Engaging primary care physicians in system change - an interpretive qualitative study in a remote and rural health region in Northern British Columbia, Canada

Primary care engagement in health system change: a scoping review of common barriers and effective strategies

BACKGROUND

The complexity of health systems necessitates coordination between a multitude of stakeholders to enact meaningful change. Primary care physicians are a crucial partner to engage, as their investment and participation are critical to the success of any system-level initiative. The aim of this scoping review is to identify common barriers and effective strategies when engaging primary care physicians in designing and implementing health system change.

METHODS

A scoping review was performed. A literature search was performed in March 2020 using five databases. 668 unique articles were identified and underwent a title and abstract review. 23 articles met criteria for full text review and 10 met final inclusion criteria. A backward citation analysis identified two articles. 12 articles underwent data extraction and thematic analysis.

RESULTS

Several barriers to engagement were identified including a lack of trust between primary care physicians and decision-makers, strong professional physician identity, clinically irrelevant and complex proposals, and a lack of capacity and supports. Described strategies to overcome these barriers included building trust and relationships, contextual engagement strategies, working with physician leadership, enabling open and intentional communication channels, designing clinically relevant and straightforward initiatives, and considering financial incentives.

CONCLUSIONS

Barriers to primary care engagement should be addressed with contextually designed strategies and a focus on relationship building, collaborative efforts, and implementing relevant and feasible initiatives. Further research should explore how to best develop relationships with primary care, working with collective voices of primary care physicians, and to better understanding the impact of financial incentives on engagement.

Primary care doctors' perceived needs for physician leadership development in rural and remote settings of Aceh province, Indonesia

BACKGROUND

Globally, rural/remote health systems fall short of optimal performance. Lack of infrastructure, resources, health professionals and cultural barriers affect the leadership in these settings. Given those challenges, doctors serving disadvantaged communities must develop their leadership skills. While high-income countries already had learning programmes for rural/remote areas, low-income and middle-income countries (LMICs), such as Indonesia, are lagging behind. Through the lens of the LEADS framework, we examined the skills doctors perceived as most essential to support their performance in rural/remote areas.

METHODS

We conducted a quantitative study, including descriptive statistics. Participants were 255 rural/remote primary care doctors.

RESULTS

We discovered that communicating effectively, building trust, facilitating collaboration, making connections and creating coalitions among diverse groups were most essential in rural/remote communities. When rural/remote primary care doctors serve in such cultures, may need to prioritise harmony within the community and social order values.

CONCLUSIONS

We noted that there is a need for culture-based leadership training in rural or remote settings of Indonesia as LMIC. In our view, if future doctors receive proper leadership training that focuses on being competent rural physicians, they will be better prepared and equipped with the skills that rural practice in a specific culture requires.

Family physicians collaborating for health system integration: a scoping review

BACKGROUND

In Canada, Ontario Health Teams (OHTs) are a new model for integrated healthcare. Core to OHTs are family physicians (FPs) and their ability to collaborate with other FPs and healthcare providers. Whereas the factors for intra-organizational collaboration have been well-studied, inter-organizational collaboration between FPs and other healthcare organizations as an integrated care network, are less understood. This paper aims to explore the structural factors, processes, and theoretical frameworks that support FPs' collaboration for integrated healthcare.

METHODS

A scoping review was undertaken based on Joanna Briggs Institute (JBI) methodology for scoping review and using the Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Review (PRISMA_ScR) checklist. A search for academic and relevant grey literature published between 2000-2021 was conducted across databases (MEDLINE, EMBASE, EBSCOhost).Thematic analysis was used to identify the key findings of the selected studies.

RESULTS

Thirty-two studies were included as eligible for this review. Three structural components were identified as critical to FPs' successful participation in inter-organizational partnerships: (1) shared vision/values, (2) leadership by FPs, and (3) defined decision-making procedures. Also, three processes were identified: (1) effective communication, (2) a collective sense of motivation for change, and (3) relationships built on trust. Three theoretical frameworks provided insight into collaborative initiatives: (1) Social Identity Approach, (2) framework of interprofessional collaboration, and (3) competing values framework.

