Abstract

Rurality and remoteness are policy-relevant concepts for planning and evaluating equitable access to services across Canada, yet existing measures rely on categorical, urban-centric, and coarse spatial definitions that obscure variation in accessibility across the rural-urban continuum. The Canadian Accessibility and Remoteness Index Plus (CARI+) is a small-area accessibility index at the dissemination-area level. It is based on road-network travel to stratified service centres, including population centres and 24-hour emergency departments stratified by settlement size. Category-specific scores are capped at 3, summed to produce an overall score, then normalized.

We examined the CARI+ values against socio-demographic indicators and compared them with the Index of Remoteness (IOR). CARI+ yields a more even population distribution than the IOR (39% vs 77% in the most accessible category) and reveals socio-demographic gradients: material deprivation and Indigenous identity increase with remoteness, while educational attainment and immigrant representation decline. In very remote areas, CARI+ identifies 25% of Indigenous residents and 27% of the population with less than high school education, versus 78% and over 50% respectively under the IOR. The CARI+ provides a transparent, service-specific, high-resolution measure of accessibility that addresses key limitations of existing Canadian indices and supports nuanced analysis for health and social service planning.

This article is part of our , which aims to make disaggregated data on health and social service access available for researchers and planners in Canada.

Read the Article:

Citation

McGaughey, T., & P. A. Peters. 202670:. Introducing the Canadian Accessibility and Remoteness Index (CARI+). Canadian Geographies / GĂ©ographies canadiennes, 70, e70082. 

The post New Article: Introducing the Canadian Accessibility and Remoteness Index (CARI+) appeared first on Determinants.

What do we know? Rural obstetrical care in Canada has limited local access, meaning many women must travel, sometimes over two hours, to give birth. Care is often provided by fewer specialists and more family physicians, and services vary widely between communities. These gaps can affect outcomes and reflect that rurality is a key social determinant of health. There are fewer obstetrical specialists in rural areas, so care depends heavily on family physicians and limited staff, which affects consistency of care.

What do we want to know? We want to know whether access to rural maternity care has improved since 2011, how to reduce travel and service gaps, and whether some maternal health risks and deaths are preventable with better access and resources.

How does it affect people? Limited access to rural OB care can lead to worse birth outcomes, increased stress, and financial strain due to travel. It also impacts overall health because rurality acts as a social determinant of health, affecting both mothers and newborns. Long travel times can lead to delayed care, emergency deliveries, and higher stress, which can affect outcomes.

ArcGIS StoryMap

An is a web-based digital storytelling tool created by that combines interactive maps and 3D scenes with multimedia content—like text, photos, audio, and video. It allows anyone to build immersive, visual narratives without needing prior GIS () experience.

View the complete ArcGIS StoryMap at: .

The post StoryMap: Access to Obstetrical Care Across Canada appeared first on Determinants.

This project aims to map existing research on the internal migration, spatial mobility or residential relocation of older adults in Canada. It focuses especially on the determinants of internal migration between urban and non-urban regions of Canada that are motivated or driven by health, health care needs, or other health-related reasons reasons.

This protocol has been registered with Open Science Foundation: .

Increasing life expectancy and declining birth rates have led to increases in the median age for many countries, including Canada. In this context, preparing for and meeting the needs of an aging population is a growing challenge [1]. While older age is not a direct indicator of poor health, older adults are disproportionally represented among those with chronic diseases and have a greater probability of suffering falls and injuries and having age-related decreases in immunity [2][3]. As such, they are more likely to be high users of the health system when compared to their younger counterparts [4][5].

Problems in accessing health care for this age group are often exacerbated in areas with less healthcare resources [6][7]. Rural and remote regions, for instance, often contend with scarcity of services and difficulties in retaining health workers [8][9]. Rural communities in Canada have low population density and less diversified services compared to urban communities [10]. Additionally, compared to urban areas, they have been shown to have a trend of out-migration of young people, in-migration of older individuals [11], and consequently, a higher proportion of older adults [12].

Existing studies cite a wide array of motivations for older adults’ migration within Canadian borders, including health-related issues [13][14][15]. In Canada, usually this group’s motivations to migrate include the search for lower cost of living, the wish to be closer to nature, or to live in age-friendly neighbourhoods after retirement [13]. Edmonston and Lee [13] identified health as one of the five most common reasons for the relocation of older adults.

