https://orcid.org/0000-0001-8680-6838
Figures
Abstract
Background
Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.
Objective
Synthesize and categorize studies that examine interventions to improve rural primary care.
Eligibility criteria
Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.
Charting methods
We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.
Results
372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997–99 to a peak of 49 papers in 2017.
Citation: Aubrey-Basler K, Bursey K, Pike A, Penney C, Furlong B, Howells M, et al. (2024) Interventions to improve primary healthcare in rural settings: A scoping review. PLoS ONE 19(7): e0305516. https://doi.org/10.1371/journal.pone.0305516
Editor: Jennifer Yourkavitch, Independent, UNITED STATES OF AMERICA
Received: September 6, 2023; Accepted: June 1, 2024; Published: July 11, 2024
Copyright: © 2024 Aubrey-Basler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data are all contained within the manuscript and its Supporting information files.
Funding: This study was funded by the Canadian Institutes of Health Research (grant # 141676) awarded to KAB. The funders (https://cihr-irsc.gc.ca/e/193.html) had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: KAB and JR are family physicians who previously practiced in rural areas. KAB, JR, and SA are rural health services researchers with an interest in the equity of health service distribution. The authors have no other disclosures to report.
Introduction
The United Nations estimates that about 3.4 billion people worldwide live in rural areas [1]. Residents of these areas have poorer health status, are more likely to live in poor socio-economic conditions, demonstrate less healthy behaviours, and tend to have higher mortality rates than people who live in urban centres [1–6]. These disparities in health outcomes indicate a greater need for health services that address these factors, and these services are usually delivered under the umbrella of primary care [7]. Countries and regions with stronger primary care tend to have improved health outcomes, lower health system costs and reduced inequity in health [7, 8]. It is important to note that the term primary care has many definitions and is sometimes used interchangeably with the term primary healthcare. For the purposes of this scoping review, we aimed to adopt a broad definition to capture a wide range of primary care services. We used the Canadian Foundation for Healthcare Improvement (CFHI) policy document (Toward a Primary Care Strategy for Canada) to guide many of the definitions used in this review [9]. As such we adopted CFHI’s definition of primary care: “an inclusive term to cover the spectrum of first-contact healthcare models from those whose focus is comprehensive, person-centered care, sustained over time, to those that also incorporate health promotion, community development and intersectoral action to address the social determinants of health” to serve as the working definition for this scoping review [9].
Despite increased needs, rural populations are not as well-served as their urban counterparts and they experience more difficulty accessing primary care [10]. Lack of access to primary care in rural areas is in part due to the difficulty of retaining physicians and other healthcare professionals in their communities [11]. Additionally, residents living in rural communities often have to travel in order to access healthcare. This can pose an added burden to individuals who do not have reliable transportation or have mobility issues. When travel is required to access services, it may mean people have to leave their communities and families and incur additional costs for accommodation and meals. Even when a person can access primary healthcare in their community, they may encounter additional barriers such as difficulty contacting the physician or clinic to schedule an appointment and long wait times for appointments [12]. Specialist care is even less equitably distributed than primary care, suggesting a greater need for services, such as an expanded scope of practice for rural primary care providers that can replace some of the care usually offered by specialists. The World Health Organization highlights that remote populations face significant health disparities compared to both urban and many rural areas due to their smaller size, isolation, and socioeconomic disadvantages [13]. Geographic isolation and sociocultural differences also intensify healthcare shortages in remote areas. Thus, addressing these challenges requires interventions focused on increasing healthcare access, ensuring equitable quality of care, and prioritizing patient-centered approaches.
Improving primary care is an important step toward improving health outcomes in rural and remote communities, and this will likely require a multifaceted approach. This scoping review synthesizes and categorizes studies that have evaluated interventions to improve primary care in rural and remote settings and it is the first comprehensive review to do so. Because of the breadth of literature we expected to find in terms of number of papers and diversity of study designs, interventions and outcomes, we elected to use scoping methodology with high-level data extraction rather than more detailed extraction and synthesis of a systematic review [14]. Following guidance for scoping reviews as described in our methods below, the purpose of this review is to provide an overview of the types of available evidence regarding interventions to improve primary care in rural and remote settings and identify the key characteristics of this body of literature (e.g., the health topics and interventions studied), health topic areas ready for systematic review, and knowledge gaps.
