Public perspectives on health improvement within a remote‐rural island community

Abstract Background Rural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health. Objective To identify and describe shared perspectives within a remote‐rural community on how to improve rural health. Method Using Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews. Results Sixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services. Discussion and conclusions Factors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice. Public Contribution Members of the public were involved in the development and piloting of the statement set.


| INTRODUC TI ON
Rural health outcomes are often worse than their urban counterparts, especially concerning mental health, with life expectancy in 'developed' countries being lower in rural communities. 1 While rurality per se is not considered to negatively affect health outcomes, the intrinsic geographical isolation of rural communities exacerbates other overarching conditions. 2,3 In response, a multifaceted approach to addressing societal conditions of 'poverty, discrimination, inequality, [and] inequalities of resource allocation' 1 is proposed to improve health outcomes in rural communities. A theoretical basis for understanding and analysing rural health emphasizes the influence of local cultures, amenities and health-care services as well as their interactions with broader health systems. 2,4 The ability of local people to influence and design contextspecific health interventions, that consider local needs, can benefit rural health outcomes. 5,6 Consequently, policymakers and researchers are increasingly engaging with rural communities to coproduce solutions. 7 Over a hundred methods of public engagement, 'including focus groups, participatory appraisal, Planning for Real, citizen's juries and future visioning' 8 seek to understand perspectives. 9 Despite the proliferation of methods to integrate public perspectives into rural health planning, published literature exploring lay perceptions of potential rural health solutions is underdeveloped. 10 The small field of literature investigating public perceptions towards rural health improvement focuses exclusively on the coproduction of rural health-care services. 6 For example, the Rural Service Futures (RSF) project engages rural residents in the coproduction of health services to aid evidence-informed health decision making in remote-rural communities. 8,[11][12][13] RSF sought to uncover, discuss and coproduce solutions to rural and remote health-care provision, but did not consider other means through which to improve health outcomes and reduce health inequalities.
Thus, a knowledge gap exists regarding public perspectives of the relative role of non-health-care means to improve rural health. This is important, as it is well established that health is determined by social, economic and environmental factors-the social determinants of health. [14][15][16] Targeting these determinants can require acting further 'upstream' on underlying causes of poor health, rather than modifying individuals' health behaviours through more 'downstream' interventions. Gaining insight into perceived solutions, that include and go beyond health-care, can help to inform resource allocation decisions, in terms of the development and implementation of interventions and policies, to improve rural health.
The aim of this paper is to identify and describe the shared perspectives of residents of one remote-rural island community in Scotland, on how to improve rural health. We do so by using Q methodology.

| ME THODS
Q methodology is a mixed-method comprising the collection, analysis and presentation of both quantitative and qualitative data collected by means of a card-sorting exercise followed by a short qualitative interview. The card-sort involves respondents' rank-ordering statements, typically statements of opinion, onto a quasi-normal shaped grid according to a condition of instruction, such as from 'Most agree' to 'Most disagree' (See Figure 1). Byperson factor analysis is then used to identify patterns of similarity between the card-sorts, known as factors. Factors represent a shared perspective on the topic in question and are represented by a distinctive ranking of the original statement set. These idealized card-sorts are then described and interpreted, with postsort interview data also drawn on, to produce a rich narrative of each factor.
Q methodology is particularly well-suited for working with 'lay' respondents on policy-relevant issues and is increasingly being used in studies of public engagement in health. 10

| The statement set
In defining the specific cards to be sorted, statements are first drawn from the 'concourse', described as 'the flow of communicability surrounding any topic' 21 from the 'universe of 'statements' so conceived for any situation or context'. 22 In practical terms, this means gathering a wide breadth of opinion on a subject, drawing on multiple sources and types of resource if necessary.
The concourse for this study was accessed through an assessment of the ways it is claimed health can be improved in rural communities. Sources analysed included the following: peer-reviewed articles relating to rural health theory or interventions 1

| Setting and participants
Respondents were drawn from residents of Eriskay, South Uist and Benbecula-neighbouring small islands (connected by causeways) in the Western Isles of Scotland. These islands were selected as part of broader research into the role of community landownership in improving rural health. 26 The South Uist Estate, which covers most of the three islands, has been owned by the resident community since 2007. 27,28 The islands are all considered 'very remote rural' in the Scottish Government's 8-fold urban rural classification. 29  to identify a diverse range of participants (see Table 2). Respondents were recruited through face-to-face visits to businesses and places of work, as well as private residences and public places. In Q studies, there is no set sample size. Once all relevant demographic characteristics were represented, recruitment closed when a stable set of factors were identified and the card-sorts of new participants only confirmed existing factors.