This review seeks to quantify and describe research on the internal mobility of older adults in Canada for health-related reasons, with a special focus on relocations across the rural-urban axis.

We use the terms “older adults”, “rural” and “internal mobility” and their synonyms to describe the different ways in which studies in the area define each of these concepts. The definition of “rural” is complex and can be based on a variety of indicators, from idealized conceptions [16] to objective measures such as concentration of services and population density [17]. In Canada, rurality is often operationally defined as region with population density of less than 400 habitants per square kilometer [12], but many studies offer their own definitions. The concept of “older adults” as well does not have a clear definition in the literature, with initial age cut points ranging from approximately 45 to 65 years. “Internal mobility” is generally understood as residential relocation within national borders, but it can also include changes of residence within shorter distances such as the same neighbourhood, or the same city, for instance, and long-distance relocations or migrations. Different conceptualizations of “rural”, “mobility”, “older adults”, as well as “health”, will be categorized and described in the review.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted. The economic [18] and health-related [19] consequences of older adult migration were discussed in some reviews, as well as the specific healthcare challenges of aging in rural areas of Canada for older adults [20]. However, to our knowledge no current or in-progress scoping reviews or systematic reviews about the specific topic of health or healthcare influence on migration for older adults in Canada were identified.

Given the disparities in the distribution of health services in Canada, especially between rural and urban areas, fully understanding the patterns of internal migration of older adults within Canadian borders is important for attaining a more equitable distribution of resources, and especially relevant for the promotion of aging-in-place policies.

The post Protocol: Health-Related Determinants Of Internal Migration Among Older Adults In Canada appeared first on Determinants.

Evaluating the impacts of the Tłı̨chǫ Highway on food security and other determinants of health in Whatì, NWT.

Sarah Jones, PhD

Abstract

Many Indigenous populations across Canada experience inequalities in the determinants of health and well-being and health outcomes compared to non-Indigenous populations. These inequalities are related to historic and contemporary structural and systemic inequities linked to processes of colonization. In Canada, inequities are compounded in isolated and remote communities by large geographic distances to the nearest administrative and service centres and, in many cases, socio-economic marginalization. The development of new transportation infrastructure is often used as an instrument for government policy to bridge this distance and improve determinants of health and well-being for isolated communities. 

In 2021, the Tłı̨chÇ« community of Whatì in northern Canada was fundamentally transformed by one such development, the Tłı̨chÇ« Highway, which connected the isolated community of Whatì to other communities in Northwest Territories (NWT) and to southern Canada. The objective of this research was to investigate the ways in which the Tłı̨chÇ« Highway has changed the community of Whatì. Through a community-based participatory research methodological approach in partnership with Tłı̨chÇ« Government (TG) Department of Culture and Lands Protection (DCLP), this research investigated the impacts of the highway on food security and food sovereignty, mobility, and economic, social, and cultural determinants of health and well-being for community members in Whatì. It also investigated how impacts may be experienced differently across sub-populations in the community and identified programs and initiatives that could address negative impacts of the highway and improve determinants of health and well-being for community members in Whatì. 

Using dirt research as a research method, the researcher took up research residence in Whatì for several months in 2023, and conducted follow-up visits throughout 2024 and 2025. Together with two community research coordinators from Whatì, the researcher conducted a total of 50 semi-structured interviews with 55 community members, a focus group, and a workshop with high school students in 2023. This research also employed an analysis of documents submitted to the Mackenzie Valley Environmental Impact Review Board (MVEIRB) for the environmental assessment review process of the Tłı̨chÇ« Highway to compare predicted and post-construction impacts of the highway specific to the market food system in Whatì. The methods used to conduct this research then shifted from observational to action-oriented to facilitate conversations between key stakeholders regarding the eligibility of the Whatì Community Store to receive a retail subsidy through the Nutrition North Canada (NNC) program, which depends on lack of year-round surface transportation to a community. This shift was grounded in t community-based participatory research methodology and driven by the researcher’s commitment to reciprocity and responsibility for ethical community engagement. 

