In Huron County, for example, recruits will come from each of the four new family health teams in addition to four family physicians in private practice. It is estimated that these medical practices alone have a patient population of about 10,000 people, a significant number to begin research on prevention programs. The long-term goal is to have an extensive network of community-based physicians and other professionals across all four counties actively engaged in clinical research.
Any new young physician recruited into the area, especially those with strong research backgrounds, will be invited to participate in clinical research from the outset. The centre will provide an immediate network and support to implement their research interests. Clinical research is a rewarding experience. We strongly believe that the centre will be an important tool to attract and retain physicians to the area helping indirectly to fight the critical shortage of physicians affecting these rural areas.
2. Certification for clinical investigators and research coordinators
Clinical investigation has become a highly regulated activity as the complexity and size of research projects increase. Regulatory agencies have developed training protocols to provide standardization to the process of clinical research in an effort to guarantee good quality data. An early goal is to encourage investigators and research coordinators to obtain formal certification as clinical investigators as this will be essential to attract both academic- and industry-sponsored research projects. The availability of several on-line courses will facilitate this process. The goal is to attain certification of at least four new investigators during the first year. Gateway will provide training for new research coordinators in clinical research and encourage them to obtain their certification.
3. Establish partnerships with academic centres
The geographic location of the Huron-Perth-Grey-Bruce region offers a great potential for active collaboration with several world-renowned academic research centres from McMaster University, York University, the University of Western Ontario and the University of Toronto. Gateway will pursue research projects that can help to sustain long-term collaborations with centres involved in population health studies, studies in outcome research, evaluation of health programs, and clinical trials.4
These academic centres will benefit from a well-established community-driven clinical research centre with qualified investigators and willing primary care and preventive care patients. In turn, investigators from the rural communities will have the opportunity to participate in large academic projects, interact with peers from other regions or countries and with world-renown medical investigators.
4. Grant applications
During the Gateway startup, a significant amount of time and effort will be dedicated to preparing grant applications to fund building infrastructure, fund an operations budget and finance initial research projects. Efforts are underway to identify appropriate government and non-government granting agencies and prepare and submit grant applications. Potential agencies include the Heart and Stroke Foundation of Ontario (HSF), the Canadian Foundation for Innovation (CFI), Rural Community Development, Canadian Institutes for Health Research (CIHR), the pharmaceutical industry, all government levels and private foundations.
5. Promoting the research centre in the community
Gateway’s success will depend in large part on the collaboration and acceptance of the centre not only by health care professionals but also by the broader community at large. Presentations are underway discussing the goals and benefits of clinical research at community gatherings such as City Council meetings, churches and school meetings across the area. The efforts are in keeping with the marketing and communications plan outlined below.
6. Research projects
A number of possible initial research projects have been considered in order to exemplify the prime purpose of the Gateway centre. Four projects have been identified.
Project 1 – Investigate the demographics and health status in under-served rural sub-populations
Project 2 – Investigate cardiovascular health (heart disease and stroke) in the Project 1 population.
Projects 1 and 2 –
Recent nation-wide health surveys have consistently shown that the health status of Canadians living in rural areas is worse than that of their urban counterparts. For example, the average frequency of ischemic heart disease, stroke, and diabetes in the Huron-Perth-Grey-Bruce region is among the highest in Ontario and Canada. The stroke rate is about 30% higher in Huron County than in cities such as London Ontario. These comparisons are based on average values representing all county populations; however, there is no data on the actual health status in rural sub-populations such as low literacy groups or rural populations without access to continuous comprehensive medical care (orphan patients).
Funds will be sought for a grant for (a) completion and expansion of the Huron (and area) Health Survey designed to determine cardiovascular risk profile, and (b) implementation of a community-based cardiovascular disease prevention program in a rural context: the Mentor project.
Although no formal sample-size calculation has been made yet for these studies, based on similar studies, it is estimated that two groups of 300 patients (N=600 subjects) will provide enough data to observe statistically significant differences (10,11).
