Primary care in Catalonia

Institut Català de la Salut
Gerència Territorial
Catalunya Central
1
Primary Care in Catalonia: The stance
and opinion of attendees of the 1st
Conference on Primary Care in Rural
Areas (2011)
Abbreviated title: 1st Conference on
Primary Care in rural areas (2011)
Autors: Màrius Fígols Pedrosa1,2,3
, Laia Font-Ribera4
, Joan Deniel Rosanas1,2,3
, Josep
Vidal-Alaball3,5
, Lurdes Alonso Vallès3,6
, Maria Gassó Tarrés3,7
1
Unitat de Suport a la Recerca Catalunya Central. IDIAP Jordi Gol.
2
Unitat Docent de MFiC Catalunya Central.
3
Institut Català de la Salut. Gerència Territorial Catalunya Central.
4
Institut Municipal d’Investigacions Mèdiques (IMIM – Barcelona)
5
Equip d’Atenció Primària de l’Alt Berguedà
6
Col—legi Oficial de Metges de Barcelona
7
Equip d’Atenció Primària de Berga.
Contact information for correspondence:
Màrius Fígols Pedrosa
Unitat de Suport a la Recerca de la Catalunya Central
C/ Pica d’Estats, 13-15
08272 (Sant Fruitós de Bages)
Telephone: 936 930 040
Fax: 938 788 876
Email: recerca.cc.ics@gencat.cat

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Abstract:
Objective: To describe the professional stance and opinion of the attendees of
the 1st
Conference on Primary Care (PC) in rural areas (Berga, May 6th
, 2011)
Design: Descriptive cross-sectional study
Participants: Conference attendees were invited to participate. A total of 77
(58.3%) responded.
Primary method of measurement: Self-completed questionnaire
of 22 closed-ended questions about the profession, employment situation in PC,
and their opinions about PC.
Results:Of the respondents, 61% were family medicine physicians and 75%
worked in rural PC. The majority worked at PC clinics more than 10km or 20min
from their reference hospital. Almost 59% did not encounter other professionals of
their field more than once a week. About 96% thought a rural medicine rotation
was necessary for family medicine and community medicine residents, while 80.4%
believe it was necessary for other specialties as well. The most important
advantage to rural medicine is the integrated approach to patients, and the main
inconvenience is professional isolation. Rural PC professionals feel more valued by
their patines (4.43/5) than their colleagues in other settings (2.48) or in
administration (2.32).
Conclusions: The main disadvantage of rural PC is the greater feeling of
isolation. One positive aspect of rural PC is the integrated approach to patients.
Rural PC professionals feel more valued by patients than their counterparts in urban
settings or in administration.
Key words: primary care, rural areas, rural medicine, professional
isolation

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Introduction
The concept of a rural setting is difficult to define and has been attempted by
various organizations. The Organization of Economical Growth and Development
(1) uses population density to delineate rural zones as less than 150 inhabitants
per square kilometer while the European Union adds geographic extension to the
definition as a region with less than 100 inhabitants per square kilometer in an area
less than or equal to 100 square kilometers (2). In Spain, the National Institute of
Statistics uses the number of inhabitants to describe a rural setting, stating that a
population less than 2,000 inhabitants is considered rural, while the National
Healthcare System adds other parameters, such as geographic dispersion, to the
definition (3).
Medicine in a rural setting has certain characteristics that distinguish it from urban
medicine (4), such as the multi-facetted nature and integrated attention to patients
(5,6). The three characteristics that can influence this are the geographical
isolation, the unique relationship with patients and easy access to a rural physician
(7).
The field of family and community medicine approved in 2005 (8) includes a
required rotation in a rural clinic for residents. Since the incorporation of this
rotation, residents’ experiences have been positive: residents consider the
relationship with patients and their community, as well as their role as a
“moderator” as highlights of rural medicine (9). Teachers emphasize the personal
and professional incentive provided by rural medicine to residents (9).
At the end of 2010, the Official College of Physicians of Barcelona (OCPB) proposed
the creation of a conference dedicated to Primary Care (PC) in the rural setting.
With the collaboration of various professional associations, such as the Catalan