This thesis presents a scoping review to map the extent, nature, and distribution of studies on the impacts of transportation infrastructure development on the determinants of health and well-being for remote communities in the circumpolar north, Australia, and New Zealand. It also presents the results of community-based participatory research, document analysis, and engagement with key stakeholders. Key findings of community-based participatory research illustrate the importance of situating food security in place and, that while the highway has improved dimensions of food security at the individual and household levels, it has negatively impacted food sovereignty at the community level in Whatì. The highway has provided marked increases in the mobility of community members in Whatì, limited short-term economic benefits, and the potential for medium- and long-term economic development and employment opportunities. However, increased connectivity has also resulted in a substantial increase in substance use in the community and changes to community safety, and has the potential to contribute to the erosion of Tłı̨chǫ Nàowo, or way of life, in Whatì. These impacts were assessed alongside efforts to mitigate food insecurity of community members and negative impacts of the highway, and to improve food sovereignty and the determinants of health and well-being in Whatì. 

Results of document analysis found that the environmental assessment review process for the Tłı̨chǫ Highway lacked discussion on the predicted impacts of the highway on the Whatì Community Store in relation to the NNC retail subsidy. As a result of engagement with key stakeholders, the Whatì Community Store received an extension of the retail subsidy and contingency funding from the NNC Community Food Programs Fund to support its transition to a road-based supply chain using the Tłı̨chǫ Highway. Results of the investigation into the interactions between the environmental assessment review process and institutional supports or barriers for the market food system also yielded four policy recommendations. These, along with the results of community-based participatory research, can inform environmental assessment review processes for proposed new roads to isolated communities in Canada including mitigative strategies specific to sub‑populations that may be disproportionately impacted by this infrastructure. Results of community-based participatory research support TG’s regulatory reporting requirements for the Tłı̨chǫ Highway to the MVEIRB. Lastly, this thesis contributes to critical population health praxis and community-based participatory research as a methodological approach to research with communities, discussing the relationship between research and advocacy for researchers external to, but partnering with, communities.

Read the Dissertation: .

Citation

Jones S. Evaluating the Impacts of the Tłı̨chÇ« Highway on Food Security and other Determinants of Health and Well-Being in Whatì, NWT [dissertation on the Internet]. Ottawa (ON): ĐÓ°ÉÔ­´´ University; 2025 [cited 2025 Oct 1]. Available from: https://doi.org/10.22215/etd/2025-16782

The post PhD Success: Sarah Jones appeared first on Determinants.

Tomoko McGaughey, George Kephart, Utkarsh J. Dang, and Paul A. Peters

Abstract

Multiple definitions have been used to identify individuals who are high system users (HSUs), through economic costs, frequency of use, or length of stay for inpatient care users. However, no definition has been validated to be representative of those residing in rural communities, who face unique service accessibility. This paper identifies an HSU definition for rural Canada that is inclusive of various levels of rurality, longitudinal patient experiences, and types of hospitalizations experienced. This study utilized the 2011 Canadian Census Health and Environment Cohort (CanCHEC) linkage profile to assess hospitalization experiences between 1 January 2009 and 31 December 2013. A range of common HSU indicators were compared using Cox proportional hazards modelling for multiple periods of assessment and types of admissions. The preferred definition for rural HSUs was individuals who are in the 90th percentile of unplanned hospitalization episodes for 2 of 3 consecutive years. This approach is innovative in that it includes longitudinal hospital experiences and multiple types of hospitalizations and assesses an individual’s rurality as a point of context for analysis, rather than a characteristic. These differences provide an opportunity for community characteristic needs assessment and subsequent adjustments to policy development and resource allocation to meet each rural community’s specific needs.

Read the Article: .

Citation

McGaughey, T.; Kephart, G.; Dang, U.J.; Peters, P.A. Creating an Inclusive Definition for High Users of Inpatient Hospital Systems That Considers Different Levels of Rurality. Int. J. Environ. Res. Public Health 2025, 22, 381. https://doi.org/10.3390/ijerph22030381

The post New Article: Creating an Inclusive Definition for High Users of Inpatient Hospital Systems That Considers Different Levels of Rurality appeared first on Determinants.