Method
Design
We used the refined Arksey and O’Malley [15] six-stage framework to structure our methods [16]. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the Johanna Briggs Institute manual to enhance review quality and reporting [14, 17].
Stage 1: Developing the research question.
We were interested in describing all studies that reported on the evaluation of a program or intervention designed to improve health care and that was implemented in a rural or remote primary care setting. We organized the papers by the outcomes studied, according to three broad categories listed by a prominent primary care policy document [9]. We assigned papers to multiple categories where appropriate:
- Quality of primary care: We classified studies addressing healthcare quality loosely based on the Institute of Medicine’s “domains of health care quality [18].” The efficiency domain was further divided and included in a separate heading below.
- Evidence-based practice
- Clinical outcomes
- Patient experience
- Equity of care
- Patient safety
- Access to primary care: Multiple policy documents recommend that patients have access to a regular, identifiable primary care provider or team and timely access to primary care through arrangements that facilitate 24/7 access to appropriate services [9, 13, 19]. We thus subdivided this statement into the following two access topics:
- Access to a primary care provider
- Access to primary care services
- Efficiency of primary care: The primary care system should continually seek to reduce waste and cost of supplies, equipment, space, capital, ideas, time and opportunities [9]. This broad category includes the following outcome variables:
- Wait Times
- Healthcare utilization
- Costing and cost-effectiveness
Setting. There is broad disagreement among researchers, policy makers, and community members about the best definition of rural, and the appropriate definition likely varies with the circumstances [20]. To maximize inclusiveness for this review, we have elected to accept any program described as rural or remote by the paper’s authors. As described in the introduction we used the CFHI’s definition of primary care, “an inclusive term to cover the spectrum of first-contact healthcare models from those whose focus is comprehensive, person-centered care, sustained over time, to those that also incorporate health promotion, community development and intersectoral action to address the social determinants of health” as the working definition for this review [9]. This definition allows for a broad range of interventions for inclusion; examples of interventions that were included and excluded following this definition can be found in Table 1. Additionally, in piloting this definition during our screening process, we realized reporting was not always clear and we amended the definition to maximise study inclusion to also accept any program described as being implemented in primary care by the paper’s authors.
Study design and language. The search was limited to papers written in English. All randomised and non-randomised experimental or observational designs were included (e.g., randomised controlled trials, controlled before-after studies, uncontrolled before-after studies, interrupted time series and observational/cohort studies). Non-experimental studies such as descriptive studies or chart reviews were excluded. We developed a protocol a priori but did not publish prospectively.
Stage 2: Identifying relevant studies.
An experienced information specialist completed an electronic literature search for articles reporting the evaluation of a program or intervention to improve rural healthcare, initially between January 1, 1996 and December 30, 2022 and cataloged in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Embase, and PubMed. A sample electronic search strategy is included in S1 Appendix.
Stage 3: Study selection.
Articles were downloaded to Covidence systematic review software [21] and duplicates removed. Initial screening of titles and abstracts (and full-text review) was completed by two reviewers independently using pre-specified eligibility criteria (Table 1). During both these screening stages, a third reviewer mediated disagreements to reach a final decision about study inclusion.
Stage 4: Charting the data.
Data extraction from each paper was initially completed by one reviewer (MH, HO, BF, CP) and double checked by a second author (KB, AP, BF) using a data extraction template. Discrepancies were reviewed with a senior author (AH). Data related to study characteristics, publication year, country, study design, study aim, intervention description, and types of outcomes assessed including assessment methods and measurement tools was extracted verbatim. The information was coded where possible; the intervention description was assigned a category code that was defined by the author team after reviewing all interventions descriptions for overarching themes as described in Table 2, and the outcomes were coded into one of the twelve possible outcomes within the three major categories as defined on page 4 under the subsection “Stage 1: Developing the Research Question”.
