Adapting the Community Paramedicine at Clinic (CP@clinic) program to a remote northern First Nation community: a qualitative study of community members’ and local health care providers’ views

ABSTRACT

The views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada on their health care landscape and adapting the Community Paramedicine at Clinic (CP@clinic) Program to their community are presented. Key informant interviews took place between September 2020 and March 2021, and were thematically analysed using the Framework Hierarchical Analysis. There were seven themes that emerged with many subthemes: available services in the community, health care access, health challenges in community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic program considerations for adaptation. CP@clinic program considerations for adaptation included defining the role of CP, refining referral processes to capture the target population, advertising and promoting, ensuring community awareness, determining clinic setting and composition, focusing on advocacy and timely continuity, adding to the program through time, managing resistance, engaging community and partners, deploying cultural training and language accommodations, leveraging community assets, and ensuring sustainability. Focusing on continuity, engagement, and leveraging available resources may support the success of the CP@clinic program implementation. Findings from this study may be useful to other underserved communities in Canada seeking health programming.

KEYWORDS:

• Chronic disease
• community paramedicine
• delivery of health care
• emergency medical technicians
• Indigenous health services
• primary health care
• rural health

Introduction

Access to health care varies across Canada and is lower in rural and remote areas [1]. Although 18.6% of the population live rurally [2], only 7.6% of physicians live there [3]. Indigenous people, including First Nation, Métis, and Inuit, represent 65% of rural dwellers in Canada [4]. This population experiences disproportionate health disparities not only due to their significant remote dwelling but also as a result of colonisation and marginalisation [5]. Rates of chronic conditions are higher among Indigenous than non-Indigenous Canadians, including diabetes and frailty [6,7]. Frailty involves a person’s increasing vulnerability to stress that leads to physical and/or functional decline [8]. Recent reports call for investigation into the experience of accessing health care and ageing well in (remote) First Nations communities in Canada [6,9]. Given the lack of physicians in rural and remote Indigenous communities in Canada, approaches to improving health care in these areas could make use of other available health providers, such as paramedics.

Community Paramedicine is an emerging field in Canada and elsewhere involving paramedics using their skills and additional training to address community-specific health care gaps and improve access to services, especially among vulnerable populations such as older adults and those with complex chronic conditions [10,11]. The Community Paramedicine at Clinic (CP@clinic) Program is a standardised evidence-based health risk assessment, chronic disease management, and health promotion program delivered in social housing buildings by Paramedic Services across Ontario and Canada [12]. Through individual CP@clinic sessions, paramedics assess the health of older adults (e.g. blood pressure, diabetes, falls risk), provide health education and promotion, refer them to health care and community services, and communicate health information to their primary care providers (e.g. family physicians) [12,13]. The CP@clinic program has been found to reduce chronic disease risk factors (e.g. blood pressure), reduce emergency 911 calls (by 25%) [14], and improve frailty-related outcomes (e.g. self-care, usual activities, decrease pain and discomfort) [15].

CP@clinic, which shows success in addressing health needs of older adults in urban centres in Ontario and Canada, may also benefit rural and remote First Nation communities by reducing frailty of older adults and improving health and quality of life. First, the program should be adapted with community members and leaders to their cultural context, specific health challenges, and available resources. The aim of this study was to elucidate the views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada for the purpose of understanding their health care landscape and adapting the CP@clinic program to their community.

Materials and methods

Design and setting

A qualitative study involving key informant interviews was conducted to elicit the views of community Elders (First Nation community members who are highly respected given the culturally-specific knowledge they possess and the guidance they provide others in their communities) and health care workers residing (or working) in a rural remote First Nation community in Ontario, Canada about adapting the CP@clinic program for this population and setting. Interviews took place between September 2020 and March 2021 and were audio-recorded with consent.

Recruitment

Community Elders were invited to participate in an interview via a radio announcement by the Principal Investigator during the local bingo program and a print advertisement that was posted in the community. Health care workers were recruited through email invitations sent to health and home care organisations in the community (e.g. Paramedic Service, Home Care, Canadian Red Cross, Local Health Integration Network, and Public Health), inviting each organisation to designate a representative to provide an interview. Some health care workers were recruited through snowball sampling which is an appropriate method to ensure participation of all relevant perspectives, especially in a context that is less known to the research team and in a small interconnected community such as the community of study. A total of six community members and seven English-speaking healthcare workers volunteered to be interviewed.

