Community participation to design rural primary healthcare services

Pathways to strengthen the climate resilience of health systems in the Peruvian Amazon by working with Indigenous leaders, communities and health officers

BACKGROUND

Indigenous knowledge and responses were implemented during the COVID-19 pandemic to protect health, showcasing how Indigenous communities participation in health systems could be a pathway to increase resilience to emergent hazards like climate change. This study aimed to inform efforts to enhance climate change resilience in a health context by: (1) examining if and how adaptation to climate change is taking place within health systems in the Peruvian Amazon, (2) understanding how Indigenous communities and leaders' responses to climatic hazards are being articulated within the official health system and (3) to provide recommendations to increase the climate change resilience of Amazon health systems.

METHODS

This study was conducted among two Peruvian Amazon healthcare networks in Junin and Loreto regions. A mixed methodology design was performed using a cross-sectional survey (13 healthcare facilities), semistructured interviews (27 official health system participants and 17 Indigenous participants) and two in-person workshops to validate and select key priorities (32 participants). We used a climate-resilient health system framework linked to the WHO health systems building blocks.

RESULTS

Indigenous and official health systems in the Peruvian Amazon are adapting to climate change. Indigenous responses included the use of Indigenous knowledge on weather variability, vegetal medicine to manage health risks and networks to share food and resources. Official health responses included strategies for climate change and response platforms that acted mainly after the occurrence of climate hazards. Key pathways to articulate Indigenous and official health systems encompass incorporating Indigenous representations in climate and health governance, training the health work force, improving service delivery and access, strengthening the evidence to support Indigenous responses and increasing the budget for climate emergency responses.

CONCLUSIONS

Key resilience pathways call for a broader paradigm shift in health systems that recognises Indigenous resilience as valuable for health adaptation, moves towards a more participatory health system and broadens the vision of health as a dimension inherently tied to the environment.

Development of a framework for the collaborative adaptation of service models for child and family health in diverse settings (CASCADES)

The impact of health service access disparities has significant implications for society. The importance of addressing health and social inequities is never more critical than in the early years of a child's life. Despite advances in healthcare implementation, there is a lack of an evidence-based framework to specifically guide the adaptation of child and family health (CFH) service models for different community contexts. This paper describes the development of a framework for the adaptation of community-based CFH service models. Drawing on the findings of an integrative review and Delphi study, Participatory Action Research was used to test the framework, resulting in the Framework for Collaborative Adaptation of Service Models for Child and Family Health in Diverse Settings (CASCADES). The Framework uses the analogy of a waterfall to represent the iterative process of collecting information to inform each step. The framework supports a collaborative co-design approach to build a comprehensive understanding of the target community to inform the adaptation and evaluation of evidence-based interventions appropriate to the local context. The ultimate aim is to enable the delivery of services that are contextually relevant for local communities and provide greater access to effective, accessible services to support children and their families.

Rurality and social innovation processes and outcomes: A realist evaluation of rural social enterprise activities

Although increasingly prominent in research, policy and practice, little is known about social innovation in a rural context. To address this knowledge gap, our paper explores how rurality might affect the social innovation process. Drawing on 68 interviews carried out with beneficiaries, service providers and external stakeholders of a rural social enterprise initiative in Scotland, the paper adopts a realist evaluation theory (Pawson and Tilley, 1997) approach combined with Calò et al.'s (2019) social innovation analytical framework to identify Context-Mechanism-Outcome configurations for rural social innovation. The findings highlight that specific characteristics of rural places can act as stimuli of social innovation. Positive outcomes of a social innovation can potentially be rooted in rural peculiarity and its problematic context. Push factors, born out of necessity, lead to reactive social innovation and pull factors, derived through harnessing perceived opportunities in the environment, lead to proactive social innovation. Importantly, push factors do not undermine the establishment of social innovation - indeed, they can actually promote social innovation and strengthen its validity. The paper also shows that outcomes of the social innovation process might not be specific to rural areas. Instead, the pathway to the desired outcomes is conditioned by rural factors, shaping the contexts and mechanisms of rural social innovation. As different rural locations might have different resources to address local challenges, social innovation processes vary from one case to another, although the challenges being addressed might be similar. As such, rural social innovation policies should not be 'over prescribed'. Context creates both challenges and solutions and influences the type and form of mechanisms used to achieve a desirable social innovation outcome.