Reyhaneh Golestani, Farideh Khalajabadi Farahani, and Paul Peters

Abstract

Background: The aim of this study is to explore young rural women’s perceived barriers in accessing healthcare services with a focus on the interrelation between three marginalization criteria: age (youth), gender (female), and place of residence (rural areas) in Australia, Canada, and Sweden.

Methods: Using a qualitative interpretive approach, we conducted semi-structured in-depth interviews with 31 young women aged 18 to 24 in selected rural communities. Data collection took place from May 2019 to January 2021, and the qualitative data were analyzed using NVivo software.

Results: Self-perceived barriers for access to healthcare services among young women living in rural and remote areas encompass various challenges across individual, institutional, and structural levels. Individual barriers include limited knowledge about available health services, negative attitudes toward healthcare, psychological discomfort when seeking assistance, and economic affordability issues. Institutional challenges involve limited healthcare resources, gender insensitivity among providers, judgmental attitudes from healthcare staff, inadequate time management of services, and a lack of privacy and confidentiality within facilities. Structural barriers further compound these issues through socio-cultural and gender norms, insufficient coverage of universal health insurance, low budget allocations for health facilities in rural and small urban areas, and the geographic distance to healthcare providers. Addressing these multifaceted barriers is crucial to improving healthcare access for rural population.

Conclusions: Appropriate strategies and policies must be introduced to promote access to healthcare services in rural and remote areas even in most high-income countries.

Read the article:

Citation

Golestani, R., Farahani, F.K. & Peters, P. Exploring barriers to accessing health care services by young women in rural settings: a qualitative study in Australia, Canada, and Sweden. BMC Public Health 25, 213 (2025). https://doi.org/10.1186/s12889-025-21387-2

The post New Article: Exploring barriers to accessing health care services by young women in rural settings: a qualitative study in Australia, Canada, and Sweden appeared first on Determinants.

Objective: The objective of this review is to determine the scope of spatial modelling approaches used to evaluate geographic access to health and care services in rural Canada.

Introduction: Canada’s health and social policy agenda has made the requirement for equal access to primary and secondary health services for rural populations a key priority. Most rural health research in Canada has focused on measuring patterns of health outcomes or modelling geographic access to a narrow range of services, health conditions, or within specific regions. This scoping review will provide an in depth look at the spatial modelling currently being used to evaluate the barriers and facilitators for access to health and care services and will provide direction for further research.

Inclusion criteria: This review will consider studies that include any person accessing health and care services in Canada, focusing on those who reside in rural or remote communities, or access health services in those areas.

Methods: Published primary studies, reviews, opinion papers, reports, theses, and dissertations published in English or French across all dates will be searched in databases including CINAHL via EBSCO, PubMed, ProQuest, Scopus, Web of Science and Dissertations and Theses Global. Following the search, all titles and abstracts will then be assessed against the inclusion criteria for the review. Potentially relevant papers will be assessed in detail against the inclusion criteria. The data extracted will include geographic location, service under study, analytic methodology, data included, and specifics of the spatial models employed.

Scoping Review Protocol

Download the complete protocol here.

Loading…

No file posts are available.

The post Protocol: Spatial models of access to health and care services in rural and remote Canada appeared first on Determinants.

Health Service Implementation and Antifragile Characteristics: A Dirt Research Approach

Petrie S & PA Peters. (2023) “Health Service Implementation and Antifragile Characteristics in Rural Communities: A Dirt Research Approach.” International Journal of Environmental Research and Public Health. 20(14): 6418.

Abstract

The implementation of health and care services within rural communities requires necessary sensitivity to the unique facets of rural places. Often, rural service implementation is executed with inappropriate frameworks based on assumptions derived from urban centres. To understand the characteristics of rural communities that can facilitate successful program implementation better, ethnographic accounts of rural health and care services were compiled in rural communities within Canada, Australia, and Iceland. Ethnographic accounts are presented in the first and third person, with an accompanying reflexive analysis immediately following these accounts. Antifragility was the guiding concept of interest when investigating rural implementation environments, a concept that posits that a system can gain stability from uncertainty rather than lose integrity. These ethnographic accounts provide evidence of antifragile operators such as optionality, hybrid leadership, starting small, nonlinear evaluation, and avoiding suboptimisation. It is shown that the integration of these antifragile operators allows programs to function better in complex rural systems. Further, the presence of capable individuals with sufficient knowledge in several disciplines and with depth in a single discipline allows for innovative local thinking initiatives.