Participants

Community Elders who were 60 years of age or older, identified as Indigenous, and were able to speak English. Health workers resided and/or worked in the community and were able to speak English.

Data collection

The key informant interviews were completed via telephone by two research team members, JA and AZ. Respondents were asked demographic questions (age, sex, Indigenous affiliation etc.) as well as their perspectives on the health needs of older adults in their community, reasons for frailty, and health resources currently available in the community. Respondents were also provided the CP@clinic program description and asked about suggestions that they may have for delivering the program, given their knowledge of the community and their own lived experiences. Interview recordings were transcribed by an official transcription service.

Data analysis

Transcripts were thematically analysed by AK using a word processor through iterative coding underpinned by framework analysis which was chosen for its hierarchical organisation of interview excerpts into themes and subthemes. AK developed a codebook to reflect this process which consisted of all interview excerpts organised into themes and subthemes. Themes, subthemes, and codes were validated by GA, FM, and MP and were further deliberated in full-team discussions. Following analysis, all respondents were contacted with permission by AK via their preferred method (email, mail, telephone) to validate study results. Respondents were asked to rate the accuracy of the results and explain what they would change, if anything.

Ethics approval

This study was approved by the Hamilton Integrated Research Ethics Board #11110

Results

Five of the six community members and seven of the seven health care workers who volunteered were ultimately interviewed. The community members were mostly Indigenous older adults in the community that do not have employment experience in healthcare. They varied in their sex, age, and marital status as shown in Table 1. Health care workers were mostly non-Indigenous younger adults that had six or more years working in the medical field and consisted of health care professionals from a paramedic service, a Local Health Integration Network (LHIN), a hospital geriatrician, an employee at the Canadian Red Cross, and a Public Health employee. They varied in their sex, age, Indigenous affiliation, and years working in health care as shown in Table 2.

Table 1. Summary of community member characteristics.

Characteristic	Categories	No. of respondents
Sex		n = 5
	Female	4
	Male	1
Age		n = 5
	60–70	2
	70–80	3
Self-identification		n = 5
	Indigenous	4
	Non-Indigneous	1
Marital Status		n = 5
	Married	2
	Single (e.g. widowed, divorced)	3

Table 2. Summary of health care workers characteristics.

Characteristic	Categories	No. of respondents
Sex		n = 7
	Female	5
	Male	2
Age		n = 7
	30–50	5
	50 +	2
Self-identification		n = 7
	Indigenous	2
	Non-Indigneous	5
Years working in health care		n = 7
	6–10	4
	10 +	3

Seven major themes were identified through the aforementioned analysis including available services in the community, health care access, health challenges in the community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic considerations for adaptation. The themes and subthemes are shown in Table 3 alongside illustrative quotes and are further contextualised in the narrative description below. Respondent validation was achieved with eight respondents (four community members and four health care workers). One community member and three health care workers could not be reached by the study team. The process of validation has provided the opportunity to add two subthemes and confirm a high level of accuracy perceived by respondents.

Table 3. Illustrative quotes.

