Lessons learned from the COVID-19 pandemic: The importance of physician leadership in responding to rural community ecosystem disruptions.

INTRODUCTION: The COVID-19 pandemic presented an unprecedented challenge for rural family physicians. The lessons learned over the course of 2 years have potential to help guide responses to future ecosystem disruption. This qualitative study aims to explore the leadership experiences of rural Canadian family physicians during the COVID-19 pandemic as both local care providers and community health leaders and to identify potential supports and barriers to physician leadership. METHODS: Semi-structured, virtual, qualitative interviews were completed with participants from rural communities in Canada from December 2021 to February 2022 inclusive. Participant recruitment involved identifying seed contacts and conducting snowball sampling. Participants were asked about their experiences during the COVID-19 pandemic, including the role of physician leadership in building community resilience. Data collection was completed on theoretical saturation. Data were thematically analysed using NVivo 12. RESULTS: Sixty-four participants took part from 22 rural communities in 4 provinces. Four key factors were identified that supported physician leadership towards rural resilience during ecosystem disruption: (1) continuity of care, (2) team-based care models, (3) physician well-being and (4) openness to innovative care models. CONCLUSION: Healthcare policy and practice transformation should prioritise developing opportunities to strengthen physician leadership, particularly in rural areas that will be adversely affected by ecosystem disruption. INTRODUCTION: La pandémie de COVID-19 a représenté un défi sans précédent pour les médecins de famille en milieu rural. Les leçons tirées au cours des deux années écoulées peuvent aider à orienter les réponses aux futures perturbations de l'écosystème. Cette étude qualitative vise à explorer les expériences de leadership des médecins de famille ruraux canadiens pendant la pandémie de COVID-19, en tant que prestataires de soins locaux et chefs de file de la santé communautaire, et à identifier les soutiens et les obstacles potentiels au leadership des médecins. MTHODES: Des entretiens qualitatifs virtuels semi-structurés ont été réalisés avec des participants issus de communautés rurales du Canada entre décembre 2021 et février 2022 inclus. Le recrutement des participants a consisté à identifier des contacts de base et à procéder à un échantillonnage boule de neige. Les participants ont été interrogés sur leurs expériences durant la pandémie de COVID-19, notamment sur le rôle du leadership des médecins dans le renforcement de la résilience des communautés. La collecte des données s'est achevée après saturation théorique. Les données ont été analysées thématiquement à l'aide de NVivo 12. RSULTATS: Soixante-quatre participants provenant de 22 communautés rurales de quatre provinces ont pris part à l'étude. Quatre facteurs clés ont été identifiés pour soutenir le leadership des médecins en faveur de la résilience rurale en cas de perturbation de l'écosystème: (1) la continuité des soins, (2) les modèles de soins en équipe, (3) le bien-être des médecins et (4) l'ouverture à des modèles de soins novateurs. CONCLUSION: La politique de santé et la transformation des pratiques devraient donner la priorité au développement d'opportunités pour renforcer le leadership des médecins, en particulier dans les zones rurales qui seront négativement affectées par la perturbation de l'écosystème.

Feasibility issues impacting optimal levels of maternity care in rural communities: implementing the Rural Birth Index in British Columbia.

INTRODUCTION: The continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation. BACKGROUND: Predictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators. METHODS: We conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC). RESULTS: Participants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport. CONCLUSIONS: Current models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.

What makes a healthy rural community?

INTRODUCTION: Health outcomes in rural populations are known to be generally worse than in urban populations but there are some exceptions to this trend. Most research evaluating these disparities has focused on rural communities with poor health outcomes. The current study set out to explore the factors that make some rural communities healthier than others. METHODS: Semi-structured interviews were conducted with a purposive sample of 12 key informants in a rural community within a healthy outlier region. The interview guide was based on the Social-Ecological Model of health and the focus was on community - as opposed to facility-based health. Interview data were analysed using directed content analysis. RESULTS: Five main themes were identified: (1) availability of amenities, (2) healthy lifestyle as a shared value, (3) transition from a mining community, (4) geographic location and (5) challenges. CONCLUSION: Many of the findings challenge traditional assumptions about determinants of health in rural communities. The phenomenon of 'amenity migration' from urban to rural areas which may increase in coming years, is one that can have important implications for health.