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Society of Family and Community Medicine (CSFCM), the Catalan Society of
Pediatrics and the Catalan Institute of Health (CIH), the first conference was help
on May 6th
, 2011 in Berga at the base of the Catalan Pyrenees. One hundred thirty
individuals attended the conference, representing a range of professional
experience from post-graduate to professors. This only highlights that rural PC is
multidisciplinary and requires the attention of many healthcare professionals.
The Catalonian Central Unit for Research took advantage of this opportunity to
collect the opinions and perspectives of the attendees through a questionnaire and
carry out a study of their responses. The objective of the study was to describe the
professional stance of the attendees of the First Conference of PC in rural areas
and evaluate their opinions about rural PC in 2011.

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Methods
Study design and population
A descriptive and cross-sectional study was performed on 132 attendees of the 1st
Conference of PC in Rural Areas in Berga, Catalonia on May 6th
, 2011. Though the
conference was open to the public, high attendance by primary care professionals,
especially from rural areas of Catalonia, was expected. The cost of attendance to
the conference was 50 euros.
Data collection
A brief questionnaire was distributed to attendees in paper form, with 22 multiple-
choice questions. The questionnaire inquired about demographic characteristics,
profession, perspectives their employment (years of experience, number of
patients, number of PC centers, distance and time from the reference hospital,
contact with other professionals, experiences in rural and urban PC), opinion about
the need for a residency rotation in rural medicine, the relationship between
doctors and pediatricians, and the access to further education. The attendees also
commented on the positive and negative aspects of working in rural PC and to
assess the fulfillment of their job in a rural, urban or administrative setting.
Statistical analysis
The statistical analysis of data was performed using SPSS v. 13. Categorical
variables were described by frequencies and continuous variables were described as
the calculated mean.
Ethics approval detail
As this was a questionnaire for physicians who works in rural areas, voluntarily
answered for participants in a rural medical congress and anonimously
collected, the local Institutional Review Board didn’t send any consideration
concerning it.

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Results
A total of 77 responses were obtained from the 132 attendees (58.3% response
rate). Among the attendees who responded to the questionnaire, the majority
were women between 30 and 45 years of age, and 61% were family medicine
doctors (Table 1). Fifty-eight (75.3%) of the individuals who completed the
questionnaire indicated they worked in rural PC. The majority of those who stated
they worked in rural PC also indicated they are from a rural setting (79% were born
in a community of less than 15,000 inhabitants).
The majority of rural PC professionals work in more than one clinic, and 19.3%
work in more than 3 clinics (Table 2). The reference hospital is more than 20
minutes away from where 76.4% of the professionals practice and more than 20
kilometers for 24.6% of respondents who practice in rural PC. Only 58.6%
encountered other professionals of their specialty at least once a week. Sixty-nine
percent had also worked in an urban setting, and 78.4% chose to work in a rural
setting (it was unclear for 3.5%).
More than 90% of the respondents considered a residency rotation in rural
medicine as necessary for family and community medicine residents and only 71%
considered it necessary for other specialties. Similar views were observed among
professionals from rural and urban settings regarding family medicine residents
(96.3% and 93.3%, respectively), whereas views differed among professionals
from rural and urban settings regarding other specialties (80.4% and 56.3%
respectively).
Rural PC professionals believed that their relationship with pediatricians was better
than in an urban setting, while the access to educational activities was more
difficult (Figure 1). This was not the opinion of professionals outside of rural PC.
The most frequently mentioned positive aspects of work in PC were the possibility
to practice an integrated approach to patients, the quality of personal life, the
autonomy of decisions, and familiarity of colleagues (Figure 2). The 16
professionals from urban settings also commented on the high quality of life and

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only moderate level of stress found in rural PC. The most frequently mentioned
negative aspects included the professional isolation of the rural setting and difficulty
to perform or participate in research. The two disadvantages of rural PC that were
mentioned by professionals from outside the field were the interference with
personal life and personal isolation.
Finally, the last question referred to the perception that the participants had about
the feeling of recognition or worth from others related to work in rural PC. On a
scale from 1 to 5, participants felt valued on a level of 2.48 by professionals that do
not work in rural areas, a level of 2.32 by administrative healthcare professionals
and a level of 4.43 by patients. Similar results were obtained from professionals
from rural and urban areas (Figure 3).

