In this study, two measures of rurality – postal code at CFU and travel distance to the nearest tertiary care facility – were used to evaluate environmental barriers, health outcomes and healthcare utilization patterns after tSCI. There were similar health outcomes between individuals from rural and urban postal codes and between individuals who lived > 100 km or ≤ 100 km from the nearest RHSCIR facility, based on measurements of function (FIM, SCIM), quality of life (LISAT-11), health status (SF36), medical complications and healthcare utilization patterns. The only difference was those individuals living more than 100 km away from the nearest tertiary care facility were more likely to report sexual dysfunction after tSCI. This may reflect the neurological level of injury and not the impact of rurality, as individuals in this group were more likely to have complete paraplegia.
There may be an inherent bias from healthcare providers to assume that individuals with disabilities who live in rural areas at an extended distance from tertiary care have worse health outcomes, as there may be limited access to recreational activities, medical care providers and work/school opportunities. This bias has been explored during patient interviews in a study by Goodridge et al. (2015) in Saskatchewan, Canada [21]. They found that most SCI participants from rural areas valued the benefits of living in rural settings and reported that their decision to remain in a rural location post-discharge was often not supported by their specialist healthcare provider. There appears to be a growing amount of evidence to suggest that SCI patients from rural areas can have similar – and sometimes better health outcomes – as compared to their urban counterparts. This may be related to the protective effects of a tight-knit community and to the accessibility of open rather than built-up environments [21]. Glennie et al. (2017) found that mental health outcomes were better in individuals with tSCI from rural areas, as compared to those living in urban settings and those who migrated from rural to urban settings [6]. A large study of 1454 individuals with tSCI in New Jersey and Alabama reported that life satisfaction was greatest in rural communities [22]. These trends may not be unique to the SCI population: an evaluation of 1200 Canadian neighbourhoods and communities found that populations exceeding 50,000 people reported less life satisfaction than smaller communities, despite having lower rates of unemployment and higher incomes [23].
A strong foundation of social support is essential for promoting mental and physical health, community re-integration and functional independence after tSCI [7]. Social relationships with friends, colleagues and family members are an important motivating factor to participate in community life following SCI [7]. The protective effect of social relationships could explain the benefits of remaining in one’s community after injury. Glennie et al. (2017) found that patients who migrated from rural to urban settings after discharge reported worse health outcomes [6]. The transition of moving is disruptive and can interfere with support networks. This may explain the benefits of living in either rural or urban locations in Atlantic Canada, and why patients did not migrate between urban and rural settings after community follow-up.
The similarities in outcomes of health and function according to measures of rurality may also have been related to comparable access to outpatient care. There were no differences in healthcare visitations to physicians and allied health professionals during CFU when participants were stratified according to postal code or travel distance after discharge. There have been a limited number of studies that have looked at healthcare utilization patterns according to travel distances. Bell et al. (2017) found that longer travel distances were inversely related with physician and physiotherapist visits [24]. In our study, there were no differences between the “≤100km” and “>100 km” groups with respect to physician and allied health professional visits during community follow-up. However, travel distance was to the nearest RHSCIR facility, so it may not necessarily reflect the location of care. Ronca et al. (2020) found that individuals who had to travel more than 69 minutes to a tertiary SCI center were more likely to forgo specialist care in exchange for more generalist local care [25]. In our study, there were similar rates of specialist care (e.g., spine surgeon, physical medicine and rehabilitation specialist, urologist) with a cut-off travel distance of 100 km, which corresponds to a travel time of approximately 60 minutes. However, a limitation of our study was that we did not record the number of visits for each provider. Individuals from rural settings may have achieved similar health outcomes by visiting physicians and allied health professionals a different number of times. Guilcher et al. (2010) reported a mean number of physician visits of 29.7 for traumatic SCI during the first year after inpatient rehabilitation [26]. There were different patterns of utilization according to rurality, with those living in an urban setting more likely to have 30 or more physician visits and 20 or more specialist visits, while those living in a rural environment were more likely to have two or more ED visits. Munce et al. (2009) also found that patients from rural locations were more likely to visit the emergency department for their healthcare needs [27]. As a result, there may have been differences in healthcare utilization patterns that were not captured with the RHSCIR dataset used in this study. In addition, we only looked at healthcare visitations within the first 9–24 months post-discharge; it is possible that the demand for healthcare may have changed and diverged between groups the longer individuals lived in their communities.