Keywords: rural health; health services; ethnography; electronic health; place-based health; antifragility

The post New Article | Health Service Implementation and Antifragile Characteristics: A Dirt Research Approach appeared first on Determinants.

Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review

LeBlanc M, McGaughey T, & PA Peters. (2023) “Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.” International Journal of Environmental Research and Public Health. 20(7): 5385. .

Abstract

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Keywords: health care; rural health; healthcare inequalities; public health systems research; health care costs; health services research

The post New Article | Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review appeared first on Determinants.

A National Epidemic with Severe Local Implications: A Global to Local Review of Substance Use to Analyze the State of Addictions in Rural Eastern Ontario

Loading…

No file posts are available.

A National Epidemic with Severe Local Implications

This research (summarized below) is also presented as an interactive ArcGIS Storymap available at the following link..

Substance Use in Canada

The dramatic rise in substance-use disorder prevalence across North America has become an urgent and escalating health issue in need of rapid intervention. In 2012, Statistics Canada conducted a study concluding that 6 million Canadians met the criteria for substance-use disorder, but even this value is thought to be an underestimate (1). It is likely this statistic has increased greatly since 2012 when considering the surging overdose crisis and significant increase in opioid-use, as well as opioid-related deaths in the past three years (2). In 2017, the cost of substance use was calculated to be $46 billion, a 5.4% increase since 2015, which factored for associated healthcare, lost productivity, criminal justice, and other direct costs (3). Substance use and addictions in Canada is therefore multifactorial, involving social, health, and economic implications.

Substance use and addiction is a global public health crisis that has rapidly escalated over the last decade. Substance use disorder is one of the most prevalent causes of morbidity and mortality internationally (4), with alcohol- and opioid-related harms being of most concern. The United States of America and Canada have historically had the highest prevalence of opioid drug use mostly due to the availability of such drugs when compared to less developed countries and have both seen an even greater increase in use since the emergence of Covid-19. Of greatest concern, is the spike in opioid deaths which has also more than doubled since 2010 (5). Canada and the United States have the highest rates of prescribed opioids worldwide, and although the US sees considerably more opioid-related deaths, per capita opioid use, and alcohol-attributed health deficits, recent data shows Canada is paralleling increases in these areas which is a cause of great concern (6). Continuing health professions education programs have begun to gain a hold on prescription opioids and their potentially harmful effects, but there has been a major increase in non-pharmaceutical opioid use across Canada which accounted for 90% of apparent opioid deaths from January to June 2021 (7).

The life expectancy of Canada has levelled for the first time since World War II, with one of the main contributors being opioid-related deaths. This negative trend was first observed in British Columbia, which has been in a declared public health emergency since 2016 due to significant opioid-related deaths, but life expectancy has since begun to plateau for all of Canada. Most deaths seen in the past five years have been males between the ages of 20-49, which therefore has a significant impact on life expectancy, with alcohol and drug use identified as the most important risk factor among young adults (7).

Alcohol and opioid use are currently a major focus for substance use disorder harms, as these sectors have seen the greatest increase in associated harms and affect the most individuals, although it should be noted that an increase in stimulant use as well as polysubstance use has been observed in the past few years. Substantially less mortality is seen with these substances, and toxic supply is less of a concern, but many of the initiatives and treatment options addressing the opioid crisis can also benefit those impacted by stimulant addiction and polysubstance use. Other addiction disorders such as gambling can also have detrimental effects on overall health and wellbeing of Canadians, but this report will have a greater focus on drug addiction and substance use disorder, specifically regarding opioid use, as it is an incredibly urgent public health crisis causing the death of thousands and therefore requires immediate intervention.

Our interactive ArcGIS Storymap provides further analysis of this epidemic for rural Eastern Ontario, highlighting both the harms and the services available in this region.

Link to the complete Storymap: .

The post ArcGIS StoryMap | Substance Use and Addictions in Rural Eastern Ontario appeared first on Determinants.