Adapting community child and family health service models for rural and other diverse settings: A modified Delphi study to identify key elements

Inequity in health outcomes is pervasive, with poorer health outcomes identified in rural, regional and remote communities. An international call to action emphasises the need for service models adapted for less well-resourced settings. The aim of this study was to identify key elements of a framework for the adaptation of specialist community-based child and family health (CFH) service models for rural and other under-resourced settings. A modified Delphi study was undertaken with a 12-person expert panel in CFH including Australian and international professionals and parents from rural and remote communities. The study was informed by the WHO Framework for Strengthening Health Service Systems building blocks, the outcomes of an integrative review of literature and a Participatory Action Research study. Experts assessed 107 potential elements for service model development and rated them for importance when adapting service models for different contexts. Round 1 of the Delphi generated considerable consensus with 80 of the 107 potential elements identified as necessary for the service model adaptation framework. A further 17 elements for CFH service models were added in round 2. While multiple varied elements are important for adapting CFH service models for diverse settings, some elements had common themes. Experts highlighted the importance of community engagement and participation; utilising both data and local knowledge to develop a robust understanding of the community context; and the need for a flexible approach to funding and modes of service delivery to address barriers to implementation and access.

Public involvement in the planning, development and implementation of community health services: A scoping review of public involvement methods

Services have improved due to public involvement in the planning, development, and implementation of health services. A wide range of public involvement methods, based on highly diversified methodological approaches and conceptualisations, have been developed. However, the extensive growth of new and different involvement methods lacks consistency and promotes uncertainty about which methods to apply when, how, and why. Aiming to identify, chart and summarise public involvement methods in the planning, development and implementation of community health services, we conducted a systematic search in April 2021. Seven databases were searched: CINAHL, Cochrane, Embase, PsycINFO, PubMed, ProQuest and Scopus. The systematic facet search corresponded with the PCC framework: Patient (P), Concept (C) and Context (C). A descriptive synthesis and a thematic analysis of included studies were conducted. Thirty-nine studies met the inclusion criteria. Two main categories of public involvement methods were identified: multiple methods approaches and single method approaches involving a variety of involvement activities. The characteristics of the two categories of methods were coded in accordance with methodological approach, activity and facilitation technique. The majority of the studies` methodological approach was either participatory or community-based. A variety of techniques to facilitate group discussions, sharing of ideas, and group processes were used. The results provide an overview of the characteristics of different public involvement methods, which may inform agencies and practitioners in choosing appropriate methods to qualify the public involvement in planning, developing, and implementing community health services. Further research is needed on how to manage public involvement in the implementation of community health services. In addition, rigorous evaluation studies of the impact of public involvement methods are needed.

Generating Plan Layouts: A Case Study on Visualization of Implicit Knowledge by "Doctor Architects"

AIM

This article presents an opportunistic case with particular focus on instances from an extended procurement operation in which medical professionals run a proactive process involving the generation of layouts through distinct modes of representational practices without any actual collaboration with designers. The questions of inquiry involve an analysis on how the visualizations came into being and a discussion into the content of drawings that was shaped by individuals without any formal design education.

BACKGROUND

Although the literature introduces examples of genuine participation, particularly in healthcare design practices, the instances in which nondesigners demonstrate accomplished skills in spatial reasoning and representation are limited.

METHOD

The research was formulated as a qualitative case study including a series of observations of the activities of the participants followed by interviews recorded at different locations. The investigation also focuses on the features of these authentic graphics which illustrate the intentions of the medical professionals concerning the function of spaces.

RESULTS

In this research, the participants went through a labor intensive and elaborate effort to produce "architectural representations" with the intention to convey their implicit professional expertise in the domain. The layouts were introduced to be the vital elements to visualize the implicit knowledge regarding the functioning of space.

CONCLUSIONS

The productive and creative engagement of clinicians within this research makes the case for a multidisciplinary approach that reframes the limits and potential contributions of participants alongside drawings, which are exclusively claimed by and strategically employed by architects as negotiation devices within participatory design processes.

Community co-produced mental health initiatives in rural Australia: A scoping review

INTRODUCTION

Inaccessibility of mental health services in rural Australia is widely reported. Community co-produced mental health and well-being initiatives could fill gaps and complement other services.

OBJECTIVE

This scoping review summarises findings from peer-reviewed articles to identify the key features of co-produced Australian rural mental health initiatives that engage communities in their design, delivery or evaluation processes.