We also demonstrated that participants with tSCI in Atlantic Canada experience relatively similar environmental barriers and difficulties accessing care according to geographical area of residence, which may have contributed to similar health and functional outcomes. The main challenges for obtaining care included a lack of available services, lack of information to access these services, and lengthy waiting times. The issue of waiting times has been previously identified as a major concern in SCI-related care in a qualitative study by Goodridge et al. (2015) [21]. Although there were some services that were well accessed by participants, there were some services that appear to be underutilized. Less than 5% of participants had access to a vocational counsellor, despite 65% being employed prior to their injury. Only one person visited a peer support person, which is discouraging as the availability of peer support after SCI discharge has been highlighted as an important resource for maintaining health and wellness [21]. Only one person visited a sexual health clinician in the first year of community follow-up, despite approximately half of participants reporting sexual dysfunction in the last 12 months.
Individuals from rural and urban living locations perceived the most environmental barriers within the physical/structural subscale of the CHIEF-SF. This finding has been recognized in three previous studies on tSCI [6, 8, 10]. Participants from rural and urban postal codes reported scores of 1.79 and 1.93 respectively on the physical/structural subscale. These scores are higher than those reported in non-disabled populations (0.39 ± 0.60) by Whiteneck et al. (2004), suggesting a common barrier to individuals with tSCI [16]. Holliday and Kurl (2016) identified an accessibility gap within Canada, which respondents attributed to older buildings which are harder to renovate, the expensive costs of creating accessible environments, the lack of general understanding about what accessibility entails, the lack of importance given to accessible designs during construction, and the lack of governmental enforcement [28]. These factors are most related to the built environment and may explain the magnitude of barriers identified within the physical/structural subscale of the CHIEF-SF. Cao et al. (2015) reported that the physical/structural and services/assistance subscales of the CHIEF-SF were most predictive of mental and physical health after SCI [10]. This may explain the health outcomes in our study, as these subscales were similar between urban and rural cohorts and between those living “≤100km” and “>100 km” from the nearest RHSCIR facility. As well, previous research has suggested that scores on the CHIEF-SF may account for only 4% and 10% of the variation in participation and life satisfaction measures [8].
Individuals with tSCI from urban postal codes in Atlantic Canada experienced more environmental barriers than those from rural locations with respect to the CHIEF-SF subscales of work/school and policies. These same findings were not replicated using travel distance as a marker of rurality. High population density, outdated infrastructure, poor urban planning and a built-up environment with obstacles such as stairs, curbs and sidewalks may pose unique challenges to individuals with tSCI from urban areas [28]. These factors may have contributed to the differences in the policies subscale scores, as the policy barriers may have been more apparent in a built-up, urban environment. In addition, individuals from rural postal codes reported no barriers within the work/school subscale. It is unclear why this was the case. There were no differences in rates of employment pre- and post-injury according to postal codes at discharge.
Glennie et al. (2017) compared environmental barriers and health outcomes between rural and urban participants in British Columbia [6]. They concluded that urban participants reported fewer perceived environmental barriers, particularly with respect to the physical/structural and services/assistance subscales. It is unclear why there may be differences in perceived barriers between rural and urban patients from Atlantic Canada and British Columbia, but this may relate to differences in climate and injury characteristics. In our study, individuals from urban areas were more likely to have a cervical neurological level of injury at discharge, which was not the case in the study by Glennie et al. (2017). It has been shown that individuals with disability reduce their community participation when exposed to snowy and cold weather [29]. This may be less of a factor in British Columbia, as the province has a much milder climate during the winter months than Atlantic Canada, particularly in major cities such as Vancouver and Victoria.
Limitations
There are several limitations to this study. As the RHSCIR data set depends on participant recall, there is the possibility of recall bias and incompleteness of the information gathered. There were some incomplete data fields on the CFU related to demographics and health outcomes for some participants. In addition to the incomplete data fields, missing postal codes contributed to a high number of patients from the RHSCIR data set that were not eligible for the study, which could have contributed to non-response bias. The use of any existing data set such as RHSCIR limits the number of potential outcome variables. For example, healthcare utilization is only documented according to whether a person has seen a healthcare specialist or not, and does not record the number of visits. In addition, we did not explore whether healthcare visits were conducted by telehealth or through in-person assessments. It is possible that telehealth services may have had an impact on the ability of rural individuals to access specialized care. Although this is a multi-centre study, it is based on a regional data set, so the results may not be generalizable to other populations. The lack of qualitative data and open-ended responses may have limited our ability to fully understand the details of the barriers perceived.