Themes & Subthemes	Illustrative direct quotes
1. Available Services in Community
(A) Health care services	The clinic … []… they don’t have a doctor. Well, they have the nurses here and a nurse practitioner, but if you’re really in need, like you know you very seriously need hospitalisation, then they take you over to the [hospital across the river] or they [air transfer] you out [of the community]. (Community Member [CM] 3)
(B) Home/community services	So there’s the homecare program which is through the [organisation]. And then there’s the Red Cross program you might have mentioned, and they have a few different workers. And then our, the one church, the soup kitchen does reach out to the Elders. (Health Care Worker [HC] 106)
2. Health Care Access
(A) Limited local primary care	… a lot of preventative stuff is not done in these communities as well as it could be because things are not accessible. (HC 2)
(B) Limited local secondary and tertiary care	And with the lack of care, because our hospital isn’t up to standard, so often patients have to be flown out to [other cities] for a higher level of care; so that kind of affects their health as well, living in an isolated community. So that causes more complications. (HC 1)
(C) Limited local home and community care	So we don’t have enough PSW [personal support worker] support to keep people at home; so they’re more at risk at home without the PSW. So the PSWs are performing all the ADLs [activities of daily living] and helping with some IADLs [instrumental activities of daily living], and if that’s not done, then their basic needs aren’t met and they’re not able to stay there safely, so they will usually have a lot of falls; they will be at risk for frequent infections. (HC 2)
(D) Challenging hospital access	We have a clinic on this side, it’s like a nursing station. They don’t even have a doctor. They bring a doctor in from the hospital once a week for medical appointments, stuff like that. The hospital is [across the water]…. In the summer, you go all the way down to the other end of town to the dock; they put you on the hospital boat, on the stretcher, and you go up to the hospital. Then they pick you up by ambulance. And it’s a rough ride if you’re hurt. I’ve been on it. And then you see the doctor in [the hospital across the water]. And if something is wrong, then they put you back in the ambulance, take you back down to the dock, put you back in the boat, pick you up by an ambulance on the other side and then to the airport, and then at the airport they fly you to [other communities]. (CM 5)
(E) Need to travel for care	So, without having everything available in the [community], these clients have to be flown out, travel multiple ambulances, multiple different aircrafts, maybe helicopter, or plane, to go out for a 15-minute follow-up appointment in [a city] to see how their broken leg was doing. (HC 100)
(F) Limited mobility makes travel difficult	It is hard to get people out from here. We used to have rheumatology come up, a lot easier for people with rheumatoid arthritis and [other forms of arthitis] that make mobility hard. They won’t travel. Some people won’t travel. (HC 2)
3. Health Challenges in Community
(A) Lack of continuity and follow-up	There’s no consistency in the care… They see a new face every single time that they go to the clinic, and that new face doesn’t know their backstory. And I think that’s a real problem for everybody in our community but especially Elders, because they’re having to start over every single time they see somebody. So instead of making progress and moving forward with getting their health issues under control, it’s more like … maintenance each time. (HC 7)
(B) Social isolation and limited technology	And our older adults are not as tech savvy, so they’re missing all these virtual opportunities that keep being suggested. They don’t get to take part in those things very much; so they’re very lonely right now. (HC 106)
(C) Few programs and services for seniors	We don’t have a lot of programming in [the mainland community] for older adults … Their Friendship Centre – they used to have a Healthy Aging Coordinator, but that’s been kind of a transient role as well. So there hasn’t been a lot going for older adults. (HC 7)
(D) Poor infrastructure	The roads … . Oh, well, it’s awful to walk down the street … There’s some big rocks there. I walk with a cane and it’s very unstable. (CM 6)
(E) Care avoidance	There is probably some Elder sitting somewhere that probably should be talking to a health care provider right now in [the community], right, but they just feel like they are wasting people’s time. (HC 5)
(F) Language barrier	But still, the Elders… even if they speak pretty good English, if there [are] medical assessments [to be] done and medical discussions [to be had], [First Nation language] is their first language, so [we] find a translator … And there is not always a proper translation for proper medical terms. (HC 2)
(G) Impacts of residential schools and trauma	And with the history of, you know, of the residential schools and the trauma and the multigenerational trauma, you start finding that a lot of Elders, for example, will refuse personal care … And it leads to things. It leads to foot issues, and skin breakdown and, you know, even the sense of self. (HC 4)
(H) Limited nutritious food affordability	Some of the chronic diseases, because of the lack of nutritional food and the price of food and lack of work, there tends to be a higher number of diabetes patients. (HC 1)
(I) Frailty and complex or chronic conditions	So we see a lot of, I guess, cardiac issues, a lot of CHF, COPD; hypertension is quite prevalent in this area, as well as diabetes and obesity … and mental health is probably the biggest one. (HC 1)
4. Causes of Frailty
(A) Lack of education provided	I think with frail adults sometimes it’s the lack of help from family and practitioners, as well as their overall health and nutrition. It starts at a young age at school where the education just isn’t up to par in [this] area, so they don’t get the health and nutrition education that they usually do. (HC 1)
(C) Stroke and cancer	Some of my friends, severe strokes, you know, that have disabled them. And then cancer, when I think of our church family and people we’ve lost. (CM 4)
(D) Poverty and inadequate living conditions	Yeah, so the other thing I didn’t really stress for frailty, of course, is money, poverty. Even with the money, you know, I find that makes a big difference for something as simple as just having a bed. (HC 4)
(E) Pandemic exacerbation	Since all the COVID stuff started, [they have] stopped walking that distance, [they have] been sitting for most of the time so [they have] developed some contractures in [their] legs which causes more pain (HC 2)
5. Health Care and Community Appreciations
(A) Positive clinic experiences	Yeah, the clinic is fantastic. Oh, it is. It’s just the people [who] make the difference. And you can tell the workers, the health care workers here, they want to be there. I have to say they’re really good. (CM 5)
(B) Strong sense of community and connection to the land	I like that sense of community, that smallness of the community. (CM 4)