DESIGN

Between 2009 and 2019 inclusive, 14 articles met inclusion criteria and were reviewed using Arksey and O'Malley's review methodology.

FINDINGS

Communities co-produced initiatives through informing, collaborating and instigating them. Some initiatives operated in specific places, for example an art gallery, while others operated across regions. Only two initiatives involved community members in multiple activities targeting prevention, early intervention, education and service accessibility; other initiatives were more focused, for example designing a new service. Over half of initiatives found were targeted at Aboriginal and Torres Strait Islander Peoples. Most articles discussed evaluation approaches, though methods were diverse.

DISCUSSION

Published peer-reviewed evidence about Australian rural community co-produced mental health initiatives appears scant. Evidence found suggests they generate a range of supports that could complement or mitigate for lack of, public health services. The overall lack of evidence, diversity of initiatives and inconsistent evaluation makes it difficult to assess effectiveness and which activities might be scaled-up for wider benefit.

CONCLUSION

Rural communities have limited resources, and evidence of what constitutes best practice in co-producing mental health services would help to avoid 'reinventing the wheel.' Greater efforts in evaluating and publishing about initiatives would be helpful.

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.

Primary healthcare nurses' involvement in patient and community participation in the context of chronic diseases: An integrative review

BACKGROUND

Primary healthcare nurses' potential to enable patient and community participation has been increasingly acknowledged. A conceptual understanding of their contributions within a broad range of participation processes is still lacking.

AIMS

The aims of this study were to develop a conceptual framework that provides information on the role of primary healthcare nurses in shaping participation processes with patients and communities in the context of chronic diseases and to identify conditions that enable or hinder the promotion of patient and community participation by nurses.

DESIGN

An integrative review was conducted.

DATA SOURCES

Twenty-three articles published from 2000 to 2019 were included in the analysis: 19 retrieved from PubMed and CHINAL and 4 added through other sources.

REVIEW METHODS

An inductive data analysis and quality appraisal of studies were conducted.

RESULTS

The analysis reveals four areas where nurses are involved in facilitating patient and community participation: (1) sharing understanding of health problems and needs, (2) developing resources and facilitating patient education for self-management, (3) raising patients' voices as an advocate in service development and (4) supporting individual and community networks. The conditions affecting nurses' engagement in fostering participation processes are as follows: (1) care priorities and overall workload, (2) nurses' attitudes towards participation and (3) users' acceptance of nurses as partners.

CONCLUSIONS

Future research can use the framework as a basis for empirical studies investigating nurses' involvement in pursuing patient and community participation. Interventions should focus less on indirect forms of participation, like patient education or advocacy, but should also focus on active forms of participation. Research is needed on nurses' involvement in community participation processes.

IMPACT

This framework can be used and adapted in future research on patient and community participation in primary healthcare. It describes areas of participation and the facilitators and barriers within the broad range of activities of primary healthcare nurses.

World Health Organization building blocks in rural community health services: An integrative review

INTRODUCTION

Developing and adapting health service models to effectively meet the needs of rural and remote communities is an international priority given inequities in health outcomes compared with metropolitan counterparts. This integrative review aims to inform rural and remote health service delivery systems by drawing on the WHO Framework building blocks to identify lessons learned from the literature describing experiences of rural and remote community health service planning and implementation; and inform recommendations to strengthen often disadvantaged rural and remote health systems for policy makers, health service managers, and those implementing international healthcare initiatives within these contexts.

METHODS

The integrative review examined the literature reporting rural and remote community health service delivery published from 2007 to 2017 (the decade following the release of the WHO Framework). Using an analytic frame, a structured template was developed to extract data and categorized against the WHO building blocks, followed by a synthesis of the key findings.

RESULTS

This integrative review identified that WHO Framework building blocks such as "Service Delivery" and "Health Workforce" are commonly reflected in rural and remote community health service delivery literature in the decade since the Framework's release. However, others such as "Sustainable Funding and Social Protection" are less commonly reported in the literature despite these elements being identified by the WHO as being integral to successful, sustainable health service delivery systems.

CONCLUSIONS

We found that collaboration across the health system governance continuum from local to policy level is an essential enabler for rural and remote health service delivery. Community-based participatory action research provides an opportunity to learn from one another, build capacity, optimize service model suitability, and promotes cultural safety by demonstrating respect and inclusivity in decision-making. Policy makers and funders need to acknowledge the time and resources required to build trust and community coalitions to inform effective planning and implementation.