Stage 5: Collating, summarizing and reporting the results.
An overall summary of all included studies was conducted using descriptive statistics to summarize study characteristics, evaluation characteristics and types of outcome categories assessed. For each of the three outcome categories (i.e., access, quality and efficiency), studies were summarised together according to the sub-outcome measured within that category. For each sub-outcome, a tabular summary of the individual study characteristics, aim, intervention code and description and the outcome assessment information were provided. Where applicable, the tabular summaries are organised by the health topic studied. Due to the large amount of data, we have included these tabular summaries in the online supplementary files. Consistent with guidance on scoping reviews, we did not appraise methodological quality or risk of bias in the included articles [14, 15].
In addition to summarizing study characteristics and health topic areas covered within each of the main outcomes, we also completed a content analysis for each outcome category to provide readers with a high-level content summary, organized by health topic. For this analysis, we included health topics that were assessed in three or more studies. We also assessed this literature for its readiness for systematic or in-depth scoping review and to identify knowledge gaps—those areas where additional research is required. The criteria we used to make these judgements is presented in Box 1.
Stage 6: Stakeholder engagement.
This review is a product of consultation between one of our authors (JR) and the Atlantic Canadian premiers and was completed with guidance from the Atlantic Canadian Ministries of Health. In an effort to progress on evidence-informed rural health policy, these stakeholders were interested to know the overall state of science regarding rural primary care. After compiling the results of the review, members of our team met with additional health policy and programming stakeholders to review the broad state of rural primary healthcare knowledge. In so doing, they also helped us determine areas within the broader body of literature where a deeper, narrative review of the literature would be helpful, which our team will focus on in several future planned reviews.
Results
The literature search returned 6,592 citations; 6,220 of those were excluded (Fig 1) leaving 372 articles for data extraction and synthesis [22–390]. Details on article characteristics are presented in S2 Appendix. Briefly, the majority of articles were published after 2010 with an increase in the number per year beginning in 2015 that peaked in 2017 before beginning to decline (Fig 2). The majority were conducted in the United States (40%), Australia (15%) and China (7%) (Table 3). Many study designs were used to evaluate interventions, the most common of which were uncontrolled before-and-after (32%) followed by randomized trials (24%), prospective or retrospective cohort (18%), controlled before-and-after (11%), and cross-sectional studies (11%). In terms of outcome categories, the majority of studies (n = 306) assessed outcomes relating to quality of care focusing on improving desired health outcomes for patients and adherence to evidence-based standards (S3 Appendix). Seventy-six studies assessed access to primary care largely focusing on recruitment and retention of family physicians and access to services (S4 Appendix). Forty-seven studies assessed outcomes related to improving the efficiency of primary care services in rural areas (e.g., cost of delivery, healthcare use; S5 Appendix). A description of the studies for each outcome category is presented in the following sections.
Quality of care
Three-hundred and six articles (82%) reported on interventions aimed at improving the quality of primary care provided in a rural/remote setting. Seventy-two percent (n = 230) focused on improving the health outcomes of patients; 30% (n = 112) aimed to improve adherence to or adoption of evidence-based practices, 11% (n = 34) aimed to improve quality of care via enhancing patient experience, 1% (n = 4) studies aimed to improve equity of care, and only one study assessed patient safety. A detailed breakdown of all intervention types, study designs, individual study outcomes, and outcome measurements for quality-of-care studies can be found in S3–S7 Appendices. We have summarized the data in the following sections.
Evidence-based practice (n = 112).
