What a Pandemic Has Taught Us 杏吧原创 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) 鈥淲hat a Pandemic Has Taught Us 杏吧原创 the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.鈥� 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 鈥渟uccessful鈥� response to the pandemic would depend on a level of local autonomy, 鈥渁bsorptive capacity,*鈥� strong service-community connections, an 鈥渁nti-fragile鈥犫�� 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.

鈥燗ntifragility 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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Leblanc M, Petrie S, Carson DB, Paskaran S, & PA Peters. (2019) Patient and Provider Perspectives on Rural eHealth Interventions in Canada and Australia. Spatial Determinants of Health Lab, 杏吧原创 University: Ottawa, ON. DOI:10.22215/sdhlab/2019.3

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

Although health care is widely accessible in most developed countries, rural areas often struggle to adequately meet health care needs. Challenges in accessing and receiving adequate health care introduce large variations in disease levels, level of treatment, life expectancy, and overall health status for rural populations.

eHealth, or electronic health, defined here as any electronic medium used to access health services, is a method used to bridge the gap between rural and urban centres to improve health care access. Including the above definition, eHealth also includes any technology designed to improve efficiencies and reduce costs in relation to health care. By providing a comprehensive overview of feedback from past interventions, policy-makers and program developers can develop strategies to improve the implementation and the use of eHealth technologies.

Although eHealth has been reported as a favourable method to increase access to health care, users report many disadvantages that warrant improvement. Updated technology, increased IT support and training, and regular meetings between urban and rural providers can improve the uptake of telemedicine in rural communities. Providers and stakeholders should recognize specific instances in which eHealth may not be the best option to deliver care, such as in mental health cases where face-to-face contact is important in treatment. The highly reported benefits of decreased travel, cost, and increased access to care indicate that the advantages of eHealth outweigh the disadvantages and will be an effective means to improve access to health care for rural areas.

Based on reviewed literature, eHealth is a favourable method to increase access to care, as denoted by levels of positive feedback from patients and providers. Although negative perspectives are still pervasive, effectively quantifying them is difficult.

The primary reported benefits of eHealth include decreased travel time, time/cost saving, and increased access to services, followed by effective technology, increased support, and increased patient involvement.

Decreased travel time was reported most from both patients and providers, regardless of the type of eHealth technology used. Before eHealth was introduced, travelling to and from appointments was an inconvenience; it took time away from work, from family, and from community involvement. The travel time and the travel itself can have negative effects on health, where patients can be exhausted from travel and may take longer to recover.

eHealth allowed rural communities to access specialist services otherwise unavailable in the area, enabling health issues to be identified and addressed earlier. The use of technology has been shown repeatedly to save time and money, for both patients and for the health system. eHealth increased primary care levels and follow-up rates, which in turn reduced inappropriate referrals or transfers to urban centres. After using eHealth, rural health care providers reported an increased level of confidence and a broader skill set by observing specialists. Regular contact with specialists also allowed rural practitioners to seek help when necessary, decreasing isolation and creating a network of providers to provide support. In some instances, patients also felt more comfortable disclosing information through technology, which facilitated communication with providers.

The primary disadvantages of telehealth identified were technological issues, lack of face-to-face contact, limited IT training, lack of coordination, confidentiality, and system cost. Technological issues stemmed from inadequate technology, such as insufficient broadband connection, and inadequate IT support or training.

Many successful programs implemented technology training programs and on-site IT support to facilitate the transition to eHealth for patients and providers. Preference for face-to-face contact varied among individuals, specialties, and situations. Providers identified specific instances in which it would not be appropriate to use eHealth, such as in feeding assessments in speech pathology. They also felt it was difficult to break bad news to patients using technology, or to note the subtle cues that could help form a more complete, accurate diagnosis. The importance of effective coordination between urban and rural providers introduced challenges, especially if the two physicians had differing opinions regarding treatment or delivery of care. The disagreements would confuse patients, leading to distrust of both providers. In some cases, the specialist was unaware of services or resources available in rural areas, which created unrealistic patient expectations. To facilitate communication, both providers should be available and easily contactable during consultations.

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