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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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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Morris Julia, Bobiak Julia, Asad Fatima, & Fozia Nur. (2021) “Report: Accessibility of Health Data in Rural Canada.” Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa ON.

A full PDF of this report is also available.

Executive Summary 

The accessibility of rural health data in Canada is constrained by multiple structural and technical challenges. Survey, administrative, and census data collected in Canada are not easily accessible to health planners, policy analysts, or local health administrators, nor does the available data correspond to rurally relevant boundaries and rural places. Additionally, those data that are available only provide rudimentary indicators of population health and social determinants, ignoring important issues such as social inequity, rural poverty, and the health conditions of concern to residents in rural regions. One solution that has been proposed is the development of a web-based, openly accessible mapping and data visualization that is informed by and specific to the needs of rural health professionals.

To inform the development of an interactive web-based rural health atlas, the Rural Atlas team within the Spatial Determinants Lab at �Ӱ�ԭ�� University, Department of Health Sciences carried out two sets of informal interviews (User Needs Assessment and Tool Development). These interviews were conducted in order to obtain insight from key stakeholders that have been involved in rural health settings, rural health policy or advocacy, or the development of health mapping tools. Interviews took place via video-conferencing software with participants in the spring of 2020. These interviews have informed the development of our mapping tool for rural regions and health care system decision makers. The input from these interviews will aid us in creating a stronger evidence base for identifying health inequities and guide potential directions for policy development.

The following report provides a brief summary of the findings of both sets of interviews. Researchers took the semi structured interview notes and further analyzed them to pull out common themes introduced throughout the interviews. Using the information identified within these common themes, the Rural Atlas team is now able to tailor the health mapping tool to best fit the needs of the communities it will aid.

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Bobiak Julia, Morris Julia, Nur Fozia, & Asad Fatima. (2021). Rural Health Infrastructure in Ontario: A Rapid Review. Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa, ON. DOI:

A full PDF of this rapid review is also available.

Public Health Topic

The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

Rural regions are composed of many unique and diverse communities where health behaviours, health literacy, perceived health, and health outcomes vary between widely. In general, rural populations in Canada are characterized as generally older, less affluent, and are faced with more health issues than their urban counterparts. While this may be the case in the aggregate, there are a diversity of communities across Canada with wide variation between and within rural places. Almost one-fifth of Canadians (18%) live in rural communities yet they are persistently faced with on-going challenges recruiting and retaining family physicians and other health-care professionals, maintaining infrastructure for health service provision, and adapting health policies developed for urban environments into rural settings. These challenges, among others, contribute to inequities in access to healthcare services for these individuals residing in rural Canada.

It is recognized that major systemic change is needed to improve health outcomes for communities in rural or remote areas, but that this cannot occur with addressing access inequities to health infrastructure such as hospitals, mental healthcare, and telehealth services.

Current Knowledge

Currently in Canada, there is a lack of systematic evidence-based rural health-care planning at national or provincial levels. The lack of this rural-focused planning proves challenging for the development of rural health infrastructure. As it is recognised that the needs of rural communities differ from their urban counterparts, rural communities need rural-based solutions. These solutions will allow rural communities to develop regional capacity to innovate, experiment, and discover what works for their needs.

Provincially, the recognizes the need for the renewal of health care infrastructure and facilitates the to address regional address renewal needs on a priority basis. However, such policies are often guided by urban health-care models which may be ill-suited or have negative impacts in rural communities.

Advocacy for the need for rural health research funding resulted in a pre-budget submission being made in August 2018 to the federal government to enable rural and remote communities to carry out rural health research through the use of infrastructure funding. In June 2019, the Canadian Institutes of Health Research (CIHR) announced that it is undertaking a strategic planning consultation with input from stakeholders across Canada. These investments are essential in order for rural health research funding to reflect the realities of rural healthcare.

It’s unclear exactly what kind of evidence, and exactly how and when it is used, to support the development of rural health care infrastructure. From initial research, it seems that a wide variety evidence is consulted; from personal anecdotes to in-depth and specific budget requirements. The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

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Rachpaul CC, Sendanyoye C, Mahling A, Sourial M, & Trto S. (2021). “Report: Service Provision for Children and Youth with Disabilities in Rural Canada and Australia.” Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa ON. DOI: 10.22215/sdhlab/2021.2.

A full PDF of this report is also available.

