“If Only Someone Had Told Me …”: Lessons From Rural Providers

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded. Findings: Emergent themes coalesced into 3 overarching themes addressing practice‐related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.     

Reframing “participation” and “inclusion” in public health policy and practice to address health inequalities: Evidence from a major resident‐led neighbourhood improvement initiative

There is a need for greater conceptual clarity in place‐based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident‐led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident‐led partnerships across England are tackling the day‐to‐day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.     

Exploration and practice of the “1 + 10 + 1100000” model

The exploration and practice of the “1 + 10 + 1100000” model of local medical consortium includes three aspects: graded diagnosis and treatment, two‐way referral, and dynamic flow; seamless connection between general practice and specialty to realize health management; and establishment of the “community health center‐East Hospital‐Tongji University” teaching platform.     

Integrated care in action: opening the “black box” of implementation

The aim of this contribution is to explain how healthcare professionals implement policies for integrated care. More specifically, we aim to understand how these policies are received, interpreted and executed by primary care professionals. By opening the “black box” of policy implementation, we also explain how and why the process of implementation of the same policy diverges in practice. The research is framed according to both the neo‐institutional and the change management perspectives. The empirical investigation is conducted through a documental analysis and a multiple‐embedded case study. The results show that three forces affect and explain differences in the implementation processes: the unstable level of internal communication among the professionals involved, the limited use of power to resist to change and the poor learning process on the part of both the professionals and policy makers. The pressure of external institutions does not play a role in shaping the process. Through our study, we further knowledge about how healthcare professionals implement policies for integrated care, and we believe this is interesting, according to emerging evidence that variations in the effectiveness of policy outcomes may be explained by choices and potential distortions made during the initial stages of the policy implementation process. Copyright © 2015 John Wiley & Sons, Ltd. StartCopTextCopyright © 2015 John Wiley & Sons, Ltd.     

“I keep it to myself”: A qualitative meta‐interpretive synthesis of experiences of postpartum depression among marginalised women

Postpartum depression (PPD) is a significant public health concern due to the physical, emotional, economic, and life course outcomes. Rates of PPD are significantly higher for marginalised populations and can impact low‐income, minority, and/or immigrant women differently when compared to white middle‐class women. Commonly studied negative effects of PPD include poor health outcomes, mother–child bonding challenges, and negative child educational outcomes. However, research surveying the postpartum experience and negative outcomes among marginalised women is sparse. This study implemented a qualitative meta‐interpretive synthesis (QIMS) methodology to synthesise themes across 12 qualitative research articles surveying postpartum experiences of marginalised women in North American countries. Articles included in the QIMS were extracted from online databases from a 10‐year window spanning January 2008–2018. The guiding research question was “What are the PPD experiences of women belonging to marginalized populations?” Constant comparative analysis was used with coding in atlas.ti and themes were synthesised with input of all three authors. Five main themes emerged. The themes are (a) intersections of PPD and poverty, (b) culture and PPD, (c) pressures of mothering, (d) strengths and coping, and (e) abuse affects my PPD experience. Subthemes such as “I keep it to myself” relating to cultural response to PPD and idealised mothering were also discovered. Implications for social workers, nurses, and future research are discussed.     

“The Tourist Season Goes Down But Not the Prices.” Tourism and Food Insecurity in Rural Costa Rica

Data from women in two communities in rural Costa Rica were analyzed in order to examine food insecurity in an area undergoing a shift from an agricultural economy to tourism (e.g., eco/adventure tourism). While there were significant differences in socio-economic status between the two communities, the prevalence of food insecurity was high in both, ranging from 67% in the agricultural community to 73% in the tourism community. Not being a member of a food cooperative (OR = 4.85), not having a working stove (OR = 6.27), and increasing body mass index (BMI) (OR = 1.32) predicted food insecurity in both communities. Additionally, the frequency of condiment use was inversely associated with food insecurity (OR = .363). These findings along with other data suggest that food insecurity is a problem in this area. Furthermore, dietary quality associated with food insecurity might be responsible for the high prevalence of obesity among the study participants.     

Making the “new American workplace” safe and healthy: A joint labor-management-researcher approach

The American workplace is now in the midst of the most significant change since the advent of mass production. Whether these changes will lead to improvements in worker health and safety is not clear. This paper describes an approach to intervention and research—participatory action research (PAR)—that has the potential to redesign work organizations to improve performance while also improving health and safety. In the PAR method, researchers, managers, workers, and unions collaborate in a process of data-guided problem solving intended both to improve the system's performance and to contribute to general scientific knowledge. A case study example illustrates the use of a PAR approach in an automobile parts facility where labor, management, and researchers jointly conducted a longitudinal project aimed at reducing the major sources of stress and enhancing employee well-being. Results from the 6 year project suggest that, properly implemented, PAR has the potential to both lead to improved intervention and contribute to theoretical advances in occupational safety and health. The PAR approach to intervention research is contrasted with the total quality approach (TQA), and some suggestions are made for improving PAR research designs. © 1996 Wiley-Liss, Inc.