Course:SOWK551/2021/Access to healthcare in rural, remote and northern areas in Canada- challenges, opportunities and implications for social work practice
Short Summary
A literature review exploring access to healthcare in rural, remote and northern regions in Canada and corresponding challenges, opportunities, recommendations and implications for social work practice.
Author: Anonymous
Date: April 9, 2023
Introduction
People living in rural, remote and northern communities are noted within existing literature to face increased health disparities and disproportionate socioeconomic burdens related to navigating healthcare compared to those living in urban settings (Oelke, Plamondon & Kornelsen, 2020; Young & Chatwood, 2017). Factors such as geographical isolation and access to healthcare services have important implications for the health and wellbeing of individuals in these regions (Huot et al., 2019). Following a review of the literature on access to healthcare services in Canada's rural, remote and northern regions, this paper has identified and will examine three themes; models of healthcare service delivery, access to care considerations and place-based approach. Implications for healthcare social work practice will also be explored. This paper will propose a social work role in enhancing avenues of communication, connection and education amidst a fragmented healthcare delivery system described within the literature. It will conclude with directions for future research.
The literature reviewed in this paper incorporates sources that span the Canadian regions of British Columbia, Quebec, Ontario, the Yukon, North West Territories and Nunavut. Classifications of the concepts of urban, rural, remote and northern are noted to differ, although similarities are evident across broader themes. Rechel et al. (2016) highlight territorial and provincial distinctions between rural, remote and northern areas. The concept of rurality is generally defined by a community's distance to a larger urban centre, low population size and low population density (Jeffery & Novik, 2022; MHCC, 2020). Moreover, a rural community is viewed as remote when marked by restricted access and the need for individuals to utilize third parties to travel to larger centres (Jeffery & Novik, 2022; MHCC, 2020). Also discussed by Jeffery & Novik (2022) is the inherent subjectivity of characterizing an area as northern due to geographical, political and social ways of conceptualizing northern as both a place and a sense of identity. Despite variations in defining such places, the literature suggests fundamental similarities relating to the physical environment, level of isolation and access to health services (Sutherns, McCallum & Haworth-Brockman, 2007). Rurality is thus viewed as a determinant of health in individuals’ lives, as the distance separating communities from a wider range of health services available in more urban settings influences the type, frequency and quality of services received (Huot et al., 2019; Sutherns et al., 2007). Acknowledging the diversity in cultures, values and livelihoods of the people who reside in these settings is also prominently emphasized (Jeffery & Novik, 2022).
Models of healthcare service delivery
Within a Canadian context, health reform and its impact on service provision are well addressed in the literature reviewed. Several articles examining the BC context note that health system centralization has resulted in a shifting of services to population-dense cities, a devolution of power to local and regional health boards and a disconnect between what is provided and what is needed (Browne, 2010; Oelke et al., 2020). Oelke et al. (2020) argue that this reduces services within rural and remote areas, while Browne (2010) posits that this has spurred a down-sizing of hospital-based services and increased responsibility placed on community-based programs that are already limited and overburdened. Moreover, it is noted that in rural and remote areas, community members and service providers are required to manage worsening health problems following shorter hospital stays or earlier discharge back to the community (Browne, 2010). The impact of systemic factors is further considered around barriers to healthcare delivery and access due to the fragmentation or siloing of health services. In examining differences between emergency health services in rural EDs in Quebec and Ontario, Fleet et al. (2015) highlight that variations in care suggest inequities in accessibility and effectiveness of services, despite Canada’s universal health care system.
A review of the literature underlines the various healthcare models that are operating within rural, remote and northern regions in Canada, particularly models of primary- and hospital-based care (Young & Chatwood, 2017; Fleet et al., 2020; Hunter et al., 2017; Kornelsen et al., 2021). Although there are differences in service delivery across regions, a primary distinction between rural and urban healthcare is the central role played by family physicians and nursing staff in both primary and hospital-based care settings (Young & Chatwood, 2017). Young and Chatwood (2017) advise that in Northern Canada, two primary care models operate; one within regional centres and capital cities with family physicians as the entry point and a second in more remote communities with nursing staff at community health centres as the entry point. Within remote communities in the Yukon, NWT and Nunavut, nurses primarily provide primary care with clinical support provided by physicians based in regional centres (Young et al., 2019). Hunter et al. (2017) similarly found that two rural hospitals in western Canada, staffed with 24-hour emergency departments, operated as regional facilities for surrounding rural communities.