Nearly three quarters of the 112 articles that aimed to improve quality of care via improving adherence to/adoption of evidence-based practices were published between 2010–2022. They were conducted in a broad range of countries, but just over half were conducted in either the United States (n = 35) or Australia (n = 20). Provider education/training (n = 35), improving coordination/referral pathways (n = 14), and patient education (n = 12) were the most frequent interventions employed. The studies were largely uncontrolled before-after studies (n = 42), randomized controlled trials (n = 32). The most commonly studied guidelines or recommendations were related to diabetes (n = 21), mental health care (n = 13), cancer screening (n = 12). Table 4 provides a content summary analysis for the nine health topics that were assessed in three or more studies. Of note, several papers did not assess a specific health topic (e.g., they were studying an intervention applicable to any condition). Information on these studies can be found in S3 Appendix. We judged three topics to be ready for systematic review: cancer (n = 12), CVD (n = 5) and respiratory infections (n = 4). Meta-analysis for each of these topics may not be possible and they would therefore require some degree of narrative synthesis based on differences in interventions. We judged an additional 4 topic areas that would benefit from in-depth scoping review including diabetes (n = 21), mental health (n = 13), asthma (n = 6) and pregnancy-related studies (n = 4). We believe additional research is required for chronic disease (n = 3) and HIV (n = 3). For both these topic areas the studies we found in both areas were not testing similar interventions or assessing similar outcomes. Additionally, we found very few studies in 23 topic areas including antibiotic prescribing, atrial fibrillation, back pain, chronic lung disease, COPD, dental care, epilepsy, hypertension, malaria, maternal and child health, neonatal care, obstetrics, palliative care, PCOS, post-abortion care, preventative care, sexually-transmitted infections, skin infections, sleep, speech impairments, surgery, vaccinations, vision impairments.
Clinical outcomes (n = 230).
Just over two thirds of the 158 studies focused on improving quality of care via improvements to clinical outcomes were published between 2010 and 2022. The studies were conducted in 45 different countries, with the majority originating in the United States (n = 100), Australia (n = 30), China (n = 16) and Canada (n = 11). Interventions commonly involved educating patients on evidence-based practices for a particular health topic or condition relating to their own health (n = 43), reorganizing health services to optimize care (n = 29), expanding the scope of practice for healthcare professionals (n = 24), upskilling or training healthcare professionals on evidence-based practices for a particular topic (n = 22), implementing a new service (n = 14), and improving co-ordination/referral pathways (n = 14). Some papers examined a single intervention while others examined a combined intervention (e.g., provider education/training + patient education), and papers may therefore be counted multiple times in the list above. The most common conditions included diabetes (n = 48), mental health (n = 34), hypertension (n = 13), and cardiovascular disease (n = 12). The most common study designs included uncontrolled before-after (n = 75) and randomized controlled trials (n = 68). Other designs reported included controlled before-after studies (n = 24), cross-sectional studies (n = 16), prospective cohort studies (n = 15), cohort studies (n = 14), retrospective cohort studies (n = 11), interrupted time series (n = 5) and Markov modelling (n = 2). Table 5 provides a content summary analysis for the 17 health topics that were assessed in 3 or more studies. Of note, several papers did not assess a specific health topic (e.g., they were studying an intervention applicable to any condition). Information on these studies can be found in S4 Appendix. We judged 7 topic areas to be ready for formal systematic review including CVD (n = 12), weight management (n = 9), pain management (n = 8), palliative care (n = 3), alcohol use (n = 3), stroke rehabilitation (n = 3), vaccination (n = 4), and sexually transmitted infections (n = 3). We judged 4 topic areas that would clearly benefit from an in-depth scoping review including diabetes (n = 48), mental health (n = 34), hypertension (n = 13) and cancer (n = 8). Additional research is required in four topic areas: HIV (n = 7), asthma (n = 6), chronic disease (n = 4), pregnancy (n = 3) and COPD (n = 3). Within each topic area there was a need for studies using controlled designs. The interventions and outcomes reported within each area were also highly variable. Additionally, we found very few studies in numerous areas including atrial fibrillation, burn rehab, chagas disease, childhood diarrhea, dementia, epilepsy, kidney disease, lung disease, osteoarthritis, osteoporosis, smoking cessation, speech impairments, vision impairments.
Patient experience (n = 34).