| Data collection
Respondents were first read a standardized introduction to set the context of the study. They were then asked to place each statement into one of three piles depending on whether they 'Agreed', 'Disagreed' or were 'Neutral' about the statement, in regard to whether they thought it could improve rural health (the condition of instruction). From the 'Agree' pile, respondents were then instructed to select the two cards they most agreed with and place them in the +5 column (Figure 1), placing the three they next most agreed with in the +4 column and so on, until the cards were fin- column towards the middle of the grid. Following the card-sort, a post-sort interview was conducted. Respondents were asked to comment on how health could be improved in rural communities overall, before being asked to justify their interpretation and placement of 'salient' statements (ie those placed in the +5 and −5 columns). Post-sort interviews were audio-recorded and transcribed. Where data were collected in group settings, cardsorts were performed individually (on separate grids) followed by a group discussion. These started with each individual first taking turns to provide reasons for their own card-sorts before engaging in broader discussion.

| Analysis
Data analysis used a Q methodology software package-Ken-Q. 33 Centroid factor extraction was followed by Varimax rotation to identify a small number of shared perspectives (factors). Preliminary analysis was based on the following criteria: (a) eigenvalue >1 and (b) at least two 'defining' card-sorts i.e. a card-sort was statistically significantly associated with a factor (P < .01) and was more associated with one factor than all other factors combined (e.g. it accounted for the majority of common variance). Following the interpretation of factors from different solutions, the factor solution that was the most interpretable and coherent was selected.
The interpretation of factors used quantitative and qualitative data, focusing upon, but not limited to, the assessment of: 'salient statements'; 'consensus statements' (non-significant between any pair of factors at P > .01); and 'distinguishing statements' (sorted statistically differently in one factor compared to all others at P < .01). 32 This study was granted ethical approval by the University ethics board (Ref: GSBS EC 015).

| RE SULTS
Sixty-two individuals participated in the study, with data collected during one field visit ( Table 2). Card-sorts were administered oneon-one (27 respondents) or individually in groups of up to five respondents (13 groups involving 35 respondents).
A four-factor solution was statistically supported and yielded interpretable accounts consistent with qualitative data. Table 1 shows the idealized card-sorts for the four factors. Thirty-six respondents were considered 'defining' sorts, indicated in Table 3 by bold type and an 'X'. Sixteen respondents were 'mixed-loaders', being significantly associated with more than one factor. The remaining ten respondents were 'null loaders', either not being significantly associated with any factor, or not accounting for the majority of common variance.
The following subsections describe each factor in turn, with ref- erence to the placement of statements and extracts from post-sort interviews. The former is represented by the statement number followed by the column in the factor array in which it was placed (eg '#33, +4' indicates that statement #33 (Table 1) was placed in the +4 column in that particular factor array). The demographic details of those defining each factor are included in Table 2, while a brief overview of each factor is outlined in Table 4.

TA B L E 3 Factor loadings and defining sorts (X)
Respondent Number Note: The formula for assessing the significance threshold for factor loadings at P < .01 requires multiplying the standard error (SE) by 2.58 32 . Card sorts with a factor loading of over 0.4079 are considered 'significant', indicated by bold type. Defining sorts must be significantly associated with only one factor and account for the majority of common variance (more associated with one factor than all other factors combined), indicated with an 'X'.

TA B L E 3 (Continued)
A resistance to public sector intervention was also present at an

| Factor 2-Protect and care for the community
Factor 2 respondents emphasized the need for adequate health and care services to look after the elderly and vulnerable within the community, specifically those struggling on low incomes, who were considered deserving of being looked after by the state (#15, +5; #6, +4; #13, +3; #38, +2). To achieve this, respondents favoured the expansion of health and care services and providing local people with the financial means to live a healthy life (#4, −5; #5, −4; #33, +1; #19, +1).
Additionally, respondents had great concern for the plight of poorer local people (as opposed to those who have moved into the community), whom they felt should be provided with enough money to access amenities and services considered crucial to living a healthy life, but which were unattainably expensive within the community (#34, +5; #31, +3, #14, +2, #17, +2).
There is a lot of poverty on the islands, and people

Factor
Overview of perceived solution to improving rural health 1. Local economic activity Support local businesses and provide services and amenities to stimulate local economic activity and retain sustainable population.
2. Protect and care for the community Provide health-care services for the elderly and vulnerable, while imposing punitive measures to curb negative health behaviours and social influences.

Redistribution of resources
Address societal inequalities to provide for the most vulnerable by redirecting political and fiscal priorities.