The goals for the above projects are to establish collaboration with the Population Health Research Institute at McMaster University to discuss project details, prepare and submit the grant application, establish a theoretical model for mentor selection and training, obtain feedback from community members, and promote programs in the community. The inclusion of the first patient into the programs is planned to occur during the fall 2008.5
Project 3 - Depression in rural women
Community surveys indicate that general depression is a major problem for women, more so for women in rural areas, and especially older women with disabilities. Women in general experience depressive symptoms twice as often as men, and twice as many rural women experience depression compared with their urban counterparts. A recent report showed that about 75% of women with disabilities living in a rural area in the USA experience moderate to severe depressive symptoms (7). In Canada, there is very little research on depression in rural women or depression in rural communities in general.
Project 4 - Diabetes Intervention Program
Investigators from the Lawson Research Institute and the University of Western Ontario are organizing a large comprehensive diabetes prevention program that requires patients from community-based practices. This program is particularly appropriate for Huron and neighboring counties as the frequency of diabetes in Huron is one of the highest in Ontario. According to the Community Health Survey of 2001, the rate of diabetes in Huron County is 8.0% whereas the average rate for the province of Ontario is 5%. In addition, this project offers the opportunity to establish formal collaboration with another academic centre.
Gateway is prepared to ensure that all aspects of conducting these research projects will be in place from protocol submissions to an ethics review board, in addition to personal training to data collection and data management.
Gateway’s research base is ripe for investigation to confirm rationales for apparently poor medical follow-up and medication compliance, and to expand the knowledge base into the orphan population to find quantifiable variations in rural-based and urban-based research.
Slides 3 to 12 in the appendixed presentation provide statistical data from 2001, the most recent survey, outlining the problems of existing treatable ailments in the area, province and nationally, and compliance with medication regimes.
In the eastern part of Huron County and western Perth where Gateway will begin, the 12,000 population has approximately 5,000 orphan patients. Statistics Canada classifies this population as 55% ‘rural’. 40% are between the ages of 45 and 84. The region proportionally has the third largest group of seniors in Canada. Huron County and area has an aging population ideal for clinical research on conditions that are prevalent in this age group.
Gateway’s premise about the nature of data gathered in rural settings will be tested through rigorous interviews and examination to differentiate why urban research differs from rural.
An interview template will be designed in a community-participatory mode to ascertain the variables affecting causality and treatment success in this strongly rural setting. As well, data will be researched from the literature on similarities and differences between the results and those gathered in an urban setting to confirm suspicions about erroneous projections of data from urban bases to rural behaviours and results.
Due to the noted differences in demographics, access to medical attention, remoteness of primary care centres and reluctance of residents to use medical facilities except under presenting medical conditions, the characteristics of the rural sector will be explored in depth to quantify the nature and extent of differences from comparable urban cohorts.
It is predicted that a growing number of drugs under development will require larger and more expensive clinical trials involving community hospitals to a greater extent. Industry will thus welcome a rural community research centre to provide uncomplicated patients with single conditions of interest, as opposed to the usually more complicated patient of any tertiary service.
The Huron-Perth-Grey-Bruce region offers exceptional conditions to conduct clinical research. It combines ideal demographic and socio-economic profiles with high quality health care professionals. Huron County alone has a total population of about 60,000 of which 40% are between the ages of 45 and 84. This region proportionally has the third largest group of seniors in Canada, an aging population ideal for clinical research on conditions that are prevalent in this age group.
For stage one of the project, using statistics in Huron County alone, there are approximately 38 physicians practicing in primary community care centres or in one of five community hospitals who could participate as investigators. The Community Health Care centres in Huron and surrounding counties have a large database of patients with diabetes mellitus, coronary heart disease, hyperlipidemia, uncomplicated arterial hypertension as well as other common chronic conditions.
The benefits of a community based research effort centered in the Huron-Perth-Grey-Bruce area bear repeating.