BACKGROUND

Children and youth with disabilities residing in rural and remote regions of Canada and Australia are faced with limited availability and accessibility of appropriate allied health services. As a result, children and families oftenfacing difficulties obtaining a timely diagnosis (1) and experience fewer options for support services compared to their urban counterparts (2-6). Common accessibility barriers include geographic isolation, limited transportation options, long travel distances, limited number of available health care providers, increased wait times to obtain services, and high costs for appropriate services (6,7). Health service provision that takes into consideration rural and remote contexts is required to mitigate challenges imposed by geographic location.

There is limited data available regarding the prevalence of children and youth with disabilities in rural and remote communities. A greater understanding of existing resources to support children and youth with disabilities in hard-to-reach areas warrants further investigation.  To better inform this topic, a structured scoping review and thematic analysis was conducted.

Additionally, there are challenges in adequately collecting data pertaining to children and youth with disabilities. Much of this challenge is due to the lack of consensus regarding the inclusion of disability types and classifications. The UN Convention of the Rights of Persons with Disabilities (8) and the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) developed a definition of disabilities by combining pertinent elements of the definition (1). Disability is defined as, “children and adolescents who require additional resources because of exceptional gifts and talents, physical, sensory, cognitive and learning challenges, mental health issues as well as problems due to social, cultural, linguistic or family factors” (2).

This report summarizes the complete scoping review aims to provide a clear understanding of allied health service provision for children and youth with disabilities living in rural and remote communities in both Canada and Australia. This is accomplished through a comprehensives synthesis and comparative analysis of the existing literature, including identifying gaps in the literature and recommendations for future research and policy improvement.

KEY FINDINGS

SOLUTIONS AND BARRIERS

The scoping review process resulted in 33 peer-reviewed articles met inclusion criteria. The thematic analysis identified both successes and barriers to allied health service provision in rural areas pertaining to three key service needs: 1) diagnostics and assessments, 2) service availability, and 3) service accessibility. The review identified 7 major barriers and 5 major solutions in establishing adequate health service for children and youth residing in rural and remote Canada and Australia, as outlined in the figure below.  Service modality was identified as a major finding in playing a significant role in addressing barriers, with finding supportive technology and mixed modes of service provision as a solution.

Findings suggest inadequate service availability in rural communities for children and youth with disabilities because of the following:

• Disadvantages in obtaining diagnosis;
• Limited support services due to geographic isolation, transportation, and travel barriers;
• Limited number of available health care providers; and,
• Increased time and cost associated with obtaining services (1, 2-7).

Articles reported numerous solutions to address the above domains. Telepractice and technology-based programs are presented as being the single reported solution in all three major domains (9, 13, 16-24). This potential solution addresses both in-person and telehealth programs having the potential to be effective for diagnostic and assessment purposes (15-18).  The solution of utilizing the internet and social media breaks service availability barriers in improving child communication skills, its aim to improve parent’s knowledge of their child’s diagnosis, and collaboration between families and service providers (10-12,14, 20, 25-27).

Lastly, the solution of telepractice services improves service accessibility for children with disabilities in rural communities (13).  Technological integration into rural communities can be utilized to improve access to occupational therapy and the engagement of mental health services (13, 28-30). Barriers to service accessibility can be addressed by improving training, infrastructure, education on attitude change towards technological advancements, and ensuring cultural and linguistic diversity (31).

FURTHER CONSIDERATIONS

There has been increased attention being paid to children and youth with disabilities over the past decades as evidenced from this review. The data collected for children and youth with disabilities in rural communities of Canada are sparse, making it difficult to ascertain research and policy needs.

This review provides an overview of existing problems and possible resolutions in improving both research and policy for children and youth with disabilities in rural Canada and Australia. The literature on this topic primary focuses on research in Australia. Future Canadian research can learn from both the successes and ongoing challenges in Australia. In addition, research within a Canadian context should incorporate provinces and territories that are neglected in this field of study. Through building on existing research and discovering new opportunities, rural health policy can be better informed. This can be accomplished via collaboration between communities, researchers, stakeholders and policy makers. Although ongoing challenges exists within diagnostic and assessment, service availability and service accessibility; through innovative services and strengthening resources within communities, rural-centered delivery models for children and youth with disabilities in Australia and Canada can be developed.