Investing in people
Improve health behaviours by reducing social isolation and low self-worth via a range of means including employment, care services and strengthening social bonds. there has to be a system that will enable them to be in a warm, dry place, and then to be able to buy proper food.  The redistribution of resources contained both a fiscal and political emphasis, but ultimately resulted in the same outcome, the wider provision and accessibility of public services within the community. Providing spaces and opportunities for leisure, recreation and other community activities. We've got a few but I don't think we have enough. I don't think there's enough encouragement for young people to go outside and go play as much as there was when I was younger.

| Factor 4-Investing in people
(Respondent 24) While respondents believed that overcoming social and economic challenges would improve self-value and health behaviours, it was acknowledged that not everyone could pursue such opportunities due to physical or mental health issues. For these individuals, there was a need for investment in health-care services, and specifically social care and counselling services to assist those struggling with mental health problems (#13, +4; #38, +2, #15, +2; #6, +1).
The need for these services to be anonymous was also emphasized (#11, +4).

| D ISCUSS I ON
This study aimed to understand the shared perspectives within one remote-rural island community on how to improve rural health. This section will discuss the nature of factors, and their convergences and divergences, in relation to rural health literature. The particular circumstances of the study locale are then considered with regard to how they improve our understanding of local perspectives on rural health improvement.  Similarly, major structural changes to power dynamics within the community were opposed, with respondents preferring things to stay as they are, or as they were. Therefore, this factor broadly reflected the tendency within remote-rural communities to be resistant to changes in health-care provision due to uncertainty as to how it may affect the community's sustainability. 13 Factor 3 adopted a broad societal approach to addressing inequalities which exacerbate the disadvantages of poorer and more vulnerable members of the community, and society at large.

| Consensus and divergence between factors
The provision of amenities and services was a strong theme in each factor, emphasizing socio-economic interventions such as employment, education and housing (F1), institutional health services (F2, F3) and community-based care (F4). The emphasis placed on their provision reflects previous research indicating the role of geographical isolation in 'inequalities of resource allocation' 1 and the need to address a lack of amenities and services to improve rural health. 2,4 Addressing rural poverty was an overarching theme of the findings, with the four factors representing different strategies for improving material conditions and financial stability for the poorest residents. 1 As well as reducing the psychological stress associated with poverty, money was considered important to allow local people to buy healthy food and access amenities, such as exercise and social events, which contributed to both mental and physical health outcomes. Structural solutions such as increased employment (F1, F4) and state provision (F2, F3) were favoured over improving access to financial products and services and financially rewarding improved health behaviours, which were considered short-term and piecemeal. This consensus was also apparent in low-income urban communities, 10 with respondents emphasizing the perceived importance of financial security for health outcomes across the urban/ rural divide.
Reflecting on the above sections, respondents' perspectives broadly converge with theories pertaining to rural health improvement, with the four factors emphasizing different aspects of a multifaceted approach to addressing 'poverty, discrimination, inequality,

| Local participatory mechanisms
This research was situated on the community-owned South Uist Estate as part of a broader study of the role of community landownership in improving rural health. 26 Local power structures are reconstituted following a community land-buyout 34 as the estate holds significant influence over social and economic conditions within the community, as well as involvement in service provision. 26

| Limitations
Q methodology does not enable claims to be made about the representativeness of the perspectives identified. However, this could be explored through sequencing survey methods. 38 Alternatively, the same statement set could be used in other locations which would be an interesting avenue of future study.

| CON CLUS ION
This study identified four shared perspectives on how to improve rural health. For the first time, public perspectives are explored that go beyond the provision of health -care to also consider how rural health could be improved by acting on the social determinants of health. In general, respondents perceived 'solutions' relating to the latter as playing a significant role in improving rural health, emphasizing the importance of including such options in future studies and coproduction activities. Importantly, this work highlights that public perspectives on rural health improvement are not homogenous within or between communities and should not be treated as such. 20 This poses a challenge to health providers in eliciting and understanding diverging perspectives and designing appropriate interventions in disparate rural and remote communities, with implications for rural health policy and practice. 13 Nevertheless, divergent opinions should not be perceived as a barrier to effective public engagement in the development of effective health policy. In our study, the use of Q methodology enabled the identification of areas of agreement among the divergent perspectives. For instance, there was shared recognition that providing access to services and amenities in rural communities, and addressing rural poverty, is important for improving the health of residents.
The ability to explore the views of local residents in relation to prob-

ACK N OWLED G EM ENTS
We would like to thank respondents and pilot participants for offering their time and knowledge in the course of conducting this research. We would also like to acknowledge the contribution of Prof Cam Donaldson to the successful completion of this research.

CO N FLI C T O F I NTE R E S T S
The authors have no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.