A five-step approach for developing and implementing a Rural Primary Health Care Model for Dementia: a community-academic partnership

Services for older adults in rural primary care memory clinic communities and surrounding areas: a qualitative descriptive study

BACKGROUND/OBJECTIVES

As part of a larger study, and in collaboration with rural primary health care teams, RaDAR (Rural Dementia Action Research) primary care memory clinics have evolved and continue to spread in communities across southeast Saskatchewan, Canada. This study focuses on the geographical areas of the four communities where RaDAR memory clinics were first developed and implemented and describes the services and supports available to older adults including memory clinic patients and families living in these areas. Our goal was to identify and describe existing programs and gaps, create inventories and maps, and explore the service experiences of family caregivers of people living with dementia in these rural areas.

METHODS

Using a qualitative descriptive design, an environmental scan of services was conducted from December 2020 to April 2021 using focus groups (n = 4) with health care providers/managers (n = 12), a secondary source (e.g., program brochures) review, and a systematic internet search targeting four RaDAR memory clinic communities and surrounding areas via community websites, online resources, and the 211 Saskatchewan service database. Data were analyzed using content analysis; findings informed semi-structured interviews with caregivers (n = 5) conducted from March to July 2022, which were analyzed thematically. Geographic areas explored in this study covered an area of approximately 5666 km2.

RESULTS

From the scan, 43 services were identified, categorized into 7 service types, and mapped by location. Seventeen services were dementia-related. Services included social/leisure activities (n = 14), general support/referrals (n = 13), transportation (n = 7), information/education (n = 4), respite (n = 2), in-home care (n = 2), and safety (n = 1). Service levels included local (n = 24), provincial (n = 17), and national (n = 2), and were offered in-person, remotely (or both) with 20 services across 4 service types offered remotely. In general, most services had no fees, involved self-referral, and providers had a range of education/training. Key interview themes reflected the need for locally available, accessible services that offer (i) individualized, flexible, needs-based approaches, (ii) in-home care and continuity of care, and (iii) both formal and informal supports. Key gaps were identified, including (i) locally accessible, available services and resources in general, (ii) dementia-related training and education for service providers, and (iii) awareness of available services. Benefits of services, consequences of gaps, and recommendations to address gaps were reported. In general, service providers and program participants were an even mix of females and males, and program content was gender neutral.

CONCLUSIONS

Findings highlight a range of available services, and a number of varied service-user experiences and perspectives, in these rural areas. Key service gaps were identified, and caregivers made some specific recommendations to address these gaps. Findings underscore multiple opportunities to inform service delivery and program participation for rural and remote people living with dementia and their families.

Perceptions and outcomes of an embedded Alzheimer Society First Link Coordinator in rural primary health care memory clinics

BACKGROUND

Primary health care has a central role in dementia detection, diagnosis, and management, especially in low-resource rural areas. Care navigation is a strategy to improve integration and access to care, but little is known about how navigators can collaborate with rural primary care teams to support dementia care. In Saskatchewan, Canada, the RaDAR (Rural Dementia Action Research) team partnered with rural primary health care teams to implement interprofessional memory clinics that included an Alzheimer Society First Link Coordinator (FLC) in a navigator role. Study objectives were to examine FLC and clinic team member perspectives of the impact of FLC involvement, and analysis of Alzheimer Society data comparing outcomes associated with three types of navigator-client contacts.

METHODS

This study used a mixed-method design. Individual semi-structured interviews were conducted with FLC (n = 3) and clinic team members (n = 6) involved in five clinics. Data were analyzed using thematic inductive analysis. A longitudinal retrospective analysis was conducted with previously collected Alzheimer Society First Link database records. Memory clinic clients were compared to self- and direct-referred clients in the geographic area of the clinics on time to first contact, duration, and number of contacts.

RESULTS

Three key themes were identified in both FLC and team interviews: perceived benefits to patients and families of FLC involvement, benefits to memory clinic team members, and impact of rural location. Whereas other team members assessed the patient, only FLC focused on caregivers, providing emotional and psychological support, connection to services, and symptom management. Face-to-face contact helped FLC establish a relationship with caregivers that facilitated future contacts. Team members were relieved knowing caregiver needs were addressed and learned about dementia subtypes and available services they could recommend to non-clinic clients with dementia. Although challenges of rural location included fewer available services and travel challenges in winter, the FLC role was even more important because it may be the only support available.

CONCLUSIONS

FLC and team members identified perceived benefits of an embedded FLC for patients, caregivers, and themselves, many of which were linked to the FLC being in person.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review

BACKGROUND

Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action.

OBJECTIVE

This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building.

METHODS

This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems).

RESULTS

The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%).

CONCLUSION

This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

Old-age mental telehealth services at primary healthcare centers in low- resource areas in Greece: design, iterative development and single-site pilot study findings

BACKGROUND

Even though communities in low-resource areas across the globe are aging, older adult mental and cognitive health services remain mainly embedded in tertiary- or secondary hospital settings, and thus not easily accessible by older adults living in such communities. Here, the iterative development of INTegRated InterveNtion of pSychogerIatric Care (INTRINSIC) services addressing the mental and cognitive healthcare needs of older adults residing in low-resource areas of Greece is depicted.