(C) Intergenerational living and support	… their children worry about them so they make them appointments or they try to keep them on the right track … (CM 3)
(D) Positive perception of paramedics	Well, if the paramedics that I know are part of this program, I think it would be successful, for sure. We have some really good paramedics. Very personable. (CM 4)
6. Community-Specific Benefits of CP@clinic
(A) Fill care gaps and increase access	And we have one home care nurse in the community; so there is quite a gap of Elders, older adults, that don’t get that much care and some that haven’t seen a doctor in years. I think having a CP@clinic would be beneficial to maybe find these people that are lost without care. (HC 1)
(B) identify health issues otherwise unaddressed	If there are people that have any kind of issues and they go to the CP clinic, they are going to be found a whole lot easier than going to a doctor’s appointment where you have got 15 minutes to tell them exactly what the problem is today and nothing more than that. (HC 2)
(C) Overcome care avoidance and improve continuity	And I think with [CP@clinic], when you’re going there and you’re sitting down with them, and you’re kind of just there for them during your visit, it almost makes them feel like, okay, now there is someone here that’s I can share this information with. Because, you know, there is probably some Elder sitting somewhere that probably should be talking to a health care provider right now in [the community], right, but they just feel like they are wasting people’s time. And I think [CP@clinic] can help bridge that gap. (HC 5)
(D) Support medication management and education	And I think just, you know, with the health care system up here, just with my experience, there seems to be a lot of miscommunication, misinformation given to a lot of older adults here – little things [such] as explaining their medications to them, access to getting the refills, letting them know that they have to go pick up refills, making sure clients follow up on their health status, not just do a CT scan and never find out the results. (HC 1)
7. CP@clinic Program Considerations for Adaptation
(A) Defining the role of CP	I kind of think of CP more as the work that you could do before it turns into an emergency and trying to make sure that we’re catching that before it turns into, “We need the paramedics right now”, and someone is having an acute issue. (HC 5)
(B) Possible referral processes to capture target population	And then another way we can get clients … would be referrals from the actual health centre, which would be probably a nurse practitioner or physician that would recommend our services, as well as self-referrals. After a paramedic call we can kind of self-refer them to our program so we can continue to monitor them and their health status. (HC 1)
(C) Advertise and promote	The easiest way is by mouth. Facebook, not a lot of the Elders or people are going to be watching Facebook for something like this. Posters – our people still [look] when they go to [the grocery store], they want to look at posters that are up and the announcements. But for some of our people that are not able to read either because they are illiterate or their vision is gone and they can’t read, then by word of mouth is the next best thing. (HC 2)
(D) Community awareness of program and how to access	People need to know that paramedics can help with this and that – they need to be given a heads up. People are not used to thinking of themselves. People should make use of the program. (CM 4)
(E) Home vs community clinic setting	Yeah, well, some of them would be in the homes. Like I say, some of them, you know, like older people, they don’t have access to vehicles. Mostly here they would probably have to call a cab or a family member that would drive them. It probably would be good too if they had one at the building. I don’t know, if a family member could drive you there, but maybe the home too. I think it would be two ways. (CM 3)
(F) Group vs individual clinic	I’m wondering if you had, say, smaller groups of five or six. And then there are certain places in town, like you could put people together and keep them six feet apart, deliver the program. Like say, I’m in the program with you watching it, and then you say, oh there’s this exercise that does this, or, oh wait there’s one. (CM 5)
(G) Focus on advocacy and timely interventions	One challenge that I see and I’m sure the local, the people that are working with the paramedics and programs probably already know this, but because we don’t have family doctors here, the challenge would be any findings would be reported to our clinic, and then it’s just the challenge of it’s always someone different looking at their charts, and not always reviewing the past information in charts. It’s an ongoing problem here. So I think it might be unique compared to other communities in that there might need to be more advocating going on to make sure that things that have been assessed in past visits or sessions with older adults still get brought forward (HC 7)
(H) To add to assessments	I’ve heard, you know, through like partners with other programs and stuff, some of our Elders have a hard time cooking for themselves, so they’re not always eating as well as they once used to, simply because maybe, you know, maybe it’s mobility issues, they can’t handle carrying a pot of water to the stove or things like that. So I think it’s something, an important aspect to be looked at during the visits with Elders. (HC 7)
(I) Change management for resistance	Some of our medicks are kicking around going, “Yeah, I don’t want to do this”.… And I think we would avoid those ones right off the bat until they heard by word of mouth what a great program it is … .Yeah, I know that a lot of paramedics sign up for, you know, the emergency care roles so when they hear about community paramedics then it’s like, oh. (HC 4)
(J) Community engagement and partnerships	Probably because I know a lot of the, not just paramedics, but I mean everybody that comes from the south up here are going to have their own idea of what each community is like, and they’re going to assume what each community is like before they even get there, but it’s not going to be anything like what they think it’s like. If you have never been in these communities before, you are not going to have any clue. (HC 2)
(K) Cultural training and language accommodations	They do have cultural sensitivity training, but a paramedic visit is into the house, assess the patient and transport them and release them…But I think it wouldn’t hurt to continue on their journey of a cultural and health … pre-hospital care. Because I have done both and there is a big difference. I have been the homecare nurse and the paramedic in a community at the same time. They’re two different visits and two different patient interactions. So, you know, it’s a bit to learn. (HC 4)
(L) Leverage community assets	That’s another issue. … this is something the paramedics can see. Wheelchairs are a real problem. If it’s broken, it’s taped together, and say, “Can somebody fix this for this guy? Can somebody figure out the problem?” (HC 4)
(M) Sustainability	Planning needs to account for sustainability – minimise turnover of staff and variability in program delivery (HC 3)