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Discussion
Our study examined the present situation of rural primary care in Catalonia through
the professional situation and opinions of attendees of the 1st
Conference of Primary
Care in Rural Areas, in May of 2011. One interesting finding was an elevated
feeling of professional isolation in rural primary care described as the main
disadvantage to working in rural PC. An integrated approach to patients and high
quality of personal life were two positive aspects described by the attendees.
Finally, rural PC professionals feel more valued by patients than their colleagues
from different specialties and than the healthcare administration.
Our study had two methodological limitations. The first is that the study sample
was created from convenience and may not be representative of the professionals
who work in PC in Catalonia. The participation in the conference could indicate a
higher level of recognition of rural PC, and our population may be representative of
other rural PC professionals who did not attend the conference. The geographical
location of the conference could have also influenced the number of attendees from
different areas, with a higher representation of individuals from central Catalonia.
The response rate to the questionnaire was 58%, thus the results may not be
accurately representative to rural PC in Catalonia. Furthermore, the study
population is small, which prevents the use of comparison of professionals from
rural settings and non-rural settings through more advanced statistical analyses.
Despite these limitations, our study reveals the opinions of rural medicine
professionals in Spain and offers new data that could be relevant to generate
discussion about rural PC.
The majority of rural PC professionals work in clinics that are between 10 and 20
kilometers from their reference hospital, which could take more than 20 minutes of
transportation. The feeling of professional isolation in rural areas is also
impressive. Four of every 10 rural PC professionals do not share their time in clinic

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with colleagues of their same specialty. This was also noted most frequently as a
negative aspect of rural medicine. Physical isolation is a known disadvantage of
rural medicine, as described by various authors in the 1990s (10,11,12).
Performing research and training were also thought to be more difficult in rural
areas, which is likely related to professional isolation. It is important to not that
resource availability was not considered to be an important disadvantage to
working in a rural setting.
The most frequently mentioned advantage to working in rural PC was the
opportunity to use an integrated approach to patient care. The use of complete
and thorough medical care includes community activities and has been described in
previous publications (12). This integrated approach is also well-received by
patients, and in turn, the professionals feel more valued by their patients.
Conversely, the value felt from other professional colleagues and administration is
lower, possibly because of the difficulty in communication and teamwork in an
isolated setting (3).
Though a response was received from 16 professionals from non-rural areas, the
responses between professionals from rural and non-rural settings differed. The
professionals who work in non-rural areas noted less stress and higher quality of
personal life as positive aspects of the rural setting. However, neither of these
factors were noted among professionals who do work in a rural setting.
Professionals from non-rural settings also thought interference with personal life
and personal isolation could be considered disadvantages of working in a rural
setting, whereas the professionals from rural settings did not consider this a
significant disadvantage. Professionals from rural settings also commented on the
limited opportunity for research.