We've got what the NHS ultimately intended for us: Experiences of community engagement in rural primary care services change

Policy promotes service user engagement in health services design and delivery. Various tools exist to support the engagement of citizens within health services design. We consider community engagement within the context of primary care delivery in remote and rural areas of Scotland. We present findings from three years of qualitative work with community members and healthcare professionals within five different remote and rural areas, undergoing primary care service changes. 364 interviews were carried out with community members and healthcare professionals on their experiences of, and feelings towards, the services changes. A key theme to emerge from our thematic analysis of the qualitative data is experiences of community engagement. In this paper we present our analysis of this theme. We identify different types of community engagement discourse within community and healthcare professional interviews. We illustrate these themes and, through consideration of five case study areas, demonstrate how these discourses can co-exist within the same service change process. The paper presents our sub-themes on community engagement relating to discourses of inclusion and exclusion; the role of the General Practitioner (GP); conceptualisations of the organisational role of the NHS; discourses of fear and, finally, community members understandings of what it means to be active "agents of change" (or not) within health services redesign. We argue that context is as important as method when it comes to facilitating a positive community engagement experience for citizens. Our findings have relevance to the emerging social science literature on citizen experience of public sector community engagement activities.

Service design in the healthcare space with a special focus on non-clinical service departments: A synthesis and future directions

Although there has been a tremendous change in the way diseases are diagnosed and treated, the ways in which health care delivery has been managed has seen very little change.Several academic studies have arisen in the area of service design, but an amalgamation of this research, especially in the area of healthcare services is not available. The aim of this systematic review is to evaluate the published research on service design in healthcare and accordingly identify the gaps and scope of future research. After analyzing the articles and reviewing the Service design in healthcare literature, the following are our main contributions: (i) clarification of the service design concept and the developments that appears in the literature review of service design in the healthcare sector; (ii) classification of the service design tools and techniques that are most commonly used in the healthcare sector; (iii) demonstration of the service design as the preponderant construct that is used as a tool and technique to improve quality and efficiency in the healthcare service.The resultant systematic review reveals a change in the type of research carried out, the service design tools used and a shift towards service design from using the co-design tool to other methods. The paper highlights the gaps in the very limited amount of empirical work in the non-clinical healthcare space and accordingly a model is recommended.

Public perspectives on health improvement within a remote-rural island community

Background

Rural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health.

Objective

To identify and describe shared perspectives within a remote‐rural community on how to improve rural health.

Method

Using Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews.

Results

Sixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services.

Discussion and conclusions

Factors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice.

Public Contribution

Members of the public were involved in the development and piloting of the statement set.

Galvanizing Action on Primary Health Care: Analyzing Bottlenecks and Strategies to Strengthen Community Health Systems in West and Central Africa

INTRODUCTION

The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based cost-effective interventions that are predicted to prevent up to one-third of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings.

METHODS

We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles.

RESULTS

The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges.

CONCLUSION

In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.

WOmen's Action for Mums and Bubs (WOMB) Trial Protocol: A Non-randomized Stepped Wedge Implementation Trial of Participatory Women's Groups to Improve the Health of Aboriginal and Torres Strait Islander Mothers and Children in Australia

Introduction: In Australia, there have been improvements in Aboriginal and Torres Strait Islander maternal health, however inequities remain. There is increasing international evidence illustrating the effectiveness of Participatory Women's Groups (PWGs) in improving Maternal and Child Health (MCH) outcomes. Using a non-randomized, cluster stepped-wedge implementation of a complex intervention with mixed methods evaluation, this study aims to test the effectiveness of PWGs in improving MCH within Indigenous primary care settings in Australia and how they operate in various contexts. Methods: This study takes place in ten primary health care services across Australia and involves the recruitment of existing PWGs or the setting up of new PWGs. Services are paired based on geography for practical reasons and two services commence the PWG intervention at three monthly intervals, with the initial four services being those with existing women's groups. Implementation of the PWGs as an intervention involves training local facilitators of PWG groups, supported engagement with local MCH data through workshops, PWGs identifying and prioritizing issues and strengths and co-implementing solutions with health services. Outcomes are measured with yearly MCH audits, a cost-effectiveness study, and process evaluation of community participation and empowerment. Discussion: This study is the first to formally implement and quantitatively, yet with contextual awareness, measure the effect of applying a community participation intervention to improve the quality of Aboriginal and Torres Strait Islander MCH in Australia. Findings from this work, including detailed theory-producing qualitative analysis, will produce new knowledge of how to facilitate improved quality of MCH care in Indigenous PHC settings and how to best engage community in driving health care improvements. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000945224. Web address: http://www.ANZCTR.org.au/ACTRN12618000945224.aspx.

