Evaluating rural health outcomes: A methodological approach using population-level data.

Background: The sustainability of rural surgical and obstetrical facilities depends on their efficacy and quality of care, which are difficult to measure in a rural context. In an evaluation of rural practice, it is often the case that the only comparators are larger referral facilities, for which facility-level comparisons are difficult due to differences in population demographics, acuity of patients, and services offered. This publication outlines these limitations and highlights a best-practice approach to making facility-level comparisons using population-level data, risk stratification, tests of noninferiority, and Firth logistic regression analysis. This includes an investigation of minimum sample-size requirements through Monte Carlo power analysis in the context of low-acuity rural surgical care. Methods: Monte Carlo power analysis was used to estimate the minimum sample size required to achieve a power of 0.8 for both logistic regression and Firth logistic regression models that compare the proportion of surgical adverse events against facility type, among other confounders. We provide guidelines for the implementation of a recommended methodology that uses risk stratification, Firth penalized logistic regression, and tests of noninferiority. Results: We illustrate limitations in facility-level comparison of surgical quality among patients undergoing one of four index procedures including hernia repair, colonoscopy, appendectomy, and cesarean delivery. We identified minimum sample sizes for comparison of each index procedure that fluctuate depending on the level of risk stratification used. Conclusion: The availability of administrative data can provide an adequate sample size to allow for facility-level comparisons in surgical quality, at the rural level and elsewhere. When they are made appropriately, these comparisons can be used to evaluate the efficacy of general practitioners and nurse practitioners in performing low-acuity procedures.

Rural patients' experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities.

Introduction: Rural patients face barriers to accessing surgical care and often need to travel long distance for pre- or post-surgical consultations. Although adaptation to the COVID-19 pandemic has demonstrated the efficacy of virtual care, there is minimal data available to evaluate patient satisfaction with this modality and consequent health service utilization if virtual services are not available. Methods: An online survey was conducted with participants living in rural British Columbia, Canada who had undergone surgery within 12 months of data collection and had either virtual or face-to-face pre- or post-surgical consultations. It was supplemented by an in-person survey administered in two rural sites to all patients who had a virtual visit prior to undergoing procedural care. A ten-point scale was used to assess satisfaction. Quantitative and qualitative data were collected and analyzed. Results: Findings from the province-wide survey (n = 163) revealed no significant differences in average satisfaction ratings between people with in-person and virtual surgical consultations (8.03 versus 8.38, p = 0.26). However, most participants indicated that virtual appointments saved them time traveling, energy, and money and made them less dependent on others, accruing significant social benefit.In the community-focused sample (n = 71), 38% said they would not have had the procedure without a virtual visit option and 21% said that they would have delayed the procedure. Virtual consultations saved patients an average of 9 h (range 1-90). Participants traveled an average of 427 kilometers round trip to have the procedures. Conclusion: Findings reveal costs and time saved in accessing care due to the introduction of pre- and post-operative virtual care visits, and further investments in virtual care are warranted. This will contribute to promoting equitable access to healthcare for rural residents.

Perinatal Outcomes at Rural Hospitals That Participated in the Rural Surgical and Obstetrical Networks (RSON) of British Columbia (2016-2021).

BACKGROUND: The goal of the Rural Surgical and Obstetrical Networks (RSON) of British Columbia was to support safe and appropriate surgery, operative birth, and perinatal care closer to home for rural communities. Family physicians with enhanced obstetrical and/or surgical skills provide cesarean delivery and family practice anesthetists manage anesthesia for labour pain and operative births at RSON-supported hospitals, with the involvement of a local specialist at one site. OBJECTIVES: The objectives of the study were to: (1) compare perinatal outcomes at hospitals participating in the RSON initiative with outcomes at referral hospitals and (2) examine temporal changes in the proportion of childbearing people who resided in RSON communities and gave birth locally. METHODS: Poisson regression analysis was used to model the effect of hospital type (RSON vs. referral) on perinatal outcomes. We restricted the analysis to singleton births and controlled for differences in maternal characteristics, obstetric history, and pregnancy complications. RESULTS: Childbearing people who gave birth at RSON-supported hospitals (n = 3498) had a 10% lower incidence of adverse maternal-newborn outcomes compared to those who gave birth at referral hospitals (n = 14 772), after controlling for referral bias. We found a small increase (3.2 %) in the proportion of local births over the study period. CONCLUSION: Findings provide evidence that childbearing people can safely give birth at smaller rural hospitals in British Columbia and that investments in rural hospitals contribute to service stability. Stabilizing local birth services in rural communities benefits the whole region because it reduces surgical overload in regional referral centres.

Changing behaviour in pregnant women: A scoping review.

OBJECTIVES: Behaviour change programmes (BCPs) for pregnant women are frequently implemented as part of health promotion initiatives. At present, little is known about the types of behaviour change programmes that are being implemented and whether these programmes are designed and delivered in accordance with the principles of high quality maternity care. In this scoping review, we provide an overview of existing interventions related to behaviour change in pregnancy with a particular emphasis on programmes that include empowerment components to promote autonomy and woman-led decision-making. METHODS: A systematic search strategy was applied to check for relevant papers in August 2017 and again in October 2018. RESULTS: Thirty studies met the criteria for inclusion. These studies addressed weight management, smoking cessation, general health education, nutrition, physical activity, alcohol consumption and dental health. The main approach was knowledge gain through education. More than half of the studies (n = 17) included three or more aspects of empowerment as part of the intervention. The main aspect used to foster women`s empowerment was skills and competencies. In nine studies midwives were involved, but not as programme leaders. CONCLUSIONS: Education for knowledge gain was found to be the prevailing approach in behaviour change programmes. Empowerment aspects were not a specific focus of the behaviour change programmes. This review draws attention to the need to design interventions that empower women, which may be beneficial through their live. As midwives provide maternal healthcare worldwide, they are well-suited to develop, manage, implement or assist in BCPs.

