Considerations for Definitions of “Remote” and “Isolated” in the Context of Pandemic (H1N1) 2009

Introduction

The Remote and Isolated Task Group (RITG) of the Public Health Network H1N1 Task Force has been engaged in building on and adapting existing national guidelines to better ensure an effective and coordinated federal, provincial and territorial influenza pandemic response in remote and isolated communities, in the context of the H1N1 outbreak. The purpose of the task group is to review issues associated with public health response and delivery of health services in a pandemic in remote and isolated communities, and to determine what is unique to these areas, what specific planning/response activities are required, and develop guidelines in response to pandemic (H1N1) 2009.

In order to fulfill its mandate, the RITG needed a working definition of “remote” and “isolated”.  Annex B¹ of the Canadian Pandemic Influenza Plan for the Health Sector (CPIP) was used as the source for the following definitions:

Remote: describes a geographical area where a community is located over 350 km from the nearest service centre having year-round road access.

Isolated: describes a geographical area that has scheduled flights and good telephone services; however, it is without year-round road access. It is noted that not all homes in a community will have phones, and that flights may be cancelled or delayed due to weather.

These definitions were adapted from definitions specific to on-reserve populations in Annex B of the CPIP.

These definitions have become the working definitions of “remote” and “isolated” used by the RITG, although it is recognized that these terms may be defined otherwise depending on the context, who is using the definitions, and for what purpose.  Therefore, this discussion document provides considerations for additional definitions of “remote” and “isolated” which can be adopted by jurisdictions in Canada when considering pandemic planning and response in remote and isolated communities.  This document begins with providing background information for considering the definitions of “remote” and “isolated” in the context of pandemic (H1N1) 2009.  It then compares and discusses various existing terms used, and concludes with providing options of definitions for consideration by public health practitioners and jurisdictions within Canada when defining the terms “remote” and ”isolated”.

Background

In a Canadian Health Services Research Foundation study, it was attempted to define the term “remote”.  The findings are summarized below².

• Geographic parameters, particularly measures of distance to medical facilities, form the basis of most published indices of remoteness.
• However, geographic parameters might not capture the essence of remoteness in the context of nurses who live and work in these areas.  Rural and remote registered nurses indicated that while distance descriptors are relevant, the concepts rural and remote include considerations of isolation, access to amenities both for themselves and their families (shopping, non-medical services, leisure activities), sociodemographic characteristics of the communities within which they live and work, availability of healthcare resources (staff, equipment and facilities, medical transportation, etc.), and the character of their nursing practices (first-line providers of care, levels of responsibility, etc.).
• Most of these are very difficult to build into a simple index of rurality or remoteness but are fundamental to the practice of nursing in these areas of Canada.

The above study highlights two important issues: geographical distances play an important role in defining “remote” and “isolated”, and consideration should also be given to other factors unique and/or important to these communities.  While many of these factors likely lie outside the scope of defining the terms “remote” and “isolated”, it is important for jurisdictions to consider them when it comes to applying the defined terms.  This is especially important when determining the needs of communities and allocating health services.  The following are some factors for such consideration:

• Population (i.e. less than 10 000 people)
• Climate
• Capacity in the community

• Socioeconomic status of the majority or average
• Health status of the population
• Presence of vulnerable group(s)
• Health care workers in the community and levels of responsibility
• Equipment and facilities
• Medical transportation
• Other infrastructure such as housing and water supply/adequacy

Existing Definitions of “Remote” and “Isolated”

1. Annex B of the CPIP Definitions

Annex B of the CPIP³ defines “remote” and “isolated” as the following:

The term "remote" is a term in federal use that describes a geographical area where a First Nations community is located over 350 km from the nearest service centre having year-round road access.

• This definition is taken from Indian and Northern Affairs Canada (INAC)⁴

The term "isolated" describes a geographical area that has scheduled flights and good telephone services; however, it is without year-round road access.