Introduction: On sait que les résultats de santé dans les populations rurales sont en général moins favorables que dans les populations urbaines, mais il y a des exceptions. La plupart des recherches s'étant penchées sur ces disparités se sont concentrées sur les communautés rurales ayant de piètres résultats de santé. L'étude actuelle explore les facteurs qui font que certaines communautés sont en meilleure santé que d'autres. Méthodologie: Des entrevues semi-structurées ont été réalisées auprès d'un échantillon intentionnel de 12 principaux intervenants dans une communauté rurale d'une région banlieusarde en bonne santé. Le guide d'entrevue, basé sur le modèle socio-écologique de la santé, se concentrait sur la santé en communauté ­ plutôt qu'en établissement. Les données de l'entrevue ont été analysées à l'aide d'une analyse du contenu dirigé. Résultats: Cinq thèmes principaux sont ressortis: 1) disponibilité des services, 2) valeur partagée de mode de vie sain, 3) transition d'une communauté minière, 4) emplacement géographique et 5) défis. Conclusion: Nombreuses sont les observations qui remettent en question les suppositions traditionnelles sur les déterminants de la santé dans les communautés rurales. Le phénomène de " migration des services " des régions urbaines aux régions rurales, qui pourrait s'intensifier dans les prochaines années, pourrait avoir des répercussions importantes sur la santé. Mots-clés: rural, communauté, santé.

Standardised early warning scores in rural interfacility transfers: A pilot study into their potential as a decision-making aid.

INTRODUCTION: While 12.4% of British Columbians live rurally, only 2.0% of specialists practise rurally, making interfacility transport of high-acuity patients vital. Decision-making aids have been identified as a way to improve the interfacility transfer process. We conducted a pilot study to explore the potential of the Standardised Early Warning Score (SEWS) as a decision-making aid for staff at sending facilities. METHODS: SEWSs were calculated from a database of 418 transfers from sending facilities in rural, small and medium population centres to larger receiving facilities. The SEWSs were compared against one another over time using McNemar's and the Wilcoxon signed-ranks tests. The SEWSs were then tested for their association with six outcomes using Pearson's or Fisher's Chi-squared test and the Mann-Whitney U-test. RESULTS: While at the sending facility, both the number of SEWSs that was four or greater and the average SEWS decreased over time (P < 0.001 for both). A first SEWS of four or greater was predictive of more intervention categories during transport (P = 0.047), an adverse event during transport (P = 0.004), an adverse event within 30 min of arrival at the receiving facility (P = 0.004) and death before discharge from the receiving facility (P = 0.043) but not deterioration during transport, or the length of stay at the receiving facility. CONCLUSION: Overall, the performance of the SEWS in the context of rural interfacility transport suggests that the tool will have utility in supporting decision-making.

Introduction: Alors que 12,4 % des résidents de la Colombie-Britannique vivent en milieu rural, seuls 2,0 % des spécialistes y pratiquent, ce qui rend essentiel le transport entre établissements des patients en état grave. Des outils de prise de décision ont été désignés comme méthode pour améliorer le processus de transfert entre établissements. Dans le cadre d'une étude pilote, nous nous sommes penchés sur le potentiel du score SEWS (Standardised Early Warning Score) comme outil de prise de décision à l'intention du personnel des établissements d'origine. Méthodes: Les scores SEWS ont été calculés dans une banque de données de 418 transferts d'établissements d'origine situés dans des agglomérations rurales de petite et moyenne taille vers des établissements de réception plus importants. Les scores SEWS ont été comparés entre eux dans le temps à l'aide des tests de McNemar et Wilcoxon Signed Ranks. L'association des scores SEWS à six paramètres d'évaluation a ensuite été testée à l'aide des tests de chi carré de Pearson ou de Fisher et du test de Mann-Whitney. Résultats: À l'établissement d'origine, le nombre de scores SEWS de quatre et plus et le score SEWS moyen se sont abaissés dans le temps (p < 0,001 dans les deux cas). Un score SEWS initial de quatre et plus prédisait un plus grand nombre de catégories d'interventions durant le transport (p = 0,047), la survenue d'un événement indésirable durant le transport (p = 0,004), la survenue d'un événement indésirable dans les 30 minutes après l'arrivée à l'établissement de réception (p = 0,004), et le décès avant le congé de l'établissement de réception (p = 0,043), mais il ne prédisait pas la détérioration durant le transport ni la durée du séjour à l'établissement de réception. Conclusion: Dans l'ensemble, le rendement du score SEWS dans le contexte du transport rural entre établissements laisse croire que l'outil serait utile à la prise de décision. Mots-clés: Early Warning Scores, Standardised Early Warning Score, Standardised Early Warning Score rural, transfert entre établissements, transport entre établissements.

High acuity rural transport: findings from a qualitative investigation.