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Overall a favorable opinion was found in regards to the necessity of a rural
medicine rotation for Family and Community Medicine residents. At the end of the
1990s, 58% of the Spanish Departments and Faculties believed that clinical
rotations in rural healthcare centers was important (Igual 1997). Opinions from
previous publications also support the incorporation of rural medicine for the
training of Family and Community Medicine residents (13,14,15) as well as for pre-
graduate training (13). However, current data suggests that the rural setting is
under-utilized in Spain for post-graduate training of Family and Community
Medicine residents (12,15). This is not true in other countries, such as Australia
and Canada, where rural medicine exists as a sub-specialty (16).
Finally, 79% of the professional from rural areas chose to work in a rural setting. If
this is a generalizable finding, it would be considered a positive aspect to working in
this setting and would also indicate that these professionals believe the advantages
of working in a rural setting outweigh the disadvantages.
Some of the findings in our study about rural PC correlate with each other, but
some do not. A healthcare professional who works in an isolated clinic which is far
from the city may have a higher quality of living, but will also feel professionally
isolated and without many resources. This traditional image of a rural healthcare
provider has now changed with the incorporation of different medical professionals
in multidisciplinary teams and reduced distances. Nonetheless, professional
isolation appears to still be an important problem, and can result in limited access
to training and research. New communication technology could eliminate this
feeling of professional isolation in the rural setting (5).
Our study should serve as motivation to reflect on different aspects of the daily
practice of rural medicine and will offer data that generates further discussion for
future PC conferences in rural settings.

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Acknowledgements
We would like to thank the attendees of the 1st
Conference on Primary Care in Rural
Areas for their participation in our questionnaire, and the members of the
Conference Organizing Committee, Pere Casafont, Marta Chandre, Joan Lozano,
Miquel Àngel Mercader, Mari Carmen Monzón, Josep Rovira, Jaume Banqué, Josep
Maria Benet, Elisa de Frutos, Sebastià Joncosa y Conxita Medina.

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References
1. Organisation for Economic Co-operation and Development. Creating rural indicators for shaping
territorial policy. OECD Publications, Paris, France. 1994.
2. European Comisión. Directorate General for Agriculture (DG VI). CAP 2000. Working Document.
3. Grupo de Trabajo de Medicina Rural de la SemFYC. El medio rural: una visión mirando al futuro.
Documentos SemFYC 11. (Online) 1999. Available
http://www.camfic.cat/CAMFiC/Seccions/GrupsTreball/Docs/Medicina_Rural/medio_rural.pdf (Accessed
20/1/2012)
4. Baldwin L.M, Rosenblatt R.A., Schneeweiss R. ,Lishner D.M. ,Hart L.G. Rural and urban
physicians: does the content of their medicare practices differ?. The Journal of rural health. Spring
1999.15 (2) p. 240-251.
5. Gérvas J, Pérez Fernández M. Aventuras y desventuras de los navegantes solitarios en el Mar de
las incertidumbres. Aten Primaria. 2005; 35:95-98.
6. Boerma WGN. Profilies of general practice in Europe. An international study of variation in the tasks
of general practicioner (PhD thesis). Utrech University 2003.
7. Serrano E. La polivalencia rural desde la práctica urbana. Aten Primaria. 2009; 41:523-24.
8. Programa formativo de la especialidad de Medicina Familiar y Comunitaria. Ministerio de Sanidad y
Ministerio de Educación. 2005. Available
http://www.msc.es/profesionales/formacion/docs/medifamiliar.pdf (Accessed 20/1/2012)
9. Arroyo IA, Galán C. Primeros pasos de los residentes de familia en el mundo rural. Aten Primaria.
2008; 40:231-32.
10. Planes Magriñà A. Primary care in the rural environment. Aten Primaria. 1991 Nov;8(10):739-40.
11. Martín Zurro A. El equipo de atención primaria. En: Martín Zurro A, Cano Pérez JA, eds. Atención
primaria. Conceptos, organización y práctica clínica. 3th edc. Barcelona: Mosby/Doyma Libros, 1995;
48-57.
12. Igual D, Fernández J, Comellas C, Palomo L. Situación de la formación postgraduada de la
medicina familiar y comunitaria en el medio rural. Aten Primaria 1997. 20: 94-98.
13. Ana Mª Vázquez Torguet, Rafael Alonso Roca. Docencia en el medio rural ¿Hay algo que aportar al
residente? Revista Electrònica RCEAP. Available
http://www.fbjoseplaporte.org/rceap/articulo2.php?idnum=14&art=03 (Accessed 20/1/2012)
14. Arroyo IA, Guerrero O, Barneto A, Güímil T. Luces y sombras de la medicina rural: a propósito de la
docencia. Aten Primaria. 2007; 39:219-20.
15. Banque Vidella, Jaume; Alonso Roca, Rafael; Vázquez Torguet, Ana M; García Fernández, Juan
Jesús. La rotación rural: un reto y una oportunidad para mejorar. Aten Primaria. 2007;39:628-9. - vol.39
núm 11.
16. Worley P, Strasser R, Prideaux D. Can medical students learn specialist disciplines based in rural
practice: lessons from students’ self reported experience
and competence. Rural and Remote Health 4: 338. (Online) 2004. Available
http://www.rrh.org.au/publishedarticles/article_print_338.pdf (Accessed 20/1/2012)