The complex role played by emergency departments (EDs) in rural, remote and northern regions is highlighted in several articles. Fleet et al. (2017) note that rural populations are older, in poorer health and more at risk for injury than urban populations, in addition to having lower income, less education and shorter life expectancy. As such, significant challenges are posed for individuals and families without family doctors, compounded by an absence of walk-in clinics and barriers posed by distance and transportation (Hunter et al., 2017). EDs thus encompass an “essential safety net” for populations with few alternatives to accessing healthcare, in part due to issues with primary healthcare accessibility (Fleet et al., 2020, p. 1; Haggerty et al., 2007). EDs provide continuous and accessible service as the foremost alternative for minor and major urgent care needs, in addition to emergency care and as a point of connection and transition to urban facilities (Haggerty et al., 2007). Though EDs and hospitals operate in these regions and support smaller communities, they often do not provide the entire range of services, resources and equipment that their urban counterparts may have, including timely access to specialty medical services (Rechel et al., 2016). The literature reviewed identifies that family physicians also frequently staff hospital and ED services and that even those connected to local providers are steered to accessing the ED for primary care concerns due to staffing shortages and long clinic wait times (Haggerty et al., 2007; Kornelsen et al., 2021).
Access to care considerations
Healthcare provider-related barriers
Healthcare provider-related barriers are discussed consistently within the literature reviewed. As Anaraki and colleagues (2022) report, though the shortage of family physicians and specialists is a prevalent issue across Canada, the number of physicians in rural and remote communities is far less, thus requiring existing staff to provide a broader scope of practice. This notion is not restricted to physicians, as healthcare staffing shortages involving different professions are identified in numerous sources as affecting service provision and access across community, primary care, hospital and long-term care settings (Fleet et al., 2020; Huot et al., 2019). The issue is reported to be two-fold and intertwined; there is not enough staff, thus increasing the burden on the people that are working and making retaining staff difficult (Smart, 2022). This is similarly discussed by Browne (2010), who identifies that rural and remote communities tend to face higher staff turnover rates and difficulty retaining providers, including nurses, physicians and allied health staff. These barriers are further heightened by challenging work conditions and limited workplace support and supervision (Browne, 2010). Limited opportunities for continuing education are also identified as a significant challenge (Browne, 2010; Huot et al., 2019; Smart, 2022). Additionally noted in the literature are the challenges related to dual relationships in smaller settings and high visibility for both staff and community members accessing services (Schmidt, 2008).
Transportation
Across the literature, the challenges posed by navigating transportation systems amidst a fragmented healthcare system are highlighted. As healthcare facilities in rural, remote and northern areas are fewer and more widely dispersed than in urban areas, people are generally required to travel great distances by land, air or boat to obtain services in regional facilities or in larger urban facilities that cannot be accessed in their home communities (Browne, 2010; Huot et al., 2019; MHCC, 2020; Oelke et al., 2020). An example includes travelling from a small town in the Yukon or NWT to a health facility in Vancouver, BC or Edmonton, AB. Transportation options, subjected to seasonal weather conditions, may include commercial air travel, air ambulance or Medevac, ferries or cars, or HandyDART and limited taxi options in larger centres (Browne, 2010; Mirza & Hulko, 2022; Rechel et al., 2016; Young et al., 2019). The influence of physical geography on accessing care is noteworthy, as it is well-recognized that transportation is a primary barrier to healthcare access, particularly for older adults and individuals with mobility limitations (Mirza & Hulko, 2022). A study by Anaraki et al. (2022) captures this by exploring residents’ perspectives; expressed are the challenges around the physical toll of travelling long distances, limited access to public transportation and out-of-pocket expenses. Additional challenges include having to leave behind support networks, families and jobs to obtain services, causing emotional and financial stress (Huot et al., 2019). Implications for hospital discharge planning and difficulties associated with transportation coordination for patients returning to home communities are also revealed (Oelke et al., 2020). Notably, transportation is distinguished as a social determinant of health for all, notwithstanding of whether living in rural or urban settings, as limited access to transportation can result in delayed medical appointments, poor health outcomes and increased utilization of healthcare services (Mirza & Hulko, 2022).
Emotional impact and social proximity
The literature reviewed also explores the emotional impact on individuals as they navigate accessing care. Beyond the frequent need to travel away from supports in home communities, families and communities are often required to find ways to compensate for periods without members who may be wage-earners or parents (Browne, 2010; Carter-Snell et al., 2019). Browne (2010) highlights as an example pregnant women who must relocate to regional centres for before delivery and the toll separation from community can have on relationships and child care.