Improving delivery of care in rural emergency departments: a qualitative pilot study mobilizing health professionals, decision-makers and citizens in Baie-Saint-Paul and the Magdalen Islands, Québec, Canada

Background

Emergency departments (EDs) in rural and remote areas face challenges in delivering accessible, high quality and efficient services. The objective of this pilot study was to test the feasibility and relevance of the selected approach and to explore challenges and solutions to improve delivery of care in selected EDs.

Methods

We conducted an exploratory multiple case study in two rural EDs in Québec, Canada. A survey filled out by the head nurse for each ED provided a descriptive statistical portrait. Semi-structured interviews were conducted with ED health professionals, decision-makers and citizens (n = 68) and analyzed inductively and thematically.

Results

The two EDs differed with regards to number of annual visits, inter-facility transfers and wait time. Stakeholders stressed the influence of context on ED challenges and solutions, related to: 1) governance and management (e.g. lack of representation, poor efficiency, ill-adapted standards); 2) health services organization (e.g. limited access to primary healthcare and long-term care, challenges with transfers); 3) resources (e.g. lack of infrastructure, limited access to specialists, difficult staff recruitment/retention); 4) and professional practice (e.g. isolation, large scope, maintaining competencies with low case volumes, need for continuing education, teamwork and protocols). There was a general agreement between stakeholder groups.

Conclusions

Our findings show the feasibility and relevance of mobilizing stakeholders to identify context-specific challenges and solutions. It confirms the importance of undertaking a larger study to improve the delivery of care in rural EDs.

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.

Exploring the neglected and hidden dimensions of large-scale healthcare change

Forms of large-scale change, such as the regiona l re-distribution of clinical services, are an enduring reform orthodoxy in health systems of high-income countries. The topic is of relevance and importance to medical sociology because of the way that large-scale change significantly disrupts and transforms therapeutic landscapes, relationships and practices. In this paper we review the literature on large-scale change. We find that the literature is dominated by competing forms of knowledge, such as health services research, and show how sociology can contribute new and critical perspectives and insights on what is for many people a troubling issue.

Unlocking the potential of rural social enterprise

In this paper, we argue that social enterprise could represent a means of tackling rural challenges of providing sustainable economic development, addressing the withdrawal of public services and promoting community cohesion. The paper draws upon a review of existing academic as well as policy literature and develops a conceptual framework that helps to understand how to unlock the potential contribution of social enterprises to rural development. Drawing on an exploratory study conducted in two rural areas of Scotland we use interview data from social enterprise stakeholders to populate the conceptual framework and its rural (geographic), policy and social enterprise domains. Our study suggests that social enterprises can potentially enable an integrated approach to addressing local issues at the local level. They can create locally responsive services that fit the rural context. However, unlocking the potential of rural social enterprise may require moving beyond traditional policy silo approaches that treat economic development, community cohesion and public services as separate and disconnected since national policy-making frameworks have not always translated into practice at the rural level. Additionally, policy treatment of social enterprise needs to move beyond efforts to 'scale up' and achieve economies of scale. Collaborations between groups of social enterprises, and between social enterprises and public authorities can lead to economies of scope, particularly where strong trust-based relations within communities harness self-help and the co-production of services. With appropriate guidance and support, many rural challenges and needs could be transformed into opportunities for social enterprise development. In highlighting the opportunities and challenges faced by rural social enterprises, the paper suggests potential research gaps that, if filled, could contribute towards recognising and unlocking their full potential.

Evaluating community participation: A comparison of participatory approaches in the planning and implementation of new primary health-care services in northern Australia

Community participation is increasingly seen as a prerequisite for more acceptable and sustainable health services. It is difficult to evaluate the extent of participation in health planning and implementation of services, and there are limited tools available to assist in evaluating such processes. Our paper reports on community participation as part of the implementation of 2 primary health programs in regional north Queensland, Australia. We define community participation as collective involvement of people, including consultation, from a community of place or interest in aspects of health service development. We pragmatically evaluate and compare the extent of participation by using a framework developed by Rifkin and colleagues in 1988 and subsequently refined. Data collected from the implementation of each program were analyzed and ranked on a spidergram against 5 process indicators: needs assessment, leadership, resource mobilization, management, and organization. Community participation was found to vary across the programs but was most extensive in both programs in identifying need and potential solutions. Both programs demonstrated high levels of integration of the implementation of health programs with preexisting community structures. Involving local communities in genuine opportunities in managing the programs and mobilizing resources was more challenging. Key differences emerged in the people involved in the programs, the settings and frameworks used to facilitate implementation. We conclude that Rifkin's process indicators are a useful starting point for assessing community participation, particularly for health planners who are required to include participatory approaches when planning and implementing services. We suggest areas that require further consideration.