Most of the 34 articles aiming to improve quality of care by enhancing patient experience were published between 2010–2022. The majority of the studies were published in the United States (n = 19). The most commonly used interventions involved reorganizing existing services to optimize care (n = 6) or expanding the scope of practice of non-family physician healthcare providers (n = 5). Some of the interventions were used in combination as well (e.g., provider education/training + audit and feedback). The most common health topics included mental health (n = 6) and pregnancy (n = 3). Additionally, patient experience related to care for minor illness, burn rehab, cancer, chronic disease, diabetes, hypertension, and pain was studied by 2 or less studies. Most studies used uncontrolled before-after designs (n = 9), randomized controlled trials (n = 8), or cross-sectional designs (n = 7). Patient experience was typically measured via questionnaires, interviews, and surveys. Table 6 provides a content summary analysis for the two health topics that were assessed in three or more studies. Among these, we judged mental health (n = 6) to be ready for systematic review. Additional research is required for pregnancy (n = 3) as all three identified studies were assessing different interventions and different outcomes. Additional research is recommended for this outcome category as a whole since there were so few studies examining this outcome.
Equity of care (n = 4).
Four studies examining equity of care were published between 2010–2022 including one study each from Ethiopia, India, Kenya, and the United States. The interventions from these studies involved reorganization of services (n = 2), provider training (n = 1), and a combination of provider training and lay community member training (n = 1). Three studies focused on mental health and one on pregnancy. Table 7 provides a content summary analysis for the health topic that was assessed in three or more studies. Of note, several papers did not assess a specific health topic (e.g., they were studying an intervention applicable to any condition). We judged the topic of mental health (n = 3) to require additional research; two studies assessed similar outcomes but there was not enough similarity among interventions to warrant a review. Additional research is recommended for this outcome category as a whole since there were so few studies examining this outcome.
Patient safety (n = 1).
Only one study conducted in 2019 from the United States examined patient safety. The intervention involved coordinating care to improve medication reconciliation in a primary care clinic. Additional research is recommended for this outcome category as a whole since there were so few studies examining this outcome.
Access to care
Seventy-six (20%) articles focused on interventions to improve access to primary care. Among these articles, 21 (28%) focused on recruitment of family physicians, 15 (20%) on retention of family physicians, 14 (18%) on recruitment of alternative health provider to provide family physician-related services, and 35 (46%) on access to other services not typically provided in primary care. Several of these studies assessed more than one outcome. A detailed breakdown of all intervention types, study designs, individual study outcomes, and outcome measurements, for access to care studies can be found in S8–S11 Appendices. This data is summarized in the following sections.
Access to a primary care provider (n = 42).
Forty-two articles focused on improving access to primary care providers. The articles were largely published between 2010–2021 and came from 13 different countries, with the majority originating from the United States (n = 19) and Australia (n = 7). The most common study designs were cohort studies (n = 19), uncontrolled before-after studies (n = 10) and controlled before-after studies (n = 7). We found three main provider access topics, all of which were assessed in 3 or more studies, including recruitment (n = 21) and/or retention (n = 15) of family physicians, and recruitment of alternative primary care providers (e.g., nurse practitioners, pharmacists) (n = 14). Across the topics, different types of interventions were used, the most common type of intervention involved extending the scope of practice of non-GPs (n = 13), and the most common types of intervention for recruiting and retaining family physicians were implemented during medical education via selective recruitment of students with a focus on rural practice into medical education (n = 10), or medical education interventions that involved exposure to rural practice (n = 9), followed by financial incentives to assist with tuition payback (n = 6). A content summary for each of the three topic areas can be found in Table 8. We judged all three topics to be ready for systematic review.
Access to services (n = 36).