METHODS

INTRINSIC was developed and piloted in three iterative phases: (i) INTRINSIC initial version conceptualization; (ii) A 5-year field testing in Andros island; and (iii) Extending the services. The INTRINSIC initial version relied on a digital platform enabling videoconferencing, a flexible battery of diagnostic tools, pharmacological treatment and psychosocial support and the active involvement of local communities in service shaping.

RESULTS

Ιn 61% of the 119 participants of the pilot study, new diagnoses of mental and/or neurocognitive disorders were established. INTRINSIC resulted in a significant reduction in the distance travelled and time spent to visit mental and cognitive healthcare services. Participation was prematurely terminated due to dissatisfaction, lack of interest or insight in 13 cases (11%). Based on feedback and gained experiences, a new digital platform, facilitating e-training of healthcare professionals and public awareness raising, and a risk factor surveillance system were created, while INTRINSIC services were extended to incorporate a standardized sensory assessment and the modified problem adaptation therapy.

CONCLUSION

The INTRINSIC model may be a pragmatic strategy to improve access of older adults with mental and cognitive disorders living in low-resource areas to healthcare services.

Profile of occupational therapy services in non-urban settings: A global scoping review

INTRODUCTION

Regional, rural, and remote people represent nearly half the world's population yet experience disproportionally higher disease, mortality, and disability rates, coupled with limited healthcare access. Occupational therapy has committed to occupational justice, yet no descriptive framework of services provided by occupational therapists in non-urban locations exists. Understanding current non-urban service practices will provide a basis for non-urban service development and research to reduce this inequity.

METHODS

Four databases were systematically searched for publications describing non-urban occupational therapy services, from any country, written in English, French, Portuguese, or Spanish, from 2010 to 2020. Publications were screened against criteria for inclusion, and data were identified using an extraction tool and presented in a frequency table, on a map, and in a searchable supporting information Table S1.

RESULTS

Only 117 publications were included discussing services provided to populations across 19 countries. They were mostly published in English (98%) and about populations from English-speaking countries (70%). Included publications discussed individualist services (65%), for defined age groups (74%), and for people with specific medical diagnoses (58%). Services were commonly provided in the client's community (56%), originating from urban locations (45%) where the provider travelled (26%) or contacted clients using telehealth (19%). Individual 1:1 enabling strategies were most described (59%), including remediation (34%), compensation (9%), or education (7%). Community enablement strategies were infrequently described (14%), focused primarily on transformation to improve existing service delivery (9%), with some redistributive justice (3%), and one community development strategy (1%). Exploratory research services accounted for the remaining studies (27%). Differences were noted between Global North and South approaches.

CONCLUSION

Globally, occupational therapy has limited focus on non-urban services and favours individualist rehabilitative strategies provided by therapists remote from the client's context. Further research is required on the effectiveness and appropriateness of occupational therapy strategies to improve rural/urban inequity and health outcomes.

Extension, austerity, and emergence: Themes identified from a global scoping review of non-urban occupational therapy services

INTRODUCTION

Rural communities contribute to national wellbeing, identities, economies, and social fabrics yet experience increased risk of mortality, morbidity, and disability, coupled with lower levels of income, formal education, and employment than urban citizens. Despite higher need, occupational therapy services are maldistributed to urban locations. Publications about non-urban services discuss predominantly outreach-based, individualist, rehabilitation for specified diagnoses/age groups. However, given this population level inequity, it is unclear why individualist focussed services are more commonly discussed. Understanding intentions expressed in publications about non-urban service design may identify assumptions/limitations to current approaches and contribute to improved future services.

METHODS

Each of 117 publications identified in a scoping review was read by two reviewers to independently identify themes. Provisional themes were discussed and modified in an iterative process to develop final themes/subthemes. The first author reinterrogated the publications and coded data to identify relevant examples to support the identified themes.

RESULTS

Three key themes and nine subthemes were identified. Hegemonic perspectives were found in the themes (i) Extension of urban practice and (ii) Austerity, particularly in the Global North. Non-urban services were typically extended to non-urban contexts underpinned by austerity and neoliberal values such that non-urban persons and their context were problematised rather than service or funding design. A counter-hegemonic perspective was found in the theme (iii) Responses to situational realities more commonly in Global South publications, which valued non-urban contexts, and focussed on developing non-urban communities and promoting justice.

CONCLUSION

The hegemonic paradigm links occupational therapy services with neoliberal notions of individualism, private provision of care, and efficiency/market value, rather than the occupational therapy values for justice. The profession must consider our role in perpetuating injustice for non-urban people and consider if and how more contextually tailored counter hegemonic place-based paradigms can be developed from and with regional, rural, and remote practice.