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Hondonga T, Sendanyoye C, Mahling A, Sourial M, Trto S, & PA Peters. (2021). “Report: Potential for eHealth in rural and remote follow-up care.” Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa ON. DOI: 10.22215/sdhlab/2021.1.

A full PDF of this report is also available.

Rural and remote communities in Canada and Australia are disproportionally affected by barriers when accessing healthcare. Barriers include, but are not limited to:  lengthy travel distances, inefficient communication between healthcare teams, and client disengagement in follow-up care (1–5).  These barriers are notably evident when seeking access to more specialized health services (1). While, Canada and Australia have implemented electronic health (eHealth) technologies to mitigate issues of access to specialized healthcare services in rural and remote areas, their routine use in follow-up care has not been fully implemented (6,7).

eHealth can be described as any technology that is used to deliver health services electronically (8). It is available in several mediums such as: mobile health, telehealth, and electronic health records. Mobile health is a medium in which healthcare services are delivered via mobile technologies such as smartphones, tablets, and wearables (9,10). Additionally, telehealth involves the use of telephones or video-conferencing technologies to correspond with clients, or remote client monitoring technologies to collect data on their clients’ health (6). Lastly, electronic health records are a form of eHealth technologies whereby health care providers securely store and share health information of clients (11,12).

eHealth technologies have been promoted in rural and remote communities as they have demonstrated the potential to dissolve barriers of access to healthcare services, facilitate efficient health service delivery, improve client care, and health outcomes in hard-to-reach areas (13). However, further research into the advantages and disadvantages of eHealth services in rural and remote communities is warranted. Thus, this report aims to identify the advantages and disadvantages of eHealth services among service users in rural and remote communities in Australia and Canada; specifically, examining the role eHealth plays in follow-up care, client experiences using eHealth as an alternative to face-to-face appointments, and suggestions for future implementation.

KEY FINDINGS

ADVANTAGES AND DISADVANTAGES

This review identified five advantages and four disadvantages of eHealth services for follow-up care for service users in rural and remote communities in Canada and Australia (Figure 1). eHealth services enabled healthcare team members to share information about diagnosis, test findings, imaging results, and medications with clients in a timely matter, avoiding unnecessary referrals and long-wait times for follow-up appointments (2,3,5). Consequently, physicians found eHealth facilitated improved client education and client self-management (2–5). eHealth services removed distance as a barrier to accessing health services. However, a major disadvantage of eHealth services included the inability to complete physical assessments (20,21). Moreover, clients reported a concerns about online privacy regarding the sharing of personal health information (14,16–19). Clients also felt that in some instances there was no need for follow-up appointments (16). Lastly, physicians reported non-relevant conversations took up extra time during appointments (16).

FUTURE CONSIDERATIONS

Although e-visits have proven to be beneficial in certain medical disciplines, in other fields they were deemed challenging (e.g., post-operative care). Therefore, it is imperative that future research analyzes how eHealth follow-up care can be implemented efficiently across various medical specialties. Logistical issues related to the availability of an electronic device and internet reliability remain common limitations. This issue may be addressed by an established eHealth site in a rural community, allowing e-visits for clients to save time and money on travel. Furthermore, alleviating client and provider privacy concerns is crucial for the sustainability of eHealth interventions. Promotion of secure and protected systems can offer clients reassurance on the safety and security of their private health information. In summary, a strong evidence-base is required centering these key priority areas to better inform policy and implementation of eHealth services in rural and remote communities.

METHODS

This report is based on a structured scoping review undertaken to identify the scope of research on the role eHealth plays in follow-up care in rural and remote regions of Canada and Australia. The identification of appropriate literature for this review followed Arksey and O’Malley’s five stage process, beginning with: 1) defining the key terms used in the search engines; 2) identification of relevant studies; 3) study selection based on a set of inclusion and exclusion criterion; 4) charting the data; and, 5) collating, summarizing, synthesizing and reporting on the findings of the articles (22).  The scoping review identified 18 primary articles that met inclusion criteria. Articles focused on the role of eHealth, specifically barriers, enablers, and the utility of electronic health services in follow-up care.

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Barnabe J., Petrie S., & P. Peters. 2020. Virtual Triage and Teletriage in Rural Canada and Australia: A Rapid Review. Spatial Determinants of Health Lab Ottawa, ON. doi: 10.22215/sdhlab/2020.2.

A complete PDF is also available for download.