The majority (77%) of the 36 studies that aimed to increase access to primary care services conducted between 2010–2022. These were conducted in the United States (n = 12), Australia (n = 3), Canada (n = 2), India (n = 2), and multiple other countries. The most commonly used interventions involved providing training to existing health professionals to deliver different types of additional services they would not normally deliver (n = 13) or training lay community members (n = 4). Other studies also commonly aimed to increase referral to existing services by improving awareness of services or ease of referral (n = 6). Most common study designs were uncontrolled before-after (n = 13), cohort designs (n = 8), cross-sectional (n = 6), interrupted time series (n = 4), and randomized controlled trials (n = 3). We identified three service area topics that were assessed in three or more studies including diabetes (n = 5), mental health (n = 4) and pregnancy (n = 4). A content summary for each health topics can be found in Table 9. Of note, several papers did not assess a specific health topic (e.g., they were studying an intervention applicable to any condition). For each of these topic areas, there was a wide range of interventions and outcome measurement methods. We judged all topics to be amenable to an in-depth scoping review.
Efficiency of care delivery
Only 47 studies (15% of the total) examined efficiency of care. Among these, 28 (60%) included interventions aimed at improving cost-savings, 26 (55%) included interventions to improve healthcare use, and three included an intervention aimed at improving patient wait times. A detailed breakdown of all intervention types, study designs, individual study outcomes, and outcome measurements for efficiency studies can be found in Table 4. This data is summarized in the following paragraphs.
Wait times (n = 3).
Three studies conducted in 2008, 2017, and 2020 in the United States (n = 2) and Canada (n = 1) assessed wait times. The interventions involved improving coordination/referral pathways, reorganization of services, and provider training. Two studies used an uncontrolled before-after study design and one used a prospective cohort design. Two studies focused on mental health and one on surgery. Wait times for new appointments were measured using data from a computerized monitoring system and electronic medical record data. Additional research is recommended for this outcome category as a whole as there were so few studies examining this outcome.
Healthcare utilization (n = 26).
Over 80% of the 26 articles assessing healthcare utilization were published between 2010–2022. Most of these studies were conducted in the United States (n = 12), Canada (n = 4), Australia (n = 3), and South Africa (n = 2). The most common intervention included reorganization of services to optimize care delivery (n = 7) and improving coordination/referral pathways (n = 5). Some studies used a combination of interventions (e.g., expanding scope of practice + provider training/upskilling). The majority of the studies used a controlled before-after (n = 8), an uncontrolled before-after (n = 7), or cohort (n = 5) design. The most common health topics assessed were mental health (n = 2) and palliative care (n = 2). Additional research is recommended for this outcome category as a whole since it was not assessed in relation to the same health topic for three or more studies.
Costing and cost-effectiveness (n = 28).
Most of the 28 studies examining cost-savings as a means to improve efficiency were published between 2010–2022. These were conducted in a variety of countries, most commonly in the United States (n = 12). The majority of the interventions focused on reorganizing services to optimize care delivery (n = 8), improving coordination/referral pathways (n = 6), and upskilling healthcare providers on evidence-based clinical practice guidelines (n = 4). The most common study design in this area was the uncontrolled before-after design (n = 10). Mental health (n = 3), preventive care (n = 2), CVD (n = 2), and epilepsy (n = 2) were the most commonly assessed health topics. A content summary for mental health can be found in Table 10. Of note, several papers did not assess a specific health topic (e.g., they were studying an intervention applicable to any condition). We recommend an in-depth scoping review for one health topic (mental health, n = 3). Additional research is also recommended for this outcome category as a whole as there were relatively few studies examining this outcome overall.
Discussion
This review serves as an overarching scoping review that primarily aims to identify what types of topics, interventions and designs are being used to improve access, quality and efficiency of primary care in rural and remote areas globally. A secondary aim is to provide a high-level content summary within each of these outcome areas and to provide recommendations for future research. We have separated our discussion of the results into two main sections, (i) content summary and recommendations for future research which includes a summary of the main findings to answer our objectives, and (ii) the burden of rurality and the need for rural-specific research which provides a thoughtful discussion of these results from the rural clinical perspective.