CONCLUSION

FPs hold unique positions in healthcare and this review is the first to synthesize the best evidence for building collaborations between FPs and other healthcare sectors. These findings will inform collaboration strategies for healthcare integration, including with OHTs.

How can rural community-engaged health services planning achieve sustainable healthcare system changes?

OBJECTIVES

The objectives of the Rural Site Visit Project (SV Project) were to develop a successful model for engaging all 201 communities in rural British Columbia, Canada, build relationships and gather data about community healthcare issues to help modify existing rural healthcare programs and inform government rural healthcare policy.

DESIGN

An adapted version of Boelen's health partnership model was used to identify each community's Health Care Partners: health providers, academics, policy makers, health managers, community representatives and linked sectors. Qualitative data were gathered using a semistructured interview guide. Major themes were identified through content analysis, and this information was fed back to government and interviewees in reports every 6 months.

SETTING

The 107 communities visited thus far have healthcare services that range from hospitals with surgical programs to remote communities with no medical services at all. The majority have access to local primary care.

PARTICIPANTS

Participants were recruited from the Health Care Partner groups identified above using purposeful and snowball sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

A successful process was developed to engage rural communities in identifying their healthcare priorities, while simultaneously building and strengthening relationships. The qualitative data were analysed from 185 meetings in 80 communities and shared with policy makers at governmental and community levels.

RESULTS

36 themes have been identified and three overarching themes that interconnect all the interviews, namely Relationships, Autonomy and Change Over Time, are discussed.

CONCLUSION

The SV Project appears to be unique in that it is physician led, prioritises relationships, engages all of the healthcare partners singly and jointly in each community, is ongoing, provides feedback to both the policy makers and all interviewees on a 6-monthly basis and, by virtue of its large scope, has the ability to produce interim reports that have helped inform system change.

Family Medicine Physicians' Perspectives Regarding Rural Behavioral Health Care: Informing Ideas for Increasing Access to High-Quality Services

Primary care settings often function as the front lines for behavioral health services in rural areas. The lack of formal behavioral health care in rural areas is also well documented. Rural family practice physicians were interviewed regarding the state of behavioral health care in their communities and their ideas for increasing access to quality care. Thirteen family practice physicians in rural locations participated in in-depth semi-structured interviews. Interviews were transcribed, coded, and analyzed following a phenomenological design. Physicians described a lack of quality behavioral health services and challenges for integrating and collaborating with those that do exist. Participants also described the changing role of stigma, service delivery strategies that are currently working, and the unique role primary care plays in rural behavioral health care. Several ideas for increasing access to and efficacy of services are discussed; these ideas are informative for future research and interventions.

Partnering for change

Purpose

Despite many calls to strengthen connections between health systems and communities as a way to improve primary healthcare, little is known about how new collaborations can effectively alter service provision. The purpose of this paper is to explore how a health authority, municipal leaders and physicians worked together in the process of transforming primary healthcare.

Design/methodology/approach

A longitudinal qualitative case study was conducted to explore the processes of change at the regional level and within seven communities across Northern British Columbia (BC), Canada. Over three years, 239 interviews were conducted with physicians, municipal leaders, health authority clinicians and leaders and other health and social service providers. Interviews and contextual documents were analyzed and interpreted to articulate how ongoing transformation has occurred.

Findings

Four overall strategies with nine approaches were apparent. The strategies were partnering for innovation, keeping the focus on people in communities, taking advantage of opportunities for change and encouraging experimentation while managing risk. The strategies have bumped the existing system out of the status quo and are achieving transformation. Key components have been a commitment to a clear end-in-view, a focus on patients, families, and communities, and acting together over time.

Originality/value

This study illuminates how partnering for primary healthcare transformation is messy and complicated but can create a foundation for whole system change.