Public Health Topic

Health care services and healthcare infrastructure in rural areas is continuously adapting in to meet the needs of rural and remote populations. Rural populations are unique and diverse, where there is a diversity of individuals within communities, and an equivalent diversity between communities. There are documented differences in health behaviours, health literacy, perceived health, and health outcomes between and within rural regions and rural communities. While geographic accessibility is often considered the primary driver, differences go beyond distance and include elements of demographic change, economic restructuring, and continued reductions in health and services.

The features of rural health care delivery are further underscored in the wake of the COVID-19 global health pandemic, a rapidly evolving situation which is undoubtedly putting pressure on already strained rural emergency departments (ED). In attempts to alleviate strain on front-line health provision and ensure the safety of the public, many healthcare facilities have rapidly implemented or have scaled-up eHealth solutions such as virtual triage and urgent care systems. These are virtual (virtual triage) or telephone systems (teletriage) in which patients can contact a physician or other healthcare professional who will guide them to appropriate care. The objective of these interventions is most often to reduce the overall number of in-person visits to EDs, potentially tackling ED overcrowding and misuse.

Current Knowledge

Overcrowding, long wait times, and lack of resources is a persistent issue in countries with publicly guaranteed health systems, with EDs being disproportionately affected. This is especially prevalent in rural Canada and Australia, where rural healthcare access and resources are limited. Although it is a complex problem, one of the main contributing factors to this pressure is the growing number of patients presenting to EDs with non-urgent complaints, many of whom are seeking primary care. Although seeking non-urgent care from the emergency department is seen as inappropriate to health system planners, it is often the only choice rural patients have. Over 4.7 million Canadians do not have a primary care provider and only 25% report they have a usual place of care such as an urgent care clinic, a luxury that is hard to come by in rural areas. A similar reality is seen in Australia, where access to general practitioners in regional or remote areas is limited, with many reporting visiting ED’s because a general practitioner was not available.

Initiatives such as telehealth and virtual visits have been suggested to bridge the gaps seen in rural healthcare and are part of broader eHealth initiatives that include electronic medical records, remote health monitoring, and other electronic health technologies. Identified benefits of using eHealth services for primary care provision include reducing the burdens that come with travelling long distances, increasing access to care, and cost savings across various domains. Despite perceived benefits, implementation is often non-existent, difficult, or slow. Cost, technological issues, and slow acceptance by providers is a recurring issue for successful long-term eHealth implementation.

Teletriage and virtual triage are eHealth initiatives proposed to mitigate rural healthcare gaps. Teletriage is the use of telephone conferencing services to guide patients to appropriate care based on patient presentation, the urgency of the condition, and the policy of the organization. Virtual triage is where secure video connections are integrated with secure voice. Various telephone triage initiatives have been slowly developed and implemented across Canada, and Australia. Despite the evidence of success with teletriage, virtual and video integration with these systems has been met with resistance, with few adopting it. However, amid the COVID-19 pandemic, Canadian and Australian healthcare providers have been advised to provide virtual care where possible, resulting in the rapid creation and scaling up of exiting teletriage platforms and integration of virtual triage.

Key Evidence

• Telephone triage (teletriage) has been slow to expanded in Canada and Australia.
• Teletriage is effective, safe, with high levels of reported patient satisfaction.
• Teletriage can provide an alternative to primary acute care when not available.
• Virtual triage is recent with most new platforms implemented due to the COVID-19 pandemic.
• Integration of video creates multiple layers of care, further improving effectiveness.
• Many of the limitations of tele- and virtual triage are related to existing inequalities in rural areas.
• Tele- and virtual systems can be effective at deferring patients from emergency departments.

Policy Recommendations

• Platforms need to be flexible, responsive, and tailored to regional circumstances
• Successful platforms are locally-based
• Leadership across stakeholders is essential to success
• Platforms are partnerships and collaborations
• Advertising and messaging are important
• Platforms use and create data, which must be analysed continuously

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Mahling A, M LeBlanc, & PA Peters. (2020). “Rural Resilience and Community Connections in Health: Outcomes of a Community Workshop.” Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa ON. DOI: 10.22215/sdhlab/2020.1.

Full PDF available.

Canadians living in rural communities are diverse, with individual communities defined by unique strengths and challenges that impact their health needs. Understanding rural health needs is a complex undertaking, with many challenges pertaining to engagement, research, and policy development. In order to address these challenges, it is imperative to understand the unique characteristics of rural communities as well as to ensure that the voices of rural and remote communities are prioritized in the development and implementation of rural health research programs and policy. Effective community engagement is essential in order to establish rural-normative programs and policies to improve the health of individuals living in rural, remote, and northern communities.

