A systematic review of the health and health care of rural sexual and gender minorities in the UK, USA, Canada, Australia and New Zealand

Introduction: Lesbian, gay, bisexual, transgender, intersex, queer and people with a diversity of sexual and gender identities (LGBTIQ+) residing in rural contexts may face additional challenges to attaining wellbeing, yet a comprehensive understanding of these experiences is lacking. The purpose of the systematic review is to address this knowledge gap. The aims of the review are to progress understanding about rural LGBTIQ+ communities with regard to: 1) wellbeing; 2) healthcare access and experience; and 3) barriers and facilitators to health care.
Methods: Peer-reviewed literature was searched in PubMed, Academic Search Premier, CINAHL, and PsychInfo databases, while grey literature was searched via Google Advanced Search. Documents produced between 2015 and 2020 in the US, Canada, Australia, New Zealand, and UK were eligible and reference lists were screened. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to. Relevant data were extracted and synthesized. The quality of the peer-reviewed literature and grey literature was assessed using the Mixed Methods Appraisal Tool and the Authority, Accuracy, Coverage, Objectivity, Date, Significance tool, respectively. At each stage of the study selection process, a second author reviewed a sample of 10% of the articles and documents to ensure consistent application of the inclusion criteria. Consultation within the team was used to resolve any discrepancies encountered.
Results: The 297 unique peer-reviewed returned records were screened with 69 full-texts assessed for eligibility, resulting in the inclusion of 42 papers. The initial result of 2,785 grey documents were similarly screened, resulting in the inclusion of 12 documents. Overall, the included literature was deemed to be of good quality, on average. Synthesis of data resulted in the reporting of findings concerning: mental, physical and sexual wellbeing; healthcare access and experiences with care; and barriers and facilitators to health care for various communities in rural areas. The findings showed rural LGBTIQ+ communities shared many of the health concerns as non-rural LGBTIQ+ communities, as well as encountering similar issues and barriers to the receipt of high-quality appropriate care. However, the evidence also indicates an array of nuanced challenges for communities in rural areas such as a lack of available appropriate providers and financial and practical barriers concerning the need to travel to obtain the services needed. The intersection of rurality and LGBTIQ+ identity was especially pronounced for: rural LGBTIQ+ elders facing potential isolation in the context of declining mobility; service providers experiencing high demand and isolation from professional networks; and for LGBTIQ+ population negotiating the complexities of disclosure in interactions with health professionals. The latter three findings in particular, extend on the existing knowledge base.
Conclusions: Investment is needed in the design, trialling, and evaluation of tailored models of care, which account for the specific challenges encountered in providing services to rural LGBTIQ+ communities. Such models, should also harness identified facilitators for rural LGBTIQ+ wellbeing, including the use of online technologies. Dedicated study is merited to inform policy and practice for aged-care services in rural areas. Further, the development and implementation of strategies to support rural health service providers is warranted.