Introduction

Access to health care in many developed countries differs for persons living in urban centers compared to those living in rural or remote areas. This difference in access to specialized health care is contrary to what most healthcare consumers in developed countries expect. Because of their geography, countries such as Australia, New Zealand, Canada, Norway and Finland face unique challenges in the delivery of healthcare services. The vastness of the landscape combined with citizens living in isolated and remote communities make it difficult to ensure that all citizens have equitable or reasonable access to healthcare services. To a great extent, population density determines whether people have access to healthcare providers, medical resources and specialized care.1,2 In countries with large, sparsely populated areas, persons living in rural and remote communities often experience inequitable access to primary care. Moreover, their access to specialty healthcare services, such as physician specialists, and diagnostic and surgical procedures, can be even more problematic. This is often related to great distances and the high cost of travel to urban centers, as well as costs associated with extended time away from family, community and social supports.2,3

Research on accessing health care in rural and remote areas, and overall health care provides evidence of the challenges that occur in these regions that do not commonly occur in urban areas. These challenges include the distance to access health care, insufficient health education and limited peer support.4 Travel time to access specialized services, such as cancer care, is negatively correlated with receiving timely treatment.5 Studies show that people living in rural areas have a poorer health status, shorter life expectancy and higher mortality rates than those living in urban areas.6-9 For example, one study found that the health status of individuals who live in remote and rural Australia is worse than those who live in cities. Twenty percent more people in remote areas of Australia are living with disease compared to those living in cities.10 The authors suggested the geographical location was a causative factor for this difference in health status. However, other studies out of the United States and Canada have suggested that the relationship between living in a rural or remote area and health outcomes may be more complex.4,11-13 For example, a study of persons living with advanced chronic respiratory illness in a rural area, which used an interpretive descriptive approach, found that the challenges of accessing specialized healthcare services are often counterbalanced by the benefits of living in a supportive community and having a close relationship with a primary care clinician.4

The world's population is aging. Using Canada as an example, 14% of Canada's population was aged 65 years or over in 2010.14 With the aging of the "baby boom" generation, this proportion is estimated to rise to about 25% in 2036.14 The healthcare needs of older adults are considerable. For example, 33% of Canadians aged 65 or over and 44% of Canadians aged 75 or over had a disability in 2006.15 The high rate of chronic diseases such as cardiovascular diseases, diabetes, cancers and mental illnesses, as well as the need for palliative care services associated with an aging population, result in an increasing demand for specialized healthcare services 16 and long wait times.6,17,18

Older persons, regardless of whether they live in urban, rural or remote regions, are especially vulnerable to the lack of access to specialized healthcare services that are not provided by primary care clinicians such as cardiovascular diseases, renal diseases, diabetes, cancers, mental illnesses and palliative care. Many older adults are negatively impacted by poverty or financial challenges. For example, in Australia, despite pension reform, more than one third of people over the age of 65 years live below the poverty line.19 In Canada, poverty has slowly increased since 2007.14 Older Canadians may not have contributed to employee pension plans and are dependent on employment income for survival.20 Furthermore, many older persons who have greater medication needs lack prescription coverage for many drugs and are paying extraordinary out-of-pocket costs for prescription medications. These barriers to accessing specialized healthcare services are particularly acute for persons living in rural and remote areas, where access to employment may be difficult.21 Seniors in rural communities face the same physical barriers to accessing health services as younger adults in rural communities such as difficult terrain and long distances to service;4 however, lack of transportation and the need for assistance are often even more problematic.22 Finally, norms and values amongst older rural adults often mean a reluctance and fear to seek health services outside their comfort area.23,24

The aging population and the associated increase in illnesses requiring specialized healthcare services mean that an increased number of older persons living in rural and remote communities will encounter challenges accessing their required health care. As people age, their need for specialized healthcare services increases. Given that many older persons who live in rural or remote areas have a chronic illness(s), may live on a fixed income, and/or not be able to drive themselves for specialized health care, it is important to know about their experience of accessing specialized services. Disparity in access to health care, especially for specialized services, is often an issue in developed countries, particularly those with dispersed populations.1

Research supports that rural and remote location does play a major role in determining the nature and level of service provision.3 A number of studies have addressed older persons' experiences of accessing specialized services while living in remote or rural areas.4,24-26 However, a search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, CINAHL, PubMed and PROSPERO, revealed no existing systematic reviews or protocols on this topic. Therefore, a systematic review is needed to integrate and summarize the literature on the experience of older persons accessing specialized healthcare services while living in remote or rural areas.

Review question

What are the experiences of older adults accessing specialized healthcare services in rural or remote areas?

Inclusion criteria

Participants

The review will consider studies that include persons 65 years and over who have self-identified as living in remote or rural settings. These persons will have on at least one occasion sought access in person to specialized healthcare services for a chronic condition(s) such as cardiovascular diseases, renal diseases, diabetes, cancers, mental illnesses or a major health concern that is beyond the scope of the primary healthcare clinician, such as palliative care.

Phenomena of interest

The phenomenon of interest is the experience of accessing any type of specialized healthcare service for older persons living in rural or remote areas.

Context

The context is accessing specialized healthcare services as an older person in a remote or rural area in a developed country. In a review article related to health and rural populations, the authors note that what constitutes rural versus urban has been the subject of debate; however, key predictors of the difference in health status between urban and rural residents include geographic isolation and accessibility of appropriate healthcare services.3 Lacking a single, standard definition of rural, the participants' self-definition of being in a rural or remote area will be used in this review. The context of developed countries as opposed to less developed countries was chosen because it is reasonable to assume that, generally, developed countries have more economic resources, including an overall higher level of availability of various specialized services.27

Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.

Studies published in English will be included. Studies published from 1980 will be included because this systematic review is interested in capturing the current context of specialized health care. While persons in remote and rural areas did receive specialized health care prior to 1980, there has been growth in these services, in medical science and technology, and in patient expectations, and therefore studies published prior to 1980 are unlikely to reflect more recent healthcare experiences.

Methods

Search strategy

The search strategy will aim to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken in February 2017 followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a search strategy, which will be tailored for each information source. A full search strategy for CINAHL is detailed in Appendix I. The reference list of all studies selected for critical appraisal will be screened for additional studies.

Information sources

The databases to be searched include: CINAHL, PubMed, PsycINFO and AgeLine.

The search for unpublished studies will include: ProQuest Dissertations and Theses, Google Scholar and MedNar.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.28 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

Selected studies will be critically appraised by two independent reviewers for methodological quality using the JBI Critical Appraisal Checklist for Qualitative Research.29 The two reviewers will then meet to discuss whether studies that have more than two criteria rated as "no" or "unclear" will be included. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table.

Data extraction

Qualitative data will be extracted by two independent reviewers from papers included in the review using the standardized data extraction tool from JBI SUMARI.29 The data extracted will include specific details about the populations, context, culture, geographical location, study methods and the phenomena of interest relevant to the review question and specific objectives. Findings and illustrations will be extracted, and each illustration will be assigned a level of credibility by consensus of two reviewers.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.30 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.31 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the table are the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review is then presented along with the type of research informing it, a score for dependability, credibility and the overall ConQual score.

Appendix I: Search strategy for CINAHL

References