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

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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

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What a Pandemic Has Taught Us �Ӱ�ԭ�� the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia

Petrie S, Carson D, Peters PA, Hurtig A-K, LeBlanc M, Simpson H, Barnabe J, Young M, Ostafichuk M, Hodge H, Glademan J, Smale M, & M Gonzalez Garcia. (2021) “What a Pandemic Has Taught Us �Ӱ�ԭ�� the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.” Frontiers in Public Health. 9: 768624 .

Abstract

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that “successful” response to the pandemic would depend on a level of local autonomy, “absorptive capacity,*” strong service-community connections, an “anti-fragile†” approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress.

*Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately.

†Antifragility is defined as an entities’ ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

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In a recent commentary published in the I argue that we need to broaden the narrative on rural health. In this commentary, I claim that in order to be sensitive and relevant, rural health research must change the perspective through which it views rural people and rural communities. First, rural communities are dynamic and not static, and change is a normal condition in small villages as much as it is elsewhere. Second, rural communities should be approached through a lends of resilience rather than disadvantage. Third, rural does not exist only in contrast to the urban. Fourth, there are implications of these theoretical shifts for health systems, health research, healthcare, and the methods we use to study these structures. This brief post expands on the implication for this perspective on rural health to how we understand rural health systems.

These ideas were first brought forth by Professor Dean Carson and we previously summarized here in an infographic presented at one of our Free Range workshops. It’s also available to download as a PDF.

Given the complex and dynamic nature of rural communities, how should health research be conducted, health services provided, and health policy developed? Anecdotal evidence suggests that rural communities are in a perpetual state of demolition, with a reduction in services, closure of hospitals, loss of physicians, etc. As a population declines (or fails to grow), how does a government continue to support a 20-bed hospital facility? With limited opportunity for families or spouses, how do small villages retain a family physician? How are prenatal and postnatal care provided when there may only be 2-3 births per year? These questions cannot be answered from an urban-normative lens, where uniform policies and programs are applied to each community.

For health researchers and practitioners, addressing the above points may require getting out of one’s comfort zone. For health policymakers, this may mean that policies need to be more flexible and less prescriptive, with allowance for adaptation and failure, as promoted in complex systems and antifragile research for eHealth implementation in Northern Sweden.

For quantitative researchers (my own domain), this shift may require involving rural residents in research design, analysis, and interpretation, and spending time living and working in the communities under study. There may be instances where the quantitative data is insufficient or where findings don’t match with theory. In these cases, the lived experience of rural residents and the ‘thick’ knowledge that comes from understanding the communities under study can assist.

One logical extension when considering this perspective of rural communities and health systems is that parts of the system can’t be viewed in isolation. One can’t examine hospitalization rates without considering access to primary care, which can’t be considered without looking at recruitment and retention, which requires an understanding of community resilience. Similarly, hospitalization rates are influenced by the social demography of the underlying population, which in rural communities may be related to colonization of indigenous populations, regional economic trends, internal migration patterns, and even shifts in international immigration.

To address this, our research lab and international collaborators have made this type of rural research a priority. We explicitly integrate a diversity of perspectives from multiple locations. We’ve done this through our funded research projects and published books and require this for our trainee scholars through our Free Range program.

Over the coming months, we’ll be presenting some research examples and personal perspectives in this blog series. The hope is that this will provide a resource for other scholars who share our perspectives, and provide a challenge to us (and others) who may disagree.

Until later,

Paul

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This article is the the latest from our international research team examining small villages in the developed world. For this research, we combined three case studies we had conducted in Australia, Canada, and Sweden and used these to confront the notion of rural “decline.” Small rural villages are often characterized by ‘decline’ in literature, media, and policy. However, this characterization reflects a value judgement of what is actually occurring in these places. Using a Dirt Research methodology, we show that there these places are anything but declining. There is change, sometimes accompanied by population loss, but assuming that this is all negative is simplistic.

Abstract

The purpose of this paper is to confront the notion of “decline” at the village level by illustrating a more immersive approach to sociological and demographic research within rural and remote communities. The research uses case studies of three villages in Australia, Canada, and Sweden, all of which have been labeled as “declining villages,” typified by population loss, an aging population, high rates of youth outmigration, and loss of businesses and services. This paper argues that focusing solely on quantitative indicators of demographic change provides a narrow view of rural village trajectories and ignores subtle processes of local adaptation that are hidden from quantitative data sets. Our research integrates quantitative data from the “outside” with qualitative data from the “inside,” including visual ethnography, to develop a more balanced perspective on how villages have been changing and what change could mean locally. These objectives are accomplished by revisiting a Dirt Research methodology applicable to a broad range of research into rural and remote villages. ()

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