Rural360: incubating socially accountable research in the Canadian North

ABSTRACT

People in Northern Newfoundland and Coastal Labrador (NNCL), Canada, face major challenges obtaining accessible and contextually-relevant healthcare. Rural360 is a socially accountable research incubator that provides funding for NNCL physicians to research solutions to these issues. NNCL graduates of the adjoined 6for6 research training program for rural physicians are invited to submit the research project they have conceptualised as part of that initiative as a letter of intent, and subsequently as a research proposal, to Rural360. These submissions are reviewed by relevant subject matter experts as part of the Rural360 adjudication process. This process is iterative and strives to guide and assist participants in refining their submission. The overarching objective of Rural360 is to collaborate with rural physicians to conduct, disseminate or otherwise catalyze unsupported community-based research in NNCL. In so doing, it is highly socially accountable, empowering participants to become change-makers who investigate contextually important health issues that emerge from NNCL communities.

KEYWORDS:

• Capacity building
• social accountability
• research skills
• physicianled
• community-driven
• Newfoundland and Labrador
• Canada

Main text introduction

Unprecedented climactic and socio-economic forces [1–4] are poised to exacerbate already considerable health disparities [5,6] endemic to the Circumpolar North. Accordingly, the Arctic Council, under Finnish and more recently, Icelandic leadership, has prioritised the wellbeing of the region’s citizens and communities [7,8], acknowledging their commitment to the Arctic people they ultimately serve. This position echoes social accountability, an approach popular with medical schools [9] and defined in this context as an “obligation to direct … education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve” [9]. Since then, this concept has proven itself a burgeoning measurement of success and a crucial planning tool for medical education initiatives [9], shifting the conversation of the value of programs toward how they “advance the health of the people and communities we serve” [9,10] and improve the capacity to respond to the needs and challenges of health care [11]. This is the vision of Memorial University of Newfoundland’s (Memorial) Faculty of Medicine (Canada), and the image in which our team set out to craft a suite of programs that empower rural physicians to research solutions to local health issues. Rural physicians have close relationships with their patients that allow them to understand local health needs and system challenges. With research training, they can learn to investigate these issues using a standardised approach and translate their findings into practice through evidence-based care or new models of practice [12]. Unfortunately, limited training in research skills, scarce funding, and a lack of research assistance can be major barriers [12,13], and these issues are particularly severe in the Northern regions of Newfoundland, and the seaboard and inlets of Labrador (Canada), collectively referred to as Northern Newfoundland and Coastal Labrador (NNCL). In 2014, the authors (from Memorial) took decisive action to address educational barriers with 6for6 [14,15], a research training program for rural physicians that uses a unique “six learners, six sessions, one year” design, empowering participants to learn research fundamentals and pursue a research project with a tailored curriculum, university resources, and mentorship. The 6for6 program succeeds in providing support to rural physicians to conceptualise and propose community-based and locally relevant research projects [12], but the dearth of research funding for rural health projects in Canada remains a challenge. This was the impetus for Rural360, an extension of 6for6 similarly crafted in the spirit of Memorial's social accountability vision. Founded in 2017, Rural360 collaborates with rural physicians to conduct