Purpose, Aims and Objectives

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