Strengthening Community Health Systems Through Novel eHealth Initiatives? Commencing a Realist Study of the Virtual Health Rooms in Rural Northern Sweden

Document Type : Original Article

Authors

1 Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

2 Arctic Research Centre (Arcum), Umeå University, Umeå, Sweden

3 School of Business and Law, CQUniversity, Rockhampton, QLD, Australia

Abstract

Background
Unlike the large body of research that has examined the ‘success’ or ‘failure’ of eHealth in terms of patient and provider perceptions or cost- and clinical effectiveness, the current study teases out ways through which a novel eHealth initiative in rural northern Sweden might result in more distal or systemic beneficial outcomes. More specifically, this paper aims to explore how and under what circumstances the so-called virtual health rooms (VHRs) are expected to improve access to person-centred care and strengthen community health systems, especially for elderly residents of rural areas.
 
Methods
The first phase of the realist evaluation methodology was conducted, involving qualitative interviews with 8 key stakeholders working with eHealth, business development, digitalisation, and process management. Using thematic analysis and following an abductive-retroductive analytical process, an intervention-context-actor-mechanism-outcome (ICAMO) configuration was developed and elicited into an initial programme theory.
 
Results
The findings indicate that a novel eHealth initiative, which provides reliable technologies in a customized facility that connects communities and providers, might improve access to person-centred care and strengthen community health systems for rural populations. This is theorized to occur if mechanisms acting at individual (such as knowledge, skills and trust) and collective (like a common vision and shared responsibilities) levels are triggered in contexts characterised by supportive societal transitions, sufficient organisational readiness and the harnessing of rural cohesiveness and creativity.
 
Conclusion
The elicited initial programme theory describes and explains how a novel eHealth initiative in rural northern Sweden is presumed to operate and under what circumstances. Further testing, refinements and continued gradual building of theory following the realist evaluation methodology is now needed to ascertain if the ‘VHRs’ work as intended, for whom, in what conditions and why.

Keywords

Full Text

 

"Watch the Video Summary"

 

  Check the full list of "CHS-Connect" special issue here. 