Available services in community

Respondents explained that locally available health services include a primary care clinic (staffed with a nurse practitioner), home care nurse, women’s clinic, public health clinic, (providing programs regarding neonatal care, vaccinations, mental health and addictions, etc.), pharmacy, and hospital. There are other services periodically available to the community such as a foot care nurse, diabetes educator, and geriatrician. Regarding community services, respondents described a variety of services ranging from home support, Red Cross (providing social programming, transportation etc.), senior supports (including assisted living), two community centres (Indigenous-driven day programming), gym and recreation activities (such as the arena), community-oriented church programs (including a soup kitchen), and shelter and victim services. Of note, respondents highlighted how the services available in this community are often less structured and programmed when compared to larger cities in Canada.

Health care access

Respondents described the overall limited availability of primary, secondary, and tertiary care within their community. One respondent expressed concern that preventative care opportunities are often missed since primary care is not accessible, resulting in the escalation of health problems. This limitation extends to home and community services. A lack of home care and allied health providers (personal support workers, social workers, occupational therapists, etc.) compared to larger cities means that community members in need of services may live at risk in their homes. Some respondents described long wait times for specialised services and clinic appointments, while others felt that wait times have improved in recent years. The only available hospital is across a body of water. Accessing the hospital is easier in the winter (by driving on the ice) and summer (by boating across the water) than in the spring and fall (i.e. during ice melt and formation), which requires travel by air (facilitated by helicopter shuttle 3–5 times per day). This transportation can be challenging, especially for community members with mobility difficulties who cannot mount and dismount a helicopter or boat/taxi unassisted. Some community members commute to the hospital across the water many times per week for health treatments (e.g. dialysis). Other speciality and tertiary health services are not available in the community, so residents must travel to larger cities for treatment. This includes optometry/ophthalmology, labour and delivery, orthodontics, operations/surgery, appointments (including follow-ups), and others. Travelling outside of the community for health care can be complicated due to weather (which may delay flights), mobility challenges (which require medical evacuation and escort), costs (since flights are chartered only for people who are Status First Nation), and fear of flying/boating among some.

Health challenges in community

Stemming from the aforementioned lack of available health services in the community (including family physicians), most respondents expressed concern about continuity of care. This is a source of frustration among respondents and is described as a barrier to improving health since knowledge of patient histories may be lacking when attended to by different health providers at each encounter. Respondents also described follow-up for health issues to be long or sometimes missed. For example, one respondent did not receive essential lab results for more than a year. Another respondent felt that poor mental health was prevalent among older adults which aligned with others concerned about loneliness among seniors, especially social isolation reinforced by lack of technology to facilitate connection. Similarly, many cited lack of social, recreation, and exercise opportunities/programs as cause for concern about the health of Elders. Infrastructure within the community was also described as a challenge. For instance, roads and sidewalks are not built for walking nor wheelchair use and many homes are difficult to access by wheelchair or stretcher. Internet in the community is not reliable, which can be challenging for virtual health care appointments and seeking health information. Another challenge observed by health care workers is that some Elders avoid seeking health or home care. They explained this behaviour as a result of not wanting to burden clinicians, fearing planes/boats, or perceiving hospitals as places of death. Many respondents tied low incomes and high costs of nutritious food (since groceries are delivered by freight) to poor health. Common health issues cited by respondents include cardiac conditions, diabetes, obesity, complex comorbidities, and the composite condition of frailty. Some Elders are more comfortable speaking their First Nation language and may face additional difficulties understanding health information, often delivered in English. And, one respondent described lasting impacts of residential schools, colonialism, and trauma that may result in care avoidance among Elders and the exacerbation of preventable health issues.