INTRODUCTION: The High Acuity Response Team (HART) was introduced in British Columbia (BC), Canada, to fill a gap in transport for rural patients that was previously being met by nurses and physicians leaving their communities to escort patients in need of critical care. The HART team consists of a critical care registered nurse (CCRN) and registered respiratory therapist (RRT) and attends acute care patients in rural sites by either stabilizing them in their community or transporting them. HART services are deployed in partnership with provincial ambulance services, which provide vehicles and coordination of all requests in the province for patient transport. This article presents the qualitative findings from a research evaluation of the efficacy of the HART model, including staffing and inter-organizational functioning. METHOD: Open-ended qualitative research interviewing was done with key stakeholders from 21 sites. Research participants included HART CCRNs, RRTs, administrative leads, as well as local emergency department (ED) physicians and nurses. Thematic analysis was done of the transcripts. RESULTS: A total of 107 interviews in 21 study sites were completed. Participants described characteristics of the model, perceptions of efficacy and areas for improvement. Rural sites reported a decrease in physician- and nurse-accompanied transports for high-acuity patients due to the HART team, but also noted challenges in delayed deployment, sometimes leading to adverse patient outcomes. CONCLUSIONS: The salient issues for the HART model were grounded in a somewhat artificial distinction between pre-hospital and interfacility transport for rural patients, which leads to a lack of service coordination and potentially avoidable delays. A beneficial systems change would be to move towards dedicated integration of high-acuity transport services into hospital organizational structures and community health services in rural areas.

Exploring fetal fibronectin testing as a predictor of labour onset: In parturient women from isolated communities.

OBJECTIVE: To investigate whether the fetal fibronectin assay would be useful for determining if a woman was close to a term delivery. If effective, this test would allow parturient women to stay in their communities longer. DESIGN: This feasibility study used a prospective cohort design to examine the negative predictive value of the fetal fibronectin test at term. SETTING: Iqaluit, NU. PARTICIPANTS: A total of 30 parturient women from rural and isolated communities in Nunavut. INTERVENTION: Starting at 36 weeks' gestation, women were tested every 2 days, and after 39 weeks this increased to every day until labour. MAIN OUTCOME MEASURES: The negative predictive value of the fetal fibronectin test was assessed. RESULTS: Women were no more likely to give birth at 7 or more days after their last negative fetal fibronectin test result relative to their likelihood of giving birth at 6 or fewer days after their last negative test result. Hence, the presence of fetal fibronectin in cervical secretion did not predict term delivery. CONCLUSION: This project indicated that the fetal fibronectin test did not have adequate sensitivity or specificity as a diagnostic measure to predict a delay of labour at term.

No. 282-Rural Maternity Care.

OBJECTIVE: To provide an overview of current information on issues in maternity care relevant to rural populations . EVIDENCE: Medline was searched for articles published in English from 1995 to 2012 about rural maternity care . Relevant publications and position papers from appropriate organizations were also reviewed . OUTCOMES: This information will help obstetrical care providers in rural areas to continue providing quality care for women in their communities .

Maternity services for rural and remote Australia: barriers to operationalising national policy.

INTRODUCTION: In Australia, many small birthing units have closed in recent years, correlating with adverse outcomes including a rise in the number of babies born before arrival to hospital. Concurrently, a raft of national policy and planning documents promote continued provision of rural and remote maternity services, articulating a strategic intent for services to provide responsive, woman-centred care as close as possible to a woman's home. The aims of this paper are to contribute to an explanation of why this strategic intent is not realised, and to investigate the utility of an evidence based planning tool (the Toolkit) to assist with planning services to realise this intent. METHODS: Interviews, focus groups and a group information session were conducted involving 141 participants in four Australian jurisdictions. Field notes and reports were thematically analysed. RESULTS: We identified barriers that helped explain the gap between strategic intent and services on the ground. These were absence of informed leadership; lack of knowledge of contemporary models of care and inadequate clinical governance; poor workforce planning and use of resources; fallacious perceptions of risk; and a dearth of community consultation. In this context, the implementation of policy is problematic without tools or guidance. CONCLUSIONS: Barriers to operationalising strategic intent in planning maternity services may be alleviated by using evidence based planning tools such as the Toolkit.

The distribution of maternity services across rural and remote Australia: does it reflect population need?