This report was informed by a community engagement workshop held in Golden Lake, Ontario in October 2019. Workshop attendees were comprised of residents from communities within the Madawaska Valley, community health care professionals, students and researchers from �Ӱ�ԭ�� University in Ottawa, Ontario, and international researchers from Australia, Sweden, and Austria. The themes identified throughout the workshop included community strengths and initiatives that are working well, challenges and concerns faced by the community in the context of health, and suggestions to build on strengths and address challenges to improve the health of residents in the Madawaska Valley.

The objectives of this report are:

• To define rural health in the Canadian context
• To provide an in-depth discussion of both the strengths and barriers impacting the health of residents in Ontario’s Madawaska Valley
• To outline current rural health policy in contrast with the experiences of these communities
• To determine potential future direction and recommendations based on the key findings of this report.

These objectives are met through an overview of rural health challenges in Canada, the identification of themes to highlight areas of importance in the context of health in the Madawaska valley, a brief overview of policy in relation to those themes, and recommendations to address challenges and establish improved rural-normative policy in Canada.

This report places the perspectives of rural residents at the forefront of the discussion and uses the themes, strengths, and challenges identified by workshop participants to frame the discussion and develop recommendations.

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Sinclair L, LeBlanc M, Sendanyoye C, & PA Peters. (2019). Rural Youth Health in Canada, Sweden, and Australia. Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa, ON. DOI: 10.22215/sdhlab/2019.6

A high-quality PDF of this report with references is available for download.

The small size coupled with remoteness of rural communities in Canada, Australia, and Sweden introduce challenges in accessing sufficient health services (1-3). The sparse health services in rural areas impose “the tyranny of distance” on rural and remote populations, necessitating lengthy travel times to receive care. Despite the increased challenges rural communities face, a dearth of research on rural health persists, particularly rural youth health (4,5).

A broad scoping review was undertaken to identify literature regarding rural youth health in Canada, Australia, and Sweden. The studies were coded according to population focus, health focus, access, and general. The scoping review produced the Rural Youth Health Scoping Review Database, which provides an overview of the available research on rural youth health.

STATE OF THE RESEARCH 

Physical health was researched most for rural youth, followed by mental health. Sexual health, substance use, and recreation were also included in studies, but were studied much less than the first two categories.

More than half of the articles included in the database focused on specific populations. Indigenous peoples and gender studies were the most prevalent categories, followed by refugees/immigrants, LGBTQ, and racism.

Codes related to access to care included travelling to receive healthcare, waitlists limiting access, recruitment and retainment of health care professionals, eHealth initiatives, and specialist availability. Specialist availability was the most studied category, with 71 articles mentioning specialists in the abstract. Travel and eHealth were also prevalent topics, with a smaller number of articles discussing waitlists and recruitment and retention.

INDIGENOUS HEALTH STUDIES

In the Canadian territories, health outcomes and life expectancy decrease as the percentage of Indigenous people increases (2). In Nunavut, where Indigenous people make up 85% of the population, the life expectancy at birth is 11 years lower than the Canadian average (2). The most frequently studied subpopulation of rural populations are Indigenous populations. The health foci of studies in Indigenous populations differ from the general population.

A higher number of studies on substance abuse in Indigenous populations have been conducted compared to the general population, while the general population has an increased number of studies regarding mental health. The findings suggest that the root structural causes of health issues, such as racism and mental health, may not be sufficiently and properly studied (6,7). Additionally, although suicide is often portrayed in the Canadian media in reference to Indigenous youth and Indigenous communities, the rates of studies regarding suicide in Indigenous-specific abstracts and general abstracts are proportionally the same. In order to improve the current state of research regarding Indigenous youth health, an exploration of the interaction between root structural problems and Indigenous health should be conducted.

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Priest L, Sinclair L, Waid C, Petrie S, Steven S, Carson DB, & PA Peters (2019). Infographic: Substance Use in Rural Youth. Spatial Determinants of Health Lab, �Ӱ�ԭ�� University: Ottawa, ON. DOI:10.22215/sdhlab/kt/2019.7

A high-quality PDF of this infographic is available for download.

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