* Physicians interested in research will have the opportunity to participate. To physicians, the research would be a rewarding experience and may greatly enhance their medical practice. As investigators, they will attend meetings where they would have the chance to interact with peers as well as “leaders of thought” in specific areas of medical research.
* A centrally-located research institute will support original research initiated by local investigators in addition to the physician base. Indirectly, Gateway has the potential to contribute in retaining or attracting physicians to the area.
* Academic centres and the pharmaceutical industry can benefit from a community-based research centre in the Huron-Perth base area. Gateway will become invaluable in the near future as trends continue and indicate that clinical research will focus increasingly on preventative, community based research.
* There is perceptibly a lower incidence of prior continuous medical contact, providing a research segment open to exploration of issues without prejudice
* There is perceptibly poor adherence to medication regimes by patients, and difficult to monitor conditions for self-administered preventive programs
* There is a strong willingness of the general population to cooperate in research studies and as test bases for recognition and for benefits of trials.
The town of Seaforth has been chosen to be the prime location for Gateway administration. The existing medical campus has excess land and excellent supporting infrastructure for Gateway startup and continuance as its role and activity expands. It is well served by provincial and county road network for year-round rural travel. Seaforth community leaders and the Municipality of Huron East have become engaged supportively7 and have recruited its prime researcher, Dr Claudio Munoz.8
Potential impediments to the project emanate from a number of sources:
1.Reluctance in the population to be involved in research in general
2.Reluctance from medical professionals to become active or engaged
3.Reluctance of the community to support economically
4.Reluctance of pharmaceutical firms to conduct rural research
5.Supply of qualified researchers
6.Competition with other research endeavours
Mitigation of these potential impediments include education, communication and word-of-mouth promotion.
Initial acceptance of the research institute concept has been supportive and encouraging. Preliminary work on business plans justifying the creation of Family Health Teams to the Ontario Ministry of Health and Long Term Care in various population centres in the area all suggest that Gateway’s catchment area and demographic base are sound and sub-populations will be enthusiastic participants in clinical research studies.
Initial contacts and ongoing discussions with local professionals have all been supportive and encouraging. Continued contact through bulletins and information newsletters will keep the professional community apprised of progress and abreast of issues in process. It is expected that most physicians in the area will participate in one form or another to the endeavour – as research supervisors or participants or referring selected patients as subjects - given the expectation of professional and peer recognition.
The Huron-Perth area has been active in initiating breakthrough endeavours in health care. HealthKick Huron, recently awarded first prize in Medical Innovation by the Economic Development Corporation of Ontario, is a prime example. The community of Huron East sponsors a community-led Family Health Team, with governance by community and business leaders in addition to representatives of the medical community.
Contact with pharmaceutical firms has been very encouraging. Pharmaceuticals seek test-beds for new or improved medications. Gateway provides an ideal site due to its tight demographic under study, uncomplicated environment and receptive test population.
Gateway has a ready supply of candidates for research work. Through HealthKick Huron, Georgian College offers extension courses for RPN9 qualifications, and students will be offered opportunities for service and possible academic credit after clinical research training. As outlined previously, Gateway will ensure adequate training to satisfy the requirements of research projects underway.
There are no other rural-based clinical research endeavours underway in Canada to the same scale envisioned by Gateway. There is currently no other agency or endeavour producing similar studies. Its approach is unique. Sufficient research efforts and topics abound in urban and academic-rich areas that do not require a concentrated focus for urban versus rural issues. In addition, transportation issues to import test subjects from Ontario rural areas where medical problems persist (and are above average) to urban areas solely for research are prohibitive.
A detailed operational and research plan, prepared at the request of a major start-up funder, is available for review. In summary, it outlined a plan to approach the medical and family physician community in the target area to brief them on the concept, elicit comment and cooperation in order to tailor the approaches to the research methodology and to the target patient cohort.
In addition, research investigators will be recruited through public advertising and through word-of-mouth contacts in the medical communities targeted. Depending on the quality of candidates, training in either the basics of research principles or as refreshers to professionals will begin in earnest as the competences of candidates are identified. All investigators will work under the direct supervision of a research professional, initially the Head of Research, and will attain provincial qualification.