Content summary and recommendations for further research
Overall, given our liberal search criteria, we found a low number of papers that met our inclusion criteria and an even lower number that used more rigorous randomized designs. While we did note an upward trend toward increased publications, the trend we observed peaked in 2017 before beginning a decline to pre-peak levels. In addition, the increase in the yearly number of rural primary care publications must be tempered by the fact that scientific output in general is doubling approximately every nine years [391]. Nevertheless, the increase we observed in rural primary care literature does appear to outpace the rate of increase in general scientific productivity. Not surprisingly, a large percentage of the papers captured in this review originate from the United States, Australia and Canada, countries that have long been known to have high levels of rurality and established programs of rural health research. Notably, a substantial proportion of papers come from Africa (n = 35 (9.4%), Tables 2–4) despite limited resources in those countries. European, Middle Eastern and Asian countries are underrepresented in this review, likely because of relatively high population density and a lower impact of rurality at the population level. In terms of our outcome areas of interest, we will present our findings summary for each separately.
Access: We found the topic area of increasing access to a primary care provider one that is ready for a formal systematic review. While each of the identified three subtopics, recruitment or retention of family physicians and recruitment of an alternate care provider, have been the subject of previous reviews there hasn’t been a comprehensive review of the effectiveness of all available strategies which would be of benefit as this issue is a high priority in all areas. A realist approach may work best as there are several different health system contexts to consider in likelihood of effectiveness. The topic of increasing access to primary care services included a number of different services for specific health issues such as diabetes or mental health which would benefit from a further scoping review to identify useful PICO questions.
Efficiency: We found only 2 topics that assessed outcomes related to improving efficiency of primary care services, mental health and pregnancy-related topics. Unfortunately, reporting regarding the outcomes of wait-times or healthcare use were unclear and follow-up with authors would be necessary to understand these outcomes in more detail before meaningful PICOs could be identified.
Quality: We found the majority of studies aimed to improve quality of primary care either via interventions to improve adherence to guidelines (improving evidence-based medicine) or to improve specific patient clinical outcomes. Much less attention has been paid to other aspects of quality such as patient experience or equity. The most common topics across all areas of quality were the health topics of diabetes, mental health, cancer, CVD and asthma. In our results, we made several recommendations for where the evidence is ready for systematic or scoping reviews within the specific health topics, however, looking at the data across outcomes, we would also recommend broader reviews for the same or interrelated health topics. For example, the health topics of diabetes, cancer, asthma, CVD, mental health and pregnancy all had studies that assessed interventions to improve patient clinical outcomes and adherence to/update of evidence-based care recommendations. In these cases, we would suggest conducting comprehensive reviews by these topic areas that include all outcomes of interest that have been assessed. Additionally, we found evidence to suggest systematic reviews for a number of related health topics such as weight management, alcohol use and pain management. We would suggest combining these topics to form a larger topic area such as lifestyle changes for a more impactful review. The last comment worth note, is that a realist approach would likely be required in almost all reviews to assess the findings in terms of contextual factors related to (i) geographical location, (ii) country economic status and (iii) health system status (private/public, etc.)
The burden of rurality and the need for rural-specific research
As we all know, there is a huge and rapidly growing literature on the management of chronic diseases and their burden on society and the health system. In most jurisdictions, rurality is associated with a 2–5 year deficit in life expectancy [2, 5, 392, 393] which does not compare to the effect of widely studied diseases such as diabetes, heart disease and stroke [394]. However, the far greater prevalence of rurality suggests that its burden, at the population level, is likely to be as great or greater than any of the chronic diseases alone. Admittedly, some of the urban/rural disparity in health outcomes is attributable to differences in rates of chronic disease [3, 4]. Thus, science that examines chronic disease may indirectly contribute to narrowing the rural-urban divide. However, health services delivery and socio-cultural issues are different in rural areas, suggesting that rural-specific research may be necessary to more completely address rural/urban health inequities than disease inquiry alone.