• This definition is taken from Health Canada⁵

2. Indian and Northern Affairs Canada (INAC)

INAC representatives provided a list of the communities they define as "isolated".  The definition provided for “isolated” was as following:

Isolated communities are communities that do not have year-round access to surface transportation; either road, rail or marine service.  They are usually referred to as fly-in only communities.

3. Treasury Board of Canada

The Treasury Board of Canada has an Isolated Posts and Government Housing Directive, which classifies “isolated posts” using the following criteria⁶:

• population;
• climate; and
• availability of commercial transportation or access by all-weather roads.

4. Other Definitions of “Remote” and “Isolated”

In a Canadian Journal of Rural Medicine article, Dr. James Rourke summarizes the following definitions, which include considerations of the terms “remote” and “isolated”⁷.

• The Faculty of Rural Medicine, Royal Australian College of General Practitioners, defines "remote rural practice" as "practice in communities more than 80 km or one hour by road from a centre with no less than a continuous specialist service in anesthesia, obstetrics and surgery and a fully functional operating theatre."
• The Rural Committee of the Canadian Association of Emergency Physicians defines "rural remote" as "rural communities about 80-­400 km or about one to four hours transport in good weather from a major regional hospital" and "rural isolated" as "rural communities greater than about 400 km or about four hours transport in good weather from a major regional hospital."
• An agreement between the Ontario Ministry of Health and the Ontario Medical Association identifies communities of fewer than 10 000 people, greater than 80 km from a regional centre of more than 50 000 people as "specified" or "isolated" communities.

Discussion

The definition of “remote” should include a specified distance and/or specified travel time required from the community to the nearest community with an acute care hospital.

The definition for “isolated” should be distinct in defining the access to the community (whether reached by air only, water only, and how this changes during the year). Communication access should also be considered.

As mentioned in the Background section of this document, there are other important factors that jurisdictions should consider when developing definitions of “remote” and “isolated”, as the definitions may impact certain aspects of pandemic planning/response for communities during the pandemic (H1N1) 2009.  For example, the definitions can impact how the jurisdiction could view the community in terms of priority for immunization.

“Remote” and “Isolated” Definitions for Consideration

Below are three options that might be considered to define the terms “remote” and “isolated”. Provinces and territories may want to consider these options or define differently as it is appropriate in that jurisdiction. The RITG is not recommending any one option, and other defintions may be used as well. It is recommended that provinces and territories consult with stakeholders and/or communities when they are developing their definition and/or identifying remote and isolated communities. 

A jurisdiction may want to consider their remote or isolated communities first when planning for emergencies or allocating health services during a pandemic.  Jurisdictions should also consider that closest access to certain communities may be outside of their jurisdiction (e.g. a community in Manitoba may more easily access acute care health services in north-western Ontario).  Other important factors such as population, climate, community capacity, socioeconomic and health status, presence of vulnerable group(s), health care workers in the community and levels of responsibility, equipment and facilities, medical transportation, and other infrastructure should be considered when developing definitions of “remote” and “isolated”, as well as how the definitions will be applied.

Option 1:

Remote
A remote community is 200-350 km or about two to four hours from a community with an acute care hospital.  Access to that community may be by ground, water or air, but is accessible year round.

Isolated
An isolated community is ≥ 350 km or ≥ four hours from a community with an acute care hospital.  Access to that community is only by water or air year round, or by roads that may be inaccessible at times (i.e. not an all-weather road). Communication services are generally available but may be unreliable.

Option 2:

Remote and Isolated
A remote and isolated community is ≥ 200 km or ≥ four hours away from a community with an acute care hospital.  Access to that community is only by water or air year round, or by roads that may be inaccessible at times (i.e. not an all-weather road). Communication services are generally available but may be unreliable.

Option 3:

Remote
A remote community is ≥ 200 km or ≥ four hours away from a community with an acute care hospital.  Access to that community is by an all-weather road that is accessible year round.

Isolated
An isolated community has no year round road access.  There may be air access, and ground access may be seasonal.  It is noted that not all homes in a community will have phones and communication services may be unreliable, and flights may be cancelled or delayed due to weather.

References