The target population is of two types – orphan patients and those served by a family physician. To reach orphan patients, advertising in local newspapers and outlets will allow the population to self-nominate and be triaged into trial, test and control sectors. Other patients will medical histories already available through existing or past medical records, will be apprised of the studies through their preferred medical professionals, and be triaged appropriately.
Initial contacts with candidates will use detailed and structured interviews rigorously designed to produce appropriate sector populations. Testing, intrusive or non-intrusive, will then be conducted appropriately for the condition to be researched.
Questionnaires and interviews will be continuously appraised and adjusted to improve the degree and nature of data to be gathered for the specific studies. They will initially be structured to confirm the expectations reported to apply to rural conditions. As interviews proceed and if other conditions deserving review or analysis present themselves, the questionnaires will be adjusted accordingly.
Medical conditions will not be evaluated, nor treatment modes recommended. Tested clients will be referred to medical treatment, either emergency or though normal referral channels, should medical conditions be identified that require medical intervention.
Forms relating to liability for information disclosed or discovered, and feedback processes about data gathering will be prepared to affirm the expectations of the studies and the involvement of clients.
The operational plan for the initial studies noted above are available on request. In summary, three modes of information gathering will be invoked.
The first will gather physical statistics, both descriptive and numerical, to confirm and generate a base for rural population characterization medically. The data will be primarily demographic but will also capture data for indices on physical and mental status as much as possible.
The second will gather data for dietary analysis, both numeric and qualitative. Access and frequency of consumption of fast-foods, high energy foods, fresh fruit and vegetables, tubers, local produce and so on will be evaluated statistically.
The third will gather data for risk factors for emergent or genetically-driven medical conditions. Again the data will be both numerical and qualitative, gleaned through oral conversation and enquiry.
For the initial Huron-Perth catchment area, approximately 300 interviews are planned to produce meaningful data and to fine-tune the initial parameters, questionnaires and interviews.
Staff needs
Initial studies will involve nurses, nurse-practitioner’s physicians, dietitians and supplementary investigators. The role of the medical professionals will be to conduct any intrusive testing or supplement medical testing normally conducted for presented conditions, in addition to participating in interviews and questionnaires tailored to the studies at hand. Non-medical investigators will conduct interviews when sufficient intrusive testing is available on the subject clients. An x-ray technician will be similarly engaged in the studies where appropriate for ultrasound investigation and operating carotid-Doppler equipment to gather data on cardiovascular conditions.
The Head of Research, Claudio Munoz PhD MD, will organize and direct all aspects of research, training and over viewing the efforts of investigators, both onsite and offsite.
A secretary will assist the Head of Research and will serve as the initial compiler of data.
A program manager will be engaged as the volume of activity increases, as staffing for individual studies evolve and as new programs become identified, funded and undertaken. The role will be expanded or assisted as communications demands and needs develop.
Similarly, an administrative manager role will evolve as volume of data and office management issues evolve.
Regular meetings with professional staff and research participants will be planned to keep the community at large informed on progress and broad research results as they are generated.
Subsidiary studies
Gateway will agree to participate or host subsidiary studies if the aims and goals of such studies are compatible with Gateway’s mission, aims and goals and preferred research involving community participation.
Subsidiary study liability issues
Gateway will arrange for appropriate insurance coverage for corporate, tenant and director liability concerns. Subsidiary studies undertaken by Gateway associate groups and individual researchers will require individual funding and sponsorship, with due regard to accountability and liability provisions in contract form acceptable to the stakeholder parties.
The initial research will require office space for the Head of Research and secretary.
Most initial research supplies will involve paper and forms, and the beginning of a computer network with high-speed internet access for accessing remote test sites.
For medical equipment, initial studies identified above will require a supply (20 sets) of blood pressure cuffs and portable monitors, for extended off-site data collection.