For this work, we deliberately chose liberal inclusion criteria to maximize reach, by including designs such as non-randomized and before-after studies, which are often excluded from reviews. During article screening, we did not tally papers that were excluded because of the lack of a comparative evaluation component (e.g., opinion pieces, rural program descriptions and uncontrolled cross-sectional evaluations), but subjectively note that this was a large number of papers. This suggests that there is considerable interest in rural healthcare delivery not reflected in this review, but a lack of resources to pursue more intensive research efforts, mirroring the lack of resources available to health service delivery in rural areas.
As we have noted in Table 2, the bulk of papers included in this review examined the quality of care delivery. We have not attempted to systematically identify whether the interventions studied in these papers were specifically tailored for rural populations or simply studied a geography-agnostic program delivered in a rural area. However, our subjective opinion is that a substantial proportion of the studied interventions did not include modifications for rural populations and provided only limited if any description of factors that may have influenced program implementation, delivery or quality specifically in the rural setting. Nearly a third of the papers examined the adoption of best practices, most of which were drawn from clinical practice guidelines which typically do not include a rural focus. Programs that did include both urban and rural programs often included only a small number of sites, limiting the generalizability of the findings. Given relatively limited attempts to create rural-specific data analyses or amendments to interventions in the quality of care papers, the contribution to the rural-specific primary care literature is somewhat less than suggested by the high number of papers in this section. This represents an important gap in the literature that could be filled by a greater number of studies that examine differences in implementation, delivery and outcomes between rural and urban sites of the same program and/or a systematic review of studies that include both rural and urban sites to elucidate factors (if any) that contribute to differences in outcomes between rural and urban populations. The results of this work could then be used to develop frameworks describing which evidence from primarily urban sites could be applied in the rural setting, and where clinical programs require modification for rural delivery.
Reflecting the challenges with and widespread attention paid to the recruitment and retention of primary care physicians as a means of overcoming one of the greatest challenges in rural care delivery [395, 396], our paper documents a considerable number of papers (n = 28) that examined these issues, but none that used randomized designs. However, given the potential for multi-disciplinary providers to meet primary care needs, it is surprising that relatively few papers (n = 14) examined the use of non-physician providers in the rural setting. In the broad primary care literature (i.e. not exclusively rural), there is widespread interest in multi-disciplinary primary care delivery, and many of the findings from that literature could be used to inform rural service delivery. However, as mentioned above, socio-cultural and other issues are different in rural areas, which may lead to service-delivery challenges not seen with urban teams. This issue further highlights the need for studies to determine the extent to which evidence developed in urban centres can be applied in the rural setting.
Limitations
Given the high number of papers included in this scoping review, we have not attempted to extract specific recommendations regarding policy or service delivery, but we intend to do so in follow-up sub-topic papers. As with any review, the quality is limited by the quality of the literature search and data extraction, but we have used an experienced information specialist and duplicate data extraction approaches to mitigate these concerns. We have used the Canadian Foundation for Healthcare Improvements’ 2012 policy document, entitled Toward a Primary Care Strategy for Canada to inform many of the working definitions for our review but we acknowledge that other frameworks and definitions exist to describe primary care and related outcomes and thus there may be some overlap or slight differences in our categorization compared to the literature [9]. Finally, in an attempt to describe the rural primary care literature as thoroughly as possible, we have classified papers into multiple categories if appropriate. Thus, interpretations about the degree of focus on a particular subject area should keep this in mind.
Supporting information
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0305516.s001
(DOCX)
S2 Appendix. Details on article characteristics.
https://doi.org/10.1371/journal.pone.0305516.s003
(DOCX)
S10 Appendix. Access to alternative primary care provider.
https://doi.org/10.1371/journal.pone.0305516.s011
(DOCX)
S11 Appendix. Access to services not normally delivered by family physicians.
https://doi.org/10.1371/journal.pone.0305516.s012
(DOCX)
S14 Appendix. Costing and cost effectiveness.
https://doi.org/10.1371/journal.pone.0305516.s015
(DOCX)
Acknowledgments
The authors wish to thank Ms. Lindsay Alcock for assistance with refining the search strategy and completing the literature search.
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