Causes of frailty

Respondents described poor diet and health management as contributing to frailty in their community, perhaps due to a lack of available health education and physicians. Multiple respondents also described poverty (e.g. lack of food and resources) and inadequate living conditions (e.g. overcrowding or isolation) as key drivers of frailty. These factors influence a person’s function through poor nutrition, increasing risk of falls, loneliness, and lack of essential needs (e.g. bed, mobility device). Some respondents described how the COVID-19 pandemic has exacerbated and accelerated functional decline among seniors in their community. For example, one resident had become bedridden since the pandemic whereby lockdowns and restrictions brought an end to their daily walks. Given these health challenges, respondents were keen to consider the implementation of a novel community paramedic-led chronic disease prevention and health promotion program.

Health care and community appreciations

Despite difficulties accessing care, respondents shared appreciation for their community and health care workers. Many described positive experiences at the clinic and especially appreciated the clinic staff and their efficiency. When speaking about what they liked about their community, a common theme among respondents was its strong sense of community, including respect for the Elders, informal gatherings, and church groups. Intergenerational living and support was described by some as a protective factor for Elders in the community to ward off the impacts of isolation during the pandemic, particularly amongst seniors, many of whom live alone. Others mentioned their appreciation for nature with access to land and water. One respondent, in particular, was impressed with the paramedics in the community and felt that they would do well to implement the CP@clinic program.

Community-specific benefits of CP@clinic

Respondents described multiple ways that CP@clinic would benefit their community and address the challenges presented. Notably, such a program would fill longstanding gaps in health care services for Elders; there are currently few opportunities to address their health needs since few health care providers are available and continuity is poor. A specific example from one respondent highlights the need for more accessible and reliable blood pressure measurement opportunities, which CP@clinic would provide. According to respondents, the additional visits and opportunities to discuss health issues with a health care provider, both through formal visits and informal discussions, would significantly improve the health of community members. Respondents also described how the program may help uncover unknown or unaddressed health issues and improve timely health care response when a person’s health status changes. One respondent felt that the dedicated role of community paramedics and the accessible format of CP@clinic, delivered in participants’ homes, may encourage older adults to share their health concerns and increase their uptake of health care (e.g. attending check-ups), thereby addressing the aforementioned health challenge in the community – care avoidance. And, the potential for community paramedics to liaise with other health professionals, improve communication between the multiple (and often changing) health providers, and ensure that patients are provided timely follow-up was perceived as a substantial benefit that CP@clinic would bring to the community. Another way that CP@clinic may be helpful, according to respondents, is through improving medication management and compliance, providing education about health conditions and their medications, and supporting Elders to make medication changes, as needed.

CP@clinic program considerations for adaptation

Respondents provided valuable feedback about how the CP@clinic program could be implemented for optimal impact in their community. Many described how they see the role of community paramedics as an extension of home-based primary care and a resource for support prior to emergency health events. Some respondents described specific examples of what community paramedics could do in the community, including assisting with flu shots and supporting housing applications.

Regarding referrals, respondents felt that the program should target many groups including those who are ineligible for home care yet need support, have mobility issues, have difficulty managing their medications and are not regularly attended to by health care workers, who call 911 often, and those who are socially isolated and experience frequent exacerbation of their conditions. One idea presented is for community paramedics to attend the soup kitchen and connect with community members who are likely low-income and may face additional health challenges as a result. Others suggested strategies for recruitment, including advertising by word of mouth, Facebook, physical posters (e.g. at the grocery store, post office), participating in/presenting at formal social gatherings (Red Cross, Friendship Centre), spreading awareness through the clinic and hospital, and having community paramedics visible in the community and initiating conversations. According to one respondent, the goal should be for community members to know what community paramedics can offer to be able to call in and request support themselves.