Social proximity, a feature often found in small areas where people are familiar with one another, is also discussed in several articles as a benefit and a challenge to accessing and engaging in healthcare services. Hunter et al. (2017) completed a study that examined care for individuals with dementia in a rural ED and found that an advantage of recognizing people is also knowing the supports they are connected to. A disadvantage was highlighted as the possibility of an incomplete assessment of an individual's current status occurring due to the belief that one is familiar with someone's condition (Hunter et al., 2017). Fleet et al. (2020) similarly consider this phenomenon and identify the challenges posed by maintaining patient confidentiality within small communities.
Of central importance and emphasized across the literature is acknowledging the longstanding reciprocal relationships that many First Nations, Métis and Inuit peoples living in Canada's rural and remote areas have with their traditional territories (Jeffery & Novik, 2022; MHCC, 2020). Within Indigenous communities, health services may also be limited in scope, overworked and reflective of Canada's past and ongoing colonial legacy (Huot et al., 2019; MHCC, 2020). A critical lens turned on how available services may exacerbate discrimination and power imbalances is required, particularly as the literature highlights that Indigenous peoples experience significantly higher rates of illness (Browne, 2010). As such, implementation of culturally appropriate services is needed within hospital and community health settings to challenge the dominance of Westernized biomedical approaches (Browne, 2010). Jeffrey and Novik (2022) propose incorporating practices of Two-Eyed Seeing to recognize Western and Indigenous healing methods and ideologies, diversity across regions and peoples, and to uphold anti-oppressive social work practice in rural and remote communities.
Recommendations
While numerous challenges and barriers are reported, sources also emphasize micro and macro-level recommendations. Improving care coordination was a central theme, as several articles note that effective and comprehensive programming relies heavily on strong collaboration between healthcare providers and community-based services to improve access and centralize a patient's experience throughout transitions of care (MHCC, 2020). Centralizing care was additionally discussed through use of virtual technology, improving collaboration between urban and rural communities and enhancing support for primary care providers (MHCC, 2020; Oelke et al., 2020). Also recommended are for services to be delivered in culturally-appropriate ways to reflect Indigenous ways of knowing and to advance health equity and accessibility by educating providers on a more holistic view of health (MHCC, 2020; Young & Chatwood, 2017).
Place-based approach
Another salient theme across the review was the importance of approaching healthcare service access in rural, remote and northern regions by acknowledging contextual and place-based diversity, as opposed to applying a "one size fits all" approach to improve delivery of care (Fleet et al., 2020, p. 2; Huot et al., 2019; Mirza & Hulko, 2022). Consensus is largely noted around the need to address the contextual challenges of different regions and tailor services to individual localities reflecting diverse health needs (Huot et al., 2019; Kornelsen et al., 2021). Central to this is engaging local stakeholders to identify challenges and solutions adapted to local contexts, socioeconomic and cultural landscapes, resources and capabilities (Fleet et al., 2020; MHCC, 2020). Kornelsen et al. (2021) emphasize the need to include citizen-patient voices in planning to better reflect regional priorities. Interestingly, several reviewed articles engaged in participatory action research to obtain stakeholders' local perspectives, create space for dialogue about challenges and solutions, and encourage rapid knowledge mobilization (Anaraki et al., 2022; Carter-Snell et al., 2019; Fleet et al., 2017). Using this methodological approach well reflects the intention for researchers and participants to collaborate around better understanding contextual realities. Of note, an article by Howard et al. (2014) examining access to services for cancer survivors living in rural areas offered a different, albeit important, perspective on where attention should be focused. The authors argue for the need to move beyond focusing solely on area-based rationale and resolutions to consider “fundamental social and structural processes operating in a broader context” to engage in service reform (Howard et al., 2014, p.319).
Notably, a substantial focus on deficits relating to access to healthcare in rural, remote and northern regions is evident throughout the literature reviewed. Despite this, several articles emphasize the significance of attuning to the strengths inherent within local communities to mitigate focusing exclusively on challenges around service access. This is reflected on by Huot et al. (2019), who acknowledge that focusing on deficits and challenges may frame rural, remote and northern regions negatively and subsequently overlook their strengths and capabilities. Aligned with this, Fleet et al. (2020) highlight their study participants’ pride in discussing the creativity and flexibility that is incorporated into practice in rural EDs in order to overcome challenges and the valuable social support that stems from social proximity within smaller communities. In exploring social work practice in rural and northern areas, Jeffery and Novik (2022) suggest that practice is “often defined in relation to urban (and southern) expectations”, and thus there is a tendency to highlight deficits of practice in areas outside urban settings (p.9). This is evident in considering some of the topics that are covered in literature around access to healthcare, as well as social work experiences working in these settings. Existing literature on social work practice has spanned burnout, staff retention issues, limited service access, experiences of geographic and social isolation and challenges with dual relationships and high visibility (Jeffery & Novik, 2022; McKenzie, 2016). While important considerations, more is needed on the advantages to working in these settings that may not be well captured (Jeffery & Novik, 2022). Jeffery and Novik (2022) also argue for the need to disrupt comparisons between urban and rural settings and social work practice, and engage place-based approaches.