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Table 1. Description of the attendees to the 1st
Conference on Primary Care
in Rural Areas. May, 2011. N=77.
N %
Sex
Men 30 39
Women 47 61
Age (years)
<30 9 11.7
30-45 36 46.8
45-60 32 41.6
Inhabitants of birthplace*
<1,000 12 15.6
1,000-5,000 15 19.5
5,001-15,000 31 40.3
>15,000 19 24.7
Profession
Family Practitioner 47 61.0
Pediatrician 5 6.5
Family Medicine Nurse 6 7.8
Management and Services 7 9.1
Pediatric Nurse 1 1.3
Nurse, other specialty 9 11.7
Physician, other specialty 2 2.6
Employment in a rural setting
Unknown
3
3.9
Yes 58 75.3
No 16 20.8
*Where attendee was born or grew up.

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Table 2. Professional conditions for those who work in rural primary care
(PC). N=58.
N %
Years of work in rural PC
0-5 9 15.5
6-15 25 43.1
16-30 22 37.9
>30 2 3.4
Number of consults at
workplace
1 24 42.1
2-3 22 38.6
>3 11 19.3
Distance from clinic to
reference hospital
(kilometers)
0-5 8 14.0
6-10 10 17.5
11-20 25 43.9
>20 14 24.6
Distance from clinic to
reference hospital (minutes)
0-10 1 1.8
11-20 12 21.8
21-40 37 67.3
>40 5 9.1
Patients attended
<1,000 12 22.2
1,000-1,400 24 44.4
1,401-1,800 17 31.5
>1,800 1 1.9
Encounters with other
professionals of same field*
Yes 34 58.6
No 24 41.4
Live and work in same
community
Yes 21 36.2
No 37 63.8
Previous work in urban PC
Yes 40 69.0
No 18 31.0
Years of work in urban PC
0-5 25 62.5
6-15 13 32.5
16-30 2 5.0
>30 0 0
Personal choice to work in
rural PC
Yes 45 7.9
No 10 1.5
Unclear 2 3.5
*At least once a week.

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Figure 1. Value of the professional relationship between physicians and
pediatritians, access to professional training in an urban setting compared to
professionals in non-rural settings among professionals who work in a rural
setting (N=58) compared to those who work in non-rural settings (N=16).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
rural no rural rural no rural
Relationship between physician anns
pediatrician Acces to training
Easiest Most difficult Equal Unknown

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Figure 2. Value of the advantages and disadvantages of rural primary care
by professionals from rural settings (N=58) and non-rural settings (N=16).
F
i
g
Advantages
0
10
20
30
40
50
60
70
80
90
100
Social
recognition
Moderatelevel
ofstress
Lowworkplace
pressure
Professional
qualityoflive
Personalquality
oflive
Comprehensive
attention
Autonomy
Economic
compensation
%
Rural Non- rural
Disadvantages
0
10
20
30
40
50
60
70
80
90
100
Highstress
Professional
isolation
Personal
isolation
Limitationsfor
research
Economic
compensation
Difficult
professional
career
Lackfor
resources
Personallife
% Rural Non-rural

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Figure 3. Opinion about the value of primary care in rural areas according
to other professionals, healthcare administration, and according to patients, by
professional from rural settings (N=58) and non-rural settings (N=16).
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
Colleagues Sanitary administration Public
rural Non- rural

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