Factors influencing sustainability and scale-up of rural primary healthcare memory clinics: perspectives of clinic team members

Background

The aging of rural populations contributes to growing numbers of people with dementia in rural areas. Despite the key role of primary healthcare in rural settings there is limited research on effective models for dementia care, or evidence on sustaining and scaling them. The purpose of this study was to identify factors influencing sustainability and scale-up of rural primary care based memory clinics from the perspective of healthcare providers involved in their design and delivery.

Methods

Participants were members of four interdisciplinary rural memory clinic teams in the Canadian province of Saskatchewan. A qualitative cross-sectional and retrospective study design was conducted. Data were collected via 6 focus groups (n = 40) and 16 workgroup meetings held with teams over 1 year post-implementation (n = 100). An inductive thematic analysis was used to identify themes.

Results

Eleven themes were identified (five that influenced both sustainability and scale-up, three related to sustainability, and three related to scale-up), encompassing team, organizational, and intervention-based factors. Factors that influenced both sustainability and scale-up were positive outcomes for patients and families, access to well-developed clinic processes and tools, a confident clinic leader-champion, facilitation by local facilitators and the researchers, and organizational and leadership support. Study findings revealed the importance of particular factors in the rural context, including facilitation to support team activities, a proven ready-to-use model, continuity of team members, and mentoring.

Conclusions

Interdisciplinary models of dementia care are feasible in rural settings if the right conditions and supports are maintained. Team-based factors were key to sustaining and scaling the innovation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07550-0.

Discerning rural Appalachian stakeholder attitudes toward memory screening

OBJECTIVE

The aim of this descriptive study was to examine Appalachian stakeholder attitudes toward routine memory screening, and to compare and contrast results from a similar study conducted in an ethnically diverse rural Florida cohort. Determining perceptions about memory screening is essential prior to developing culturally relevant programs for increasing early dementia detection and management among rural underserved older adults at risk of cognitive impairment. Benefits of early detection include ruling out other causes of illness and treating accordingly, delaying onset of dementia symptoms through behavior management and medications, and improving long-term care planning (Dubois, Padovani, Scheltens, Rossi, & Dell'Agnello, 2016). These interventions can potentially help to maintain independence, decrease dementia care costs, and reduce family burdens (Frisoni, et al., 2017).

METHOD

Researchers applied a parallel mixed method design (Tashakkori & Newman, 2010) of semi-structured interviews, measurements of health literacy (REALM-SF) (Arozullah, et al., 2007), sociodemographics, and cognitive screening perceptions (PRISM-PC) (Boustani, et al., 2008), to examine beliefs and attitudes about memory screening among 22 FL and 21 WV rural stakeholders (residents, health providers, and administrators).

RESULTS

Findings included that > 90% participants across both cohorts were highly supportive of earlier dementia detection through routine screening regardless of sample characteristics. However, half of those interviewed were doubtful that provider care or assistance would be adequate for this terminal illness. Despite previous concerns of stigma associated with an Alzheimer's disease diagnosis, rural providers are encouraged to educate patients and community members regarding Alzheimer's disease and offer routine cognitive screening and follow-through.

Barriers and facilitators to development and implementation of a rural primary health care intervention for dementia: a process evaluation

BACKGROUND

With rural population aging there are growing numbers of people with dementia in rural and remote settings. The role of primary health care (PHC) is critical in rural locations, yet there is a lack of rural-specific PHC models for dementia, and little is known about factors influencing the development, implementation, and sustainability of rural PHC interventions. Using a community-based participatory research approach, researchers collaborated with a rural PHC team to co-design and implement an evidence-based interdisciplinary rural PHC memory clinic in the Canadian province of Saskatchewan. This paper reports barriers and facilitators to developing, implementing, and sustaining the intervention.

METHODS

A qualitative longitudinal process evaluation was conducted over two and half years, from pre- to post-implementation. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) which consists of 38 constructs within five domains: innovation characteristics, outer setting, inner setting, individual characteristics, and process. Data were collected via focus groups with the PHC team and stakeholders, smaller team workgroup meetings, and team member interviews. Analysis was conducted using a deductive approach to apply CFIR codes to the data and an inductive analysis to identify barriers and facilitators.

RESULTS

Across all domains, 14 constructs influenced development and implementation. Three domains (innovation characteristics, inner setting, process) were most important. Facilitators were the relative advantage of the intervention, ability to trial on a small scale, tension for change, leadership engagement, availability of resources, education and support from researchers, increased self-efficacy, and engagement of champions. Barriers included the complexity of multiple intervention components, required practice changes, lack of formal incentive programs, time intensiveness of modifying the EMR during iterative development, lack of EMR access by all team members, lack of co-location of team members, workload and busy clinical schedules, inability to justify a designated dementia care manager role, and turnover of PHC team members.

CONCLUSIONS

The study identified key factors that supported and hindered the development and implementation of a rural-specific strategy for dementia assessment and management in PHC. Despite challenges related to the rural context, the researcher-academic partnership was successful in developing and implementing the intervention.