Application to practice
In considering implications for practice, it is clear that social work perspectives may bring a lens that considers challenges and opportunities across micro, mezzo and macro levels. There are several ways that social workers across different health practice settings can work alongside patients, families and other healthcare providers to incorporate a strengths-based, anti-oppressive and trauma-informed lens to address barriers and mobilize strengths around access to healthcare, amidst systemic limitations and fragmentation. Firstly, there is a role for social workers in strengthening awareness of the barriers discussed in this review and the impact that a fragmented healthcare system can have on the experiences of individuals. At the micro level, central to this is engaging in care coordination and transition planning alongside patients and families needing to travel to access required health services. This holds significance for both social workers who work alongside rural populations and those who work in larger, urban centres who may work with patients and families who have travelled to receive specialist or emergency care and will return to their home community when able. With consent, communication between social workers in hospital or community health settings that assist in coordinating travel with social workers or other healthcare providers in receiving facilities may improve transition and communication relating to the specifics of a case. Practical needs, including medical travel insurance and documentation requirements, accommodation for families, financial support and discharge planning, may be more readily met, as well as emotional and psychosocial needs that patients or families may have that can be communicated to staff at the receiving facility to follow-up and provide support around. In doing so, linkages and connections can be made between healthcare and allied health staff that streamline communication and strengthen awareness around the unique challenges individuals travelling for health services may face. Patient and family education around accommodations, travel reimbursement, and support for family members who wish to join or must stay in their home community can also be provided in accessible and individualized ways. In addition, opportunity is highlighted for supporting the compounding feelings of uncertainty and stress that accompany medical travel, whether anticipated or not, in addition to the stress experienced by many stemming from navigating health states, adjustment to illness and dominant biomedical systems and ideologies.
A social work assessment should also incorporate transportation as a feature, as the literature reviewed affirms that transportation significantly impacts health outcomes and access to healthcare services. Integrating questions around transportation into the biopsychosocialspiritual assessment creates space to highlight existing needs and resources and problem-solve solutions so that responsibility is not left solely on the patient or family when transportation is required.
Finally, though the literature highlights reduced opportunities for continuing education when practicing in rural, remote and northern settings, an awareness of this from a social work perspective may encourage establishing creative and flexible opportunities for growth and learning across practice settings. Education may take various forms, including journal clubs for social work staff or accessing virtual opportunities. Similar to other professions and as noted in the literature, social workers may be called upon to practice from a broader scope, whether working in hospital settings, community health, home care, mental health or substance use services. Ongoing education around evidence-based frameworks and scope of practice is thus vital to do so in safe, ethical and effective ways.
Conclusion
In summary, this review highlights the challenges and opportunities around access to healthcare in rural, remote and northern regions in Canada by considering models of service delivery, primary considerations around access to healthcare services and engaging place-based approaches. It also explores the role that social workers can play in strengthening communication, connection and educational practices amidst the challenges identified. Future research areas can enhance community engagement in research practices, policy development and service re-structuring by engaging in participatory research methodology that elevates the perspectives of community members. It can also examine experiences of specific groups engaging in healthcare services that are not presently well represented in current literature, such as newcomers, temporary workers and LGBTQ+ communities living in rural and remote settings.
References
Anaraki, N. R., Mukhopadhyay, M., Wilson, M., Karaivanov, Y. & Asghari, S. (2022). Virtual Healthcare in Rural and Remote Settings: A Qualitative Study of Canadian Rural Family Physicians’ Experiences during the COVID-19 Pandemic. International Journal of Environmental Research and Public Health, 19(20).
Browne, A. (2010). Issues affecting access to health services in northern, rural and remote regions of Canada. Prince George, BC: University of Northern British Columbia Northern Article Series. https://www2.unbc.ca/sites/default/files/sections/northern-studies/issuesaffectingaccesstohealthservicesinnorthern.pdf
Carter-Snell, C., Jakubec, S. & Hagen, B. (2019). Collaboration with Rural and Remote Communities to Improve Sexual Assault Services. Journal of Community Health, 45, 377-387.
Fleet, R. et al. (2015). Differences in Access to Services in Rural Emergency Departments of Quebec and Ontario. Public Library of Science One, 10(4).
Fleet, R., Dupuis, G., Gravel, J., Ouimet, M., Poitras. J. & Legare, F. (2017). Rural emergency care 360°: mobilising healthcare professionals, decision-makers, patients and citizens to improve rural emergency care in the province of Quebec, Canada: a qualitative study protocol. British Medical Journal Open, 7.
Fleet, R., Turgeon-Pelchat, C., Smithman, M. A., Alami, H., Fortin, J., Poitras, J., Ouellet, J. Gravel, J., Renaud, M., Dupuis, G. & Legare, F. (2020). 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, Quebec, Canada. BMC Health Services Research, 20(62).
Haggerty, J. L., Roberge, D., Pineault, R., Larouche, D. & Touati, N. (2007). Features of Primary Healthcare Clinics Associated with Patients’ Utilization of Emergency Rooms: Urban Rural Differences. Healthcare Policy, 3(2).
Howard, A. F., Smillie, K., Turnbull, K., Zirul, C., Munroe, D., Ward, A., Tobin, P., Kazanjian, A. Olson, R. (2014). Access to medical and supportive care for rural and remote cancer survivors in northern British Columbia. Journal of Rural Health, 30(3), 311-321.
Hunter, K. F., Parke, B., Babb, M., Forbes, D. & Strain, L. (2017). Balancing safety and harm for older adults with dementia in rural emergency departments: healthcare professionals’ perspectives. Rural and Remote Health, 17.
Huot, S., Ho, H., Lam, S., Tactay, P., MacLachlan, J. & Raanaas, R. K. (2019). Identifying barriers to healthcare delivery and access in the Circumpolar North: important insights for health professionals. International Journal of Circumpolar Health, 78(1).
Jeffery, B. & Novik, N. (Eds.) (2022). Rural and Northern Social Work Practice: Canadian Perspectives, Regina, SK: University of Regina is licensed under a Creative Commons Attribution 4.0 International License.
Kornelsen, J. et al. (2021). Rural citizen-patient priorities for healthcare in British Columbia, Canada: findings from a mixed methods study. BMC Health Services Research, 21(987).
McKenzie, C. (2016). Burnout North of 60: Supporting Social Workers in Nunavut, Canada. Critical Social Work, 17(2).
Mental Health Commission of Canada (MHCC). (2020). Rural and Remote Mental Health in Canada: Evidence Brief on Best and Promising Practices.
https://mentalhealthcommission.ca/resource/rural-and-remote-mental-health-in-canada-evidence-brief-on-best-and-promising-practices/
Mirza, N. A. & Hulko, W. The complex nature of transportation as a key determinant of health in primary and community care restructuring initiatives in rural Canada. Journal of Aging Studies, 60.
Oelke, N., Plamondon, K. & Kornelsen, J. (2020). Rural Stories of Getting Back Home: An integrated knowledge translation study of people’s experiences of navigating access to healthcare from rural and remote communities in British Columbia. International Journal of Integrated Care, 20(1).
Rechel, B., Dzakula, A., Duran, A., Fattore, G., Edwards, N., Grignon, M., Haas, M., Habicht, T., Marchildon, G. P., Moreno, A., Ricciardi, W., Vaughan, L. & Smith, T. A. (2016). Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health policy, 120(7), 758-769.
Smart, K. (Guest). (2022, January 10). Rural and Remote Health Care in Canada- Canadian Health Information Podcast. [Audio podcast]. Retrieved from https://www.cihi.ca/en/podcast/dr-katharine-smart-rural-and-remote-health-care-in-canada
Schmidt, G. (2008). Professional Work in Remote Northern Communities: A Social Work Perspective. Prince George, BC: UNBC Community Development Institute.
https://www2.unbc.ca/sites/default/files/sections/community-development-institute/g_schmidt_cdi_paper.pdf
Sutherns, R., McCallum, M. & Haworth-Brockman, M. (2007). A THEMATIC BIBLIOGRAPHY AND LITERATURE REVIEW OF RURAL, REMOTE AND NORTHERN WOMEN’S HEALTH IN CANADA 2003-2006. Resources for Feminist Research, 32(3-4), 142-178.
Young, T. K., Tabish, T., Young, S. K. & Healey, G. (2019). Patient transportation in Canada’s northern territories: patterns, costs and providers’ perspectives. Rural Remote Health, 19(2).
Young, T. K. & Chatwood, S. (2017). Delivering more equitable primary health care in Northern Canada. Canadian Medical Association Journal, 189(45).
<a rel="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/"><img alt="Creative Commons License" style="border-width:0" src="https://i.creativecommons.org/l/by-nc-nd/4.0/88x31.png" /></a><br />This work is licensed under a <a rel="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.
|