A systematic review of nonpharmacological prenatal interventions for pregnancy-specific anxiety and fear of childbirth.

BACKGROUND: Despite a sharp increase in the number of publications that report on treatment options for pregnancy-specific anxiety and fear of childbirth (PSA/FoB), no systematic review of nonpharmacological prenatal interventions for PSA/FoB has been published. Our team addressed this gap, as an important first step in developing guidelines and recommendations for the treatment of women with PSA/FoB. METHODS: Two databases (PubMed and Mendeley) were searched, using a combination of 42 search terms. After removing duplicates, two authors independently assessed 208 abstracts. Sixteen studies met eligibility criteria, ie, the article reported on an intervention, educational component, or treatment regime for PSA/FoB during pregnancy, and included a control group. Independent quality assessments resulted in the retention of seven studies. RESULTS: Six of seven included studies were randomized controlled trials (RCTs) and one a quasi-experimental study. Five studies received moderate quality ratings and two strong ratings. Five of seven studies reported significant changes in PSA/FoB, as a result of the intervention. Short individual psychotherapeutic interventions (1.5-5 hours) delivered by midwives or obstetricians were effective for women with elevated childbirth fear. Interventions that were effective for pregnant women with a range of different fear/anxiety levels were childbirth education at the hospital (2 hours), prenatal Hatha yoga (8 weeks), and an 8-week prenatal education course (16 hours). CONCLUSIONS: Findings from this review can inform the development of treatment approaches to support pregnant women with PSA/FoB.

The outcomes of perinatal surgical services in rural British Columbia: a population-based study.

INTRODUCTION: A substantial number of small surgical services in rural Canada have been discontinued in the past 15 years because of difficulties recruiting and retaining practitioners, health care restructuring and a lack of a coherent evidence base regarding the safety of small services. The objective of this study was to examine the safety of small perinatal surgical services. METHODS: We accessed perinatal data for singleton births that occurred in British Columbia between Apr. 1, 2000, and Mar. 31, 2007. We defined hospital service levels, population catchment areas surrounding each hospital and the postal codes linked to those catchment areas. Births were linked with specific catchment areas and amalgamated by service level. We made comparisons among service strata populations and adjusted for potentially confounding characteristics. RESULTS: A total of 87 294 births occurred during the study period. The births were distributed across 6 strata of services, which ranged from no local maternity services to services supported by obstetricians. Fifteen catchment areas were served by general practitioners with enhanced surgical skills (GPESSs), and 9174 births were included from this obstetric service level. Outcomes for surgical services provided by GPs compared favourably to those provided by obstetricians. CONCLUSION: Our results suggest that small surgical services supported by GPESSs are a safe health services model to meet the needs of rural women and families.

INTRODUCTION: Plusieurs raisons expliquent la fermeture d'un nombre substantiel de petits services chirurgicaux en milieu rural ces 15 dernières années au Canada : difficulté à recruter et à fidéliser les médecins, restructuration des soins de santé et manque de preuves cohérentes à l'appui de la sécurité de ces services de petite taille. L'objectif de cette étude était de vérifier la sécurité des services chirurgicaux périnataux de petite taille. MÉTHODES: Nous avons accédé aux données périnatales concernant les naissances simples survenues en Colombie-Britannique entre le 1er avril 2000 et le 31 mars 2007. Nous avons défini les niveaux de services hospitaliers, délimité les bassins de populations entourant chaque hôpital et identifié les codes postaux correspondants. Les naissances ont été assorties aux différents bassins de population, puis amalgamées par niveau de services. Nous avons procédé à des comparaisons entre les populations par niveau de services, puis effectué les ajustements nécessaires pour tenir compte de variables de confusion potentielles. RÉSULTATS: En tout, 87 294 naissances ont eu lieu au cours de la période de l'étude. Les naissances ont été distribuées entre 6 niveaux de services allant de « absence de services locaux de maternité ¼ à « services assurés par des obstétriciens ¼. Quinze des bassins de populations étaient desservis par des omnipraticiens ayant des compétences chirurgicales avancées et 9174 naissances ont été assorties à ce niveau de services obstétricaux. Au plan des résultats, les services chirurgicaux fournis par les omnipraticiens se sont comparés favorablement aux services offerts par les obstétriciens. CONCLUSION: Nos résultats donnent à penser que les petits services chirurgicaux assurés par des omnipraticiens ayant des compétences chirurgicales avancées constituent un modèle de services de santé sécuritaire pour répondre aux besoins des femmes et des familles des milieux ruraux.

Correlates and predictors of tobacco use among immigrant and refugee youth in a Western Canadian city.

BACKGROUND: Tobacco control is a priority of the British Columbia Ministry of Health as illnesses associated with tobacco use are the leading cause of preventable death in the province. As a result of increased immigration, British Columbia's demographic profile is becoming more diverse and necessitates approaches to health promotion and disease prevention that are culturally relevant. In order to develop culturally relevant anti-smoking messages and resources for immigrant and refugee youth, surveys were administered to 194 youth to better understand their attitudes towards smoking and to explore predictors of tobacco use. RESULTS: Twelve percent of respondents reported smoking all or part of a cigarette within the past 30 days. Male respondents were three times more likely to smoke than female respondents. Logistic regression analysis showed that immigrant and refugee youth were more likely to be non-smokers if they did not have a father who smokes, drank alcohol less frequently and had fewer close friends who smoke. IMPLICATIONS: These findings support previous research studies that relate youth smoking to social influences and demonstrate a need to address gender differences, the confluence of smoking and drinking and the significance of family and peer pressure on smoking when designing culturally relevant anti-smoking resources.