Social justice, access and quality of healthcare in an age of austerity: users' perspective from rural Iceland

Iceland is sparsely populated but social justice and equity has been emphasised within healthcare. The aim of the study is to examine healthcare services in Fjallabyggð, in rural northern Iceland, from users’ perspective and evaluate social justice, access and quality of healthcare in an age of austerity. Mixed-method approach with transformative design was used. First, data were collected with questionnaires (response rate of 53% [N=732] in 2009 and 30% [N=415] in 2012), and analysed statistically, followed by 10 interviews with healthcare users (2009 and 2014). The results were integrated and interpreted within Bronfenbrenner’s Ecological Model. There was significantly less satisfaction with accessibility and variety of healthcare services in 2012 after services downsizing. Solid primary healthcare, good local elderly care, some freedom in healthcare choice and reliable emergency services were considered fundamental for life in a rural area. Equal access to healthcare is part of a fundamental human right. In times of economic downturn, people in rural areas, who are already vulnerable, may become even more vulnerable and disadvantaged, seriously threatening social justice and equity. With severe cutbacks in vitally important healthcare services people may eventually choose to self-migrate.

Community participation for rural healthcare design: description and critique of a method

This paper outlines a community participation process that was developed to engage rural community stakeholders in designing new health services. The paper explains what led up to the process and provides critique around applying the process for other health services and in other communities. Internationally, community participation is widely invoked, but it is only broadly explained in the literature, other than reviews of outcomes or descriptions of problems. This paper provides an actual process, derived from iterative research, that others could use, but explains caveats in the method and its application. From developing this method of community participation for service design, we conclude that rather than being a benign and inherently 'good thing', community participation is a process into which health services managers and communities should enter cautiously. Stronger parameters around desirable outcomes and awareness of potential pitfalls in the process are important to address.

A Community-Based, Technology-Supported Health Service for Detecting and Preventing Frailty among Older Adults: A Participatory Design Development Process

Frailty is a multifaceted condition that affects many older adults and marks decline on areas such as cognition, physical condition, and nutritional status. Frail individuals are at increased risk for the development of disability, dementia, and falls. There are hardly any health services that enable the identification of prefrail individuals and that focus on prevention of further functional decline. In this paper, we discuss the development of a community-based, technology-supported health service for detecting prefrailty and preventing frailty and further functional decline via participatory design with a wide range of stakeholders. The result is an innovative service model in which an online platform supports the integration of traditional services with novel, Information Communication Technology supported tools. This service is capable of supporting the different phases of screening and offers training services, by also integrating them with community-based services. The service model can be used as a basis for developing similar services within a wide range of healthcare systems. We present the service model, the general functioning of the technology platform, and the different ways in which screening for and prevention of frailty has been localized. Finally, we reflect on the added value of participatory design for creating such health services.

An exploration of the longer-term impacts of community participation in rural health services design

This article explores what happened, over the longer term, after a community participation exercise to design future rural service delivery models, and considers perceptions of why more follow-up actions did or did not happen. The study, which took place in 2014, revisits three Scottish communities that engaged in a community participation research method (2008-2010) intended to design rural health services. Interviews were conducted with 22 citizens, healthcare practitioners, managers and policymakers all of whom were involved in, or knew about, the original project. Only one direct sustained service change was found - introduction of a volunteer first responder scheme in one community. Sustained changes in knowledge were found. The Health Authority that part-funded development of the community participation method, through the original project, had not adopted the new method. Community members tended to attribute lack of further impact to low participation and methods insufficiently attuned to the social nuances of very small rural communities. Managers tended to blame insufficient embedding in the healthcare system and issues around power over service change and budgets. In the absence of convincing formal community governance mechanisms for health issues, rural health practitioners tended to act as conduits between citizens and the Health Authority. The study provides new knowledge about what happens after community participation and highlights a need for more exploration.