References

  1. World Health Organization (WHO). The World Health Report 2008-Primary Health Care (Now More Than Ever). Geneva: WHO; 2008.
  2. SOU. Effektiv vård - Slutbetänkande av en nationell samordnare för effektivare resursutnyttjande inom hälso- och sjukvården [Effective care - Final report of a national coordinator for more efficient use of resources in health care]. Stockholm: Ministry of Health and Social Affairs; 2016:12.
  3. SOU. God och nära vård – Vård i samverkan [Good and close care - Care in collaboration]. Stockholm: Ministry of Health and Social Affairs; 2019:29.
  4. Janssen R, Hettinga M, Visser S, et al. Innovation routes and evidence guidelines for eHealth Small and Medium-sized Enterprises. Int J Adv Life Sci. 2013;5(3-4):188-203.
  5. Granja C, Janssen W, Johansen MA. Factors determining the success and failure of eHealth interventions: systematic review of the literature. J Med Internet Res. 2018;20(5):e10235. doi:10.2196/10235
  6. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752. doi:10.7326/0003-4819-144-10-200605160-00125
  7. Fatehi F, Armfield NR, Dimitrijevic M, Gray LC. Clinical applications of videoconferencing: a scoping review of the literature for the period 2002-2012. J Telemed Telecare. 2014;20(7):377-383. doi:10.1177/1357633x14552385
  8. Abimbola S, Keelan S, Everett M, et al. The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation. Health Econ Rev. 2019;9(1):21. doi:10.1186/s13561-019-0239-5
  9. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform. 2010;79(11):736-771. doi:10.1016/j.ijmedinf.2010.08.006
  10. Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state of telehealth evidence: a rapid review. Health Aff (Millwood). 2018;37(12):1975-1982. doi:10.1377/hlthaff.2018.05132
  11. Bujnowska-Fedak MM, Grata-Borkowska U. Use of telemedicine-based care for the aging and elderly: promises and pitfalls. Smart Homecare Technol Telehealth. 2015;3:91-105. doi:10.2147/shtt.s59498
  12. Peek ST, Wouters EJ, van Hoof J, Luijkx KG, Boeije HR, Vrijhoef HJ. Factors influencing acceptance of technology for aging in place: a systematic review. Int J Med Inform. 2014;83(4):235-248. doi:10.1016/j.ijmedinf.2014.01.004
  13. Bradford NK, Caffery LJ, Smith AC. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health. 2016;16(4):3808.  
  14. Hage E, Roo JP, van Offenbeek MA, Boonstra A. Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review. BMC Health Serv Res. 2013;13:19. doi:10.1186/1472-6963-13-19
  15. Marx W, Kelly JT, Crichton M, et al. Is telehealth effective in managing malnutrition in community-dwelling older adults? a systematic review and meta-analysis. Maturitas. 2018;111:31-46. doi:10.1016/j.maturitas.2018.02.012
  16. Scogin F, Lichstein K, DiNapoli EA, et al. Effects of integrated telehealth-delivered cognitive-behavioral therapy for depression and insomnia in rural older adults. J Psychother Integr. 2018;28(3):292-309. doi:10.1037/int0000121
  17. Karnoe A, Kayser L. How is eHealth literacy measured and what do the measurements tell us? a systematic review. Knowledge Management & E-Learning: An International Journal. 2015;7(4):576-600. doi:10.34105/j.kmel.2015.07.038
  18. De Rosis S, Nuti S. Public strategies for improving eHealth integration and long-term sustainability in public health care systems: findings from an Italian case study. Int J Health Plann Manage. 2018;33(1):e131-e152. doi:10.1002/hpm.2443
  19. Alami H, Gagnon MP, Wootton R, Fortin JP, Zanaboni P. Exploring factors associated with the uneven utilization of telemedicine in Norway: a mixed methods study. BMC Med Inform Decis Mak. 2017;17(1):180. doi:10.1186/s12911-017-0576-4
  20. Urueña A, Hidalgo A, Arenas ÁE. Identifying capabilities in innovation projects: evidences from eHealth. J Bus Res. 2016;69(11):4843-4848. doi:10.1016/j.jbusres.2016.04.041
  21. Hübner U. What are complex eHealth innovations and how do you measure them? position paper. Methods Inf Med. 2015;54(4):319-327. doi:10.3414/me14-05-0001
  22. Lennon MR, Bouamrane MM, Devlin AM, et al. Readiness for delivering digital health at scale: lessons from a longitudinal qualitative evaluation of a national digital health innovation program in the United Kingdom. J Med Internet Res. 2017;19(2):e42. doi:10.2196/jmir.6900
  23. Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4:67. doi:10.1186/1748-5908-4-67