BACKGROUND: Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need. METHODS: Health facilities in Australia were identified and a service catchment was determined around each using a one-hour road travel time from that facility. Catchment exclusions: metropolitan areas, populations above 25,000 or below 1,000, and a non-birthing facility within the catchment of one with birthing. Catchments were attributed with population-based characteristics representing need: population size, births, demographic factors, socio-economic status, and a proxy for isolation - the time to the nearest facility providing a caesarean section (C-section). Facilities were dichotomised by service level - those providing birthing services (birthing) or not (no birthing). Birthing services were then divided by C-section provision (C-section vs no C-section birthing). Analysis used two-stage univariable and multivariable logistic regression. RESULTS: There were 259 health facilities identified after exclusions. Comparing services with birthing to no birthing, a population is more likely to have a birthing service if they have more births, (adjusted Odds Ratio (aOR): 1.50 for every 10 births, 95% Confidence Interval (CI) [1.33-1.69]), and a service offering C-sections 1 to 2 h drive away (aOR: 28.7, 95% CI [5.59-148]). Comparing the birthing services categorised by C-section vs no C-section, the likelihood of a facility having a C-section was again positively associated with increasing catchment births and with travel time to another service offering C-sections. Both models demonstrated significant associations with jurisdiction but not socio-economic status. CONCLUSIONS: Our investigation of current birthing services in rural and remote Australia identified disparities in their distribution. Population factors relating to vulnerability and isolation did not increase the likelihood of a local birthing facility, and very remote communities were less likely to have any service. In addition, services are influenced by jurisdictions.

Rural health service planning: the need for a comprehensive approach to costing.

The precipitous closure of rural maternity services in industrialized countries over the past two decades is underscored in part by assumptions of efficiencies of scale leading to cost-effectiveness. However, there is scant evidence to support this and the costing evidence that exists lacks comprehensiveness. To clearly understand the cost-effectiveness of rural services we must take the broadest societal perspective to include not only health system costs, but also those costs incurred at the family and community levels. We must consider manifest costs (hard, easily quantifiable costs, both direct and indirect) and latent costs (understood as what is sacrificed or lost), and take into account cost shifting (reallocating costs to different parts of the system) and cost downloading (passing costs on to women and families). Further, we must compare the costs of having a rural maternity service to those incurred by not having a service, a comparison that is seldom made. This approach will require determining a methodological framework for weighing all costs, one which will likely involve attention to the rich descriptions of those experiencing loss.

Reconceptualising risk: Perceptions of risk in rural and remote maternity service planning.

OBJECTIVE: to explore perceptions and examples of risk related to pregnancy and childbirth in rural and remote Australia and how these influence the planning of maternity services. DESIGN: data collection in this qualitative component of a mixed methods study included 88 semi-structured individual and group interviews (n=102), three focus groups (n=22) and one group information session (n=17). Researchers identified two categories of risk for exploration: health services risk (including clinical and corporate risks) and social risk (including cultural, emotional and financial risks). Data were aggregated and thematically analysed to identify perceptions and examples of risk related to each category. SETTING: fieldwork was conducted in four jurisdictions at nine sites in rural (n=3) and remote (n=6) Australia. PARTICIPANTS: 117 health service employees and 24 consumers. MEASUREMENTS AND FINDINGS: examples and perceptions relating to each category of risk were identified from the data. Most medical practitioners and health service managers perceived clinical risks related to rural birthing services without access to caesarean section. Consumer participants were more likely to emphasise social risks arising from a lack of local birthing services. KEY CONCLUSIONS: our analysis demonstrated that the closure of services adds social risk, which exacerbates clinical risk. Analysis also highlighted that perceptions of clinical risk are privileged over social risk in decisions about rural and remote maternity service planning. IMPLICATIONS FOR PRACTICE: a comprehensive analysis of risk that identifies how social and other forms of risk contribute to adverse clinical outcomes would benefit rural and remote people and their health services. Formal risk analyses should consider the risks associated with failure to provide birthing services in rural and remote communities as well as the risks of maintaining services.

The safety of Canadian rural maternity services: a multi-jurisdictional cohort analysis.

BACKGROUND: Small Canadian rural maternity services are struggling to maintain core staffing and remain open. Existing evidence states that having to travel to access maternity services is associated with adverse outcomes. The goal of this study is to systematically examine rural maternal and newborn outcomes across three Canadian provinces. METHODS: We analyzed maternal newborn outcomes data through provincial perinatal registries in British Columbia, Alberta and Nova Scotia for deliveries that occurred between April 1st 2003 and March 31st 2008. All births were allocated to maternity service catchments based on the residence of the mothers. Individual catchments were stratified to service levels based on distance to access intrapartum maternity services or the model of maternity services available in the community. The amalgamation of analyses from each jurisdiction involved comparison of logistic regression effect estimates. RESULTS: The number of singleton births included in the study is 150,797. Perinatal mortality is highest in communities that are greater than 4 h from maternity services overall. Rates of prematurity at less than 37 weeks gestation are higher for rural women without local access to services. Caesarean section rates are highest in communities served by general surgical models. CONCLUSION: Composite analysis of data from three Canadian provinces provides the strongest evidence to date demonstrating that we need to sustain small community maternity services with and without caesarean section capability.