When discussing the implementation of CP@clinic, respondents considered if the program would be best delivered individually in people’s homes or in community spaces. Some respondents felt that meeting with a community paramedic in the community, such as in the common room of a seniors apartment building, would be valuable. One respondent felt that group interventions with community paramedics would be useful as an opportunity for collective learning and empowering social aspects of wellness (e.g. accountability, group exercise). Still, home visits were described by many as beneficial to ensure that vulnerable community members are attended to since it is an accessible form of care (i.e. requires no transportation, which can be expensive and a barrier to accessing care).

Respondents shared considerations specific to the content of the CP@clinic intervention. Multiple respondents felt that the clinic should focus on solutions that can be implemented promptly, given resource constraints in the community – that is, conducting assessments and referring to services that are readily available in the community as opposed to specialised services available once a year. Many felt that the program should focus on advocating for patients within the health system and one added that paramedics should teach patients to advocate for themselves given their observation that Indigenous people might not complain since they are not used to having a voice in colonial systems. Respondents generally felt that the program, as described, was comprehensive. Some described certain items that they would like to see addressed such as assessing the adequacy of mobility devices, social determinants of health (e.g. lack of food/nutrition, poor living environment), and elder abuse/neglect. One respondent felt that additions to the program might need to be made after starting the program, based on observation and feedback.

Respondents also provided social and cultural considerations. For instance, one respondent described the need for change management in response to some resistance reported among paramedics to fulfil this role. Multiple respondents spoke about the importance of engaging with the community by empowering Elders with various life experiences as advisors to CP@clinic. Others spoke about the need to understand the community and consider cultural aspects such as the timing of trapping season which could limit participation at certain times of the year. One respondent suggested including cultural sensitivity training for paramedics in this new role since it involves a new kind of patient interaction in a low-acuity role compared to when attending to emergencies. Anti-racism Indigenous cultural safety training is being completed by the local paramedic service. Other respondents described the need for someone fluent in the local First Nation language to be available for the CP@clinic program to accommodate for community members’ most comfortable language in health interactions (e.g. medical assessments). Other community assets that respondents felt should be considered for this program include the community network. That is, for the skills of community members and other health care workers to be put to use to cover gaps such as ensuring health coverage when a caregiver is away or fixing broken wheelchairs. Lastly, in pursuit of a sustainable successful program, one respondent described the importance of minimising staff (i.e. community paramedic) turnover and promoting program fidelity.

Discussion

This study sought to understand the perspective of local health care workers and Elders regarding the health care landscape and potential application of the CP@clinic program in their community. Respondents of this study described limited health and home care services in their community resulting in health challenges such as poor continuity of care and follow-up – factors which negatively impact the health of community members. The intersection of poverty, high cost of living, limited resources, poor infrastructure, and health and wellbeing were prominent in the results of this study. Still, appreciations for health care providers and an overall sense of community were strong and consistent among respondents. Regarding the application of CP@clinic in the community, respondents felt that the program could be beneficial, especially by providing additional care in an underserved area. It was also perceived by respondents that CP@clinic could increase care-seeking behaviour and improve medication management and blood pressure monitoring. Lastly, respondents provided considerations for the adaptation of CP@clinic to their community including how to target people in need, where to implement the program, and what aspects of health care to focus on.

Accessible health care, a focus of this study, is that which is available, acceptable, accommodating, affordable, physically accessible and for which there is awareness and culturally safe communication [16–18]. Similar to our study, other studies have found that limited availability of health professionals and geography can create barriers to accessing health services in rural and remote Indigenous communities [19]. For example, a recent scoping review found that geography impacts Indigenous communities since limited on-site health care means that people must travel for many levels of care, which can result in treatment delays due to weather or other barriers (e.g. financial and time cost to travel) [20]. Similar to what was described by respondents in this study, appreciation for one’s community, or “community belonging”, is described in the literature as part of rural culture [19]. In the literature, this sense of belonging can both improve health when neighbours are looking after one another and it can impair health if stigma creates barriers to seeking help [19].

There are also differences between the findings from this study and the literature. Not mentioned in this study, though prevalent in the literature, is the effect of negative bias from health care providers towards Indigenous people who continue to be harmed by colonisation and intergenerational traumas [20]. This discrepancy may be explained by health care providers in the community of study being Indigenous themselves and/or absent of negative bias, given the appreciation described towards health care providers in the community by respondents. Still, negative bias may not have been mentioned by respondents given the sensitive nature of the topic and the format of the interviews which took place over the phone with non-Indigenous interviewers. Possible program-level mitigation strategies for negative bias include completing cultural competency and sensitivity training (currently underway for all paramedics in the community of study), hiring Indigenous staff, and providing cross-cultural training [20].

There is some alignment between program adaptation suggestions from respondents in this study and those found in the literature. Similar to what respondents described as the need for community engagement, Indigenous governance is described elsewhere as essential for culturally accessible care [21]. Another consideration discussed by one respondent and found in the literature is the challenge of recruiting and retaining health care workers in rural and remote communities in Canada [20]. Although a high proportion of Indigenous health care workers return to their home communities to work [22], only 1.2% of all Canadian health care professionals are Indigenous [23]. For the sustained success of the program, strategies for retaining program implementers and leaders should be identified and deployed.

In future steps of adapting the program, considerations should be made to leverage the strong sense of community and other community assets for the CP@clinic program. Increasing community engagement with the program could further support its integration and sustainability through fostering a sense of community ownership [24]. Drawing on results from this preliminary study and discussions with partners, community-based co-design of adaptations would support the integration and success of CP@clinic in this community of study. For instance, the incorporation of an Indigenous Patient Navigator, who is peer trained in medical terminology and able to facilitate communication and navigate the health system, may help mitigate barriers discussed and support the culturally appropriate adaptation of this community paramedic-led program to the rural remote First Nation community of study [20].

Gaps and future directions

Future work will include further defining and operationalising adaptations through community-based discussions. The potential implementation of an adapted CP@clinic program in a rural and remote First Nation community does not operate in a vacuum. Rather, other efforts to improve health, such as diabetes management, should consider the persistent effects of racism and colonisation (e.g. land removal, intergenerational trauma, diet and lifestyle) [7]. Ultimately, there are many barriers and challenges that Indigenous peoples in Canada face regarding access to health care beyond this program of study. Work remains to be done to address the root causes of health disparities in Canada and close the gap by improving the health of vulnerable populations [20]. Moreover, an effective home-based program could benefit international Indigenous communities as well given that the themes and subthemes identified by responders (i.e. healthcare access and availability, and health challenges in the community) are not unique to Canada. In considering the applicability of these findings to other communities, it is important to be cognisant that Indigenous populations are diverse with unique cultural practices, languages, and beliefs.

Limitations

The sample size of this study is relatively small. This is perhaps explained by the COVID-19 pandemic resulting in difficulty recruiting community members (who were staying home) and health care workers (who faced competing public health priorities). Still, the importance of this study and the rich findings from the interviews are valuable as an initial exploration into the health landscape of the region. As mentioned in the discussion, respondents described positive interactions with health care providers in their community. It is possible that self-selection increased the representation of such positive views.

Few health care providers in this study identified as Indigenous. This may limit their insights into Indigenous considerations and perspectives. Although the non-Indigenous identities of most of the health care workers may impact their perspectives on the reasons behind various healthcare seeking behaviours of the community members, we believe that the health care workers have gained significant first-hand knowledge of the challenges experienced by and viewpoints of the community members by residing and working in the communities. The sample of respondents reflects the available health care workers in the region and therefore their views and considerations are valuable and relevant, coupled with the views of Indigenous Elders captured in the sample of community members.

Given the virtual interview format of this study (as a result of pandemic restrictions) instead of the planned in-person focus groups, in-depth and detailed adaptations and consensus among respondents are not provided. Determining adaptations to the program requires further investigation and discussion with partners to build consensus. Still, these results provide an appropriate starting place for such discussions and refinements.

Conclusions

This study aimed to understand and represent the perspectives of local Elders and health care providers about the health landscape of their rural and remote northern First Nation community and how it may impact the application of a chronic disease management and health promotion community paramedic-led program – the CP@clinic program. Results from this study could be useful to both the implementors of the program and other communities interested in such a program. With a focus on promoting continuity, building trust, and leveraging community assets, the CP@clinic program may provide a much needed service and contribute to improving access to health care in a rural and remote underserved First Nation community in Canada.

Geolocation information

This study took place in a rural remote First Nation community in Ontario, Canada.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Canadian Frailty Network (Technology Evaluation in the Elderly Network), under the Indigenous Health Grant (IH-011), which is supported by the Government of Canada through the Networks of Centre of Excellence (NCE) program.