  24. Emerson K, Nabatchi T, Balogh S. An integrative framework for collaborative governance. J Public Adm Res Theory. 2012;22(1):1-29. doi:10.1093/jopart/mur011
  25. Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. Integration of targeted health interventions into health systems: a conceptual framework for analysis. Health Policy Plan. 2010;25(2):104-111. doi:10.1093/heapol/czp055
  26. Brinkerhoff JM. Assessing and improving partnership relationships and outcomes: a proposed framework. Eval Program Plann. 2002;25(3):215-231. doi:10.1016/s0149-7189(02)00017-4
  27. Kenny A, Hyett N, Sawtell J, Dickson-Swift V, Farmer J, O'Meara P. Community participation in rural health: a scoping review. BMC Health Serv Res. 2013;13:64. doi:10.1186/1472-6963-13-64
  28. Jagosh J. Retroductive theorizing in Pawson and Tilley's applied scientific realism. J Crit Realism. 2020;19(2):121-130. doi:10.1080/14767430.2020.1723301
  29. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. doi:10.1186/1475-9276-12-18
  30. Schneider H, Lehmann U. From community health workers to community health systems: time to widen the horizon? Health Syst Reform. 2016;2(2):112-118. doi:10.1080/23288604.2016.1166307
  31. Näverlo S, Carson DB, Edin-Liljegren A, Ekstedt M. Patient perceptions of a Virtual Health Room installation in rural Sweden. Rural Remote Health. 2016;16(4):3823.
  32. Carson DB, Lundmark L, Carson DA. The continuing advance and retreat of rural settlement in the northern inland of Sweden. J North Stud. 2019;13(1):7-33.
  33. Carson DB, Schoo A, Berggren P. The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries. Health Policy. 2015;119(12):1550-1556. doi:10.1016/j.healthpol.2015.08.001
  34. Woods M. Rural Geography: Processes, Responses and Experiences in Rural Restructuring. London: SAGE Publications; 2005.
  35. Shucksmith M. Re-imagining the rural: from rural idyll to Good Countryside. J Rural Stud. 2018;59:163-172. doi:10.1016/j.jrurstud.2016.07.019
  36. Pawson R. The Science of Evaluation: A Realist Manifesto. Thousand Oaks, CA: SAGE Publications; 2013.
  37. Swedish Association of Local Authorities and Regions (SALAR). Chart for the Regions. SALAR; 2020. https://skr.se/ekonomijuridikstatistik/ekonomi/sektornisiffror/diagramforregionerna.1883.html. Accessed 20 March, 2020.
  38. Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Med. 2016;14(1):96. doi:10.1186/s12916-016-0643-1
  39. Pawson R, Tilley N. Realistic Evaluation. London: SAGE Publications; 1997.
  40. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  41. Manzano A. The craft of interviewing in realist evaluation. Evaluation. 2016;22(3):342-360. doi:10.1177/1356389016638615
  42. Mukumbang FC, Marchal B, Van Belle S, van Wyk B. Using the realist interview approach to maintain theoretical awareness in realist studies. Qual Res. 2020;20(4):485-515. doi:10.1177/1468794119881985
  43. Kazi MAF. The contribution of realist evaluation for practice. In: Realist Evaluation in Practice. London: SAGE Publications; 2003:158-167. doi:10.4135/9781849209762
  44. Pawson R, Sridharan S. Theory-driven evaluation of public health programmes. In: Killoran A, Kelly MP, eds. Evidence-Based Public Health: Effectiveness and Efficiency. Oxford: Oxford University Press; 2009:43-62.
  45. Mukumbang FC, Marchal B, Van Belle S, van Wyk B. A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa. BMC Med Res Methodol. 2018;18(1):47. doi:10.1186/s12874-018-0503-0
  46. The RAMESES II Project. What is a mechanism? What is a programme mechanism?: The RAMESES II Project—Resources and training materials for realist evaluation; 2017.
  47. The RAMESES II Project. Retroduction in realist evaluation: The RAMESES II Project—Resources and training materials for realist evaluation; 2017.
  48. Shucksmith M, Brown DL. Routledge International Handbook of Rural Studies. Abingdon: Routledge; 2016.
  49. Blom B, Morén S. Analysis of generative mechanisms. J Crit Realism. 2011;10(1):60-79. doi:10.1558/jcr.v10i1.60
  50. Dalkin SM, Greenhalgh J, Jones D, Cunningham B, Lhussier M. What's in a mechanism? development of a key concept in realist evaluation. Implement Sci. 2015;10:49. doi:10.1186/s13012-015-0237-x
  51. Farmer J, Munoz SA, Threlkeld G. Theory in rural health. Aust J Rural Health. 2012;20(4):185-189. doi:10.1111/j.1440-1584.2012.01286.x

Files

History

  • Receive Date: 07 July 2020
  • Revise Date: 27 January 2021
  • Accept Date: 30 January 2021
  • First Publish Date: 09 February 2021

Share

How to cite

Statistics