A supply of cholesterol test strips (5,000) normally available in nurse and physician stations will also be required.
In time, additional equipment, notably a dedicated carotid-Doppler instrument will be required, as studies expand.
There are a number of periodicals and research reporting entities available and targeted to receive and publish Gateway’s research results for dissemination to other professional researchers, to pharmaceutical firms and groups, and to the public.
They include:
* Canadian Medical Association Journal
* Canadian Journal of Rural Medicine
* Journal of Epidemiology and Community Health
* Australian Journal of Rural Health
* Rural and Remote Health
* American Rural Health Association Journal
* American Journal of Nursing
The value of Gateway research to peers, funders and the public will determine the viability, success and growth of the research institute. Two side-benefits of the work will also be quickly apparent. The work is expected to attract other synergistic and compatible research programs. As an example, an August 5, 2008 Medical Post article reported on a novel study in Boston that identified that the risk of heart attack is related to pre-existing depression. In the Huron-Perth area, as related in Section 3 above, women in general experience depressive symptoms twice as often as men, and twice as many rural women experience depression compared with their urban counterparts. A recent report showed that about 75% of women with disabilities living in a rural area in the USA experience moderate to severe depressive symptoms. In Canada, there is very little research on depression in rural women or depression in rural communities in general. This study will be explored further in Study 3 to be undertaken.
And there will be benefit to other researchers when the design of questionnaires is undertaken for studies. Gateway studies will pose questions designed to elicit rural-specific response. The analysis of responses will enable other researchers to fine-tune their enquiries to include this sector more competently.
There is a high degree of chronic illness in the study areas. Many residents would benefit from better education about the critical issues affecting their health. Gateway will provide an opportunity for information and action.
Information to be provided as part of Gateway’s communications plan is new. A rural research centre has not existed before and the public has no sense of involvement, or the benefits of involvement. To address this, much of the communications plan must be devoted to education purposes.
On many levels, the following communications plan is calling the audience to action – the real information that the audience wants to know is “What is Gateway, why should I be involved and how do I access it” – this information must be paramount in all communications activities and materials.
For many who have not traditionally accessed any form of healthcare services, or have given up finding a family physician, the communication plan is seeking to change behaviour by convincing them to become involved, at least to change the status quo for the sake of their own health.
With these principles in mind, Gateway’s plan has four initial communication goals as it prepares to commence operations:
* To create a comprehensive Gateway website to form the prime tool for marketing its services and to disseminate information.
* To encourage uptake of research activity by informing the public of the availability and benefits of rural medical research opportunities provided through Gateway and how those services can be accessed
* To develop an understanding within the local healthcare service community of Gateway’s vision, mission, values and objectives
* To raise awareness within the community at large of Gateway’s role in improving individual and community health.
Gateway has the following assets which help provide a solid foundation for a communication plan.
* A governance group composed of community leaders with experience and interest in the healthcare sector and an extensive knowledge of the community through personal and professional networks.
* Support of local officials, partners and residents gleaned through extensive outreach and awareness activities prior to development of the Plan
* Valuable partnerships between Gateway and existing community healthcare partners, including the Healthkick initiative, Family Health Teams, Community Care Access Centres, long-term care homes, family clinics, and healthcare professionals.
* A receptive audience of both attached and orphan patients who have cited access to healthcare services as a major priority concern in their lives.
The target audiences for a communications plan involve six sectors:
* The orphan patients within the areas of Huron-Perth, estimated to be approximately 8,000 in number, expanding to the areas of Grey and Bruce
* Individuals with at-risk or now experiencing chronic illnesses that currently require on-going medical attention
*The medical community in southwestern Ontario, and those primarily in Huron Perth Grey and Bruce.
*The medical research community across major Ontario urban centres and beyond
*Academic investigators focused on rural health issues seeking an established community-based rural research infrastructure.
*The public in general but in particular, the high proportion of seniors (17.4%) within the target audiences of Huron Perth Grey and Bruce.
From data collected during the start-up of current healthcare-related activities in the area, a number of assumptions can be extended to Gateway’s audiences.
* Audiences have a high degree of concern for access to healthcare services; both for themselves and the community as a whole
* Audiences are less aware but still cognizant of the role that research can play in providing healthcare service to themselves and their communities
* Have only vague notions about the interdisciplinary and collegial aspects of the Gateway model and what to expect from the research service
* Know virtually nothing at this point about who to contact or how to access services, and in some cases may have become discouraged and are no longer seeking health care in any form
* Are prepared to “do what it takes” in terms of changing their notions about healthcare services (e.g. the role of research, the role of the family doctor/general practitioner and other professionals) provided that their needs are met
The messages in Gateway’s communications plan addressing these issues include the following elements.
* Your individual health is important and your healthcare needs must be met
* There is a high degree of chronic illness in the region
* Research is an efficient tool to incite action for the region’s medical problems
* A large number of currently unattached patients are in need of help
* Long-term discouragement has lead to patients not bothering
* Participating in research is an effective action by individuals to change the status quo
* Participating in research services are now easy to access
* Involvement in Gateway activities is not complex, and results are widely published
* The Gateway Rural Health Research Institute is an acknowledgement of innovation and leading-edge activity within the southwestern Ontario community – i.e. access to health care is such an important issue recognized by community leaders in the counties that new and more effective means are being created to address what has been identified as a major priority in community surveys and public meetings;
* By creating a rural centre dedicated to rural health issues, Huron, Perth, Grey and Bruce are building upon our historical “can-do” culture
There are a number of communications tools readily developed and attuned to the introduction of the Gateway initiative in addition to a leading-edge, effective and informative website.
* Board members and community leaders with far-reaching community networks
* Existing base of community partner organizations
* Supportive local media contacts – these include community newspapers as well as radio stations with a high degree of local content in the region.
Gateway has a number of communication tactics available to promote.
* Creation of a logo and a tag line or theme
* Marketing materials – brochures, flyers, posters distributed throughout community at municipal buildings, public offices, libraries, information centres, newsletters
* Selected mail-outs of brochures through community channels (e.g. Focus newsmagazine in Huron Perth)
* Use of community cable channels for information on accessing Gateway services
*Press releases generated and distributed to all regional media every 3 weeks providing updates on programs and services
*Use of existing e-newsletter networks to circulate monthly updates to community partners (Chambers of Commerce, BIAs, service clubs, municipalities, patients)
* One-to-one discussions with selected community leaders throughout the region (e.g. elected officials, clergy, seniors groups, youth groups, etc.) to discuss Gateway aims, objectives and values
* Periodic reports to the community (in print and in presentation format) regarding the progress and results of research studies underway and planned
There are four general methods and indicators for evaluating the effectiveness of the communications plan. These include:
*Hits on the website gauging public and professional enquiry for additional information.
*Measurement of the actual number of patients accessing Gateway as a proportion of the target audience within the region.
*Periodic survey of community residents to determine their awareness, understanding and use of the Gateway services – first survey to establish a baseline, and subsequent ones to determine progress in awareness, understanding and use.
* A responsive community-based board of directors
Gateway Rural Health Research Institute is incorporated as an Ontario not-for-profit corporation, approved as an Institute by the Ontario Ministry of Training, Colleges and Universities, and has applied for charitable status. Its founding board is composed of business and community leaders with a vision and passion for healthcare improvement in rural areas. The Huron Business Development Corporation and the Huron East Seaforth Development Trust are handling initial banking. Heartland Community Credit Union accounts will be arranged as incorporation and activities proceed.
Founding board members and business affiliation are as follows:
Lin Steffler, education, retired
Mary Lapaine, healthcare, retired
Dan Stringer, pharmacist
Rob Evans, businessman retired
Gwen Devereaux, healthcare recruiter
Jim Whaley, healthcare executive
Bob Saxby, banker
Chris Lee, businessman
Ralph Laviolette, businessman, retired
1. How healthy are Canadians? An assessment of their health status and health determinants. (2006) Prepared by Canadian Institute for Health Information. http://www.icis.ca/cihiweb/products/summary_rural_canadians_2006_e.pdf
2.Chow CM, Donovan L, Manuel D, Johansen H, Tu JV, for the Canadian Cardiovascular Outcomes Research Team. Regional variation in self-reported heart disease prevalence in Canada. Can J Cardiol 2005;21(14):1265-1271
3.Stats Canada. Canadian Community Health Survey. Cycle 3.1. 2005. http://www.statcan.ca/english/concepts/hs/index.htm
4.Interview with Dr. John Wooton, “New Office to Focus on Rural Health Issues,” Farm Family Health, Vol. 7, No. 1, Spring 1999
5. Manson DJ, and Thornton T. Workshop Summary of the British Columbia Rural and Remote Health Conference, University of Northern British Columbia, 2000
6.Stats Canada. Census 2006. Community Profiles
http://www12.statcan.ca/english/census06/data/profiles/community/Index.cfm
7. Hughes, R., Nosek, M., & Robinson-Whelen, S. (2007). Correlates of depression and rural women with physical disabilities. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(1), 105-114.
8. Probst, J., Laditka, S., Moore, C., Harun, N., Powell, M., & Baxley, E. (2006). Rural-urban differences in depression prevalence: Implications for family medicine. Family Medicine, 38(9), 653-660.
9. Touboul PJ, Labreuche J, Vicaut E, Amarenco P; GENIC Investigators. Carotid intima-media thickness, plaques, and Framingham risk score as independent determinants of stroke risk. Stroke. 2005 Aug; 36(8):1741-5
10. Chalmers ML, Housemann RA, Wiggs I, Newcomb-Hagood L, Malone B, Brownson RC. Process evaluation of a monitoring log system for community coalition activities: five-year results and lessons learned. Am J Health Promot. 2003 Jan-Feb;17(3):190-6.
11.Berra K, Ma J, Klieman L, Hyde S, Monti V, Guardado A, Rivera S, Stafford RS. Implementing cardiac risk-factor case management: lessons learned in a county health system. Crit Pathw Cardiol. 2007 Dec;6(4):173-9.
12.Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):145-53
13. Depression raises risk of more cardiac events within weeks of MI, Medical Post, Aug 5, 2008, page 5
14. ICES Report: the impact of not having a primary care physician among people with chronic conditions Ontario Medical Review, July/August 2008, page 21
1 Patients without a family doctor are termed ‘orphan patients’.
2 Other modes inferred are traditional research and community-engaged research. Traditional research is driven by the researcher, usually for personal or academic gain. The research is originated, controlled, organized and managed by the researcher(s) who own the results of their studies and conclusions. Clients and patients are subjects and do not participate in the research in other than interviews, trials and interviews. In community-engaged research, the population is more involved in research as participants in identifying topics and subjects of research in a more interactive mode as research proceeds. Again, researcher(s) own the data, results and conclusions.
In community-participatory (or community-driven or community-based) research, as proposed for Gateway, the population and the researcher(s) identify the problem presented, in this case, the degree to which the rural population is at higher risk for malady, which malad(ies), why, and what treatment modes are available or needed. The population is involved as collaborators and participants, yet the research is done with the same objectivity by researcher(s) as in the traditional mode. Resulting data is shared and disseminated to the benefit of both researcher(s) and the population engaged.
3 A more detailed outline of these initiatives is available on request.
4 CCACs engage health professionals including nurses, physiotherapists, pharmacists and dieticians who actively provide basic health care to rural residents.
5 Two such agencies are the Population Health Research Institute from McMaster University, and the Lawson Research Institute at the University of Western Ontario.
6 More information on this project can be supplied on request.
7 Supporting letters can be provided.
8 See biographies of key personnel and directors.
9 Registered practical nurse
10 As voiced most recently and consistently in Huron East community surveys, Huron Community Matters consultations and the Huron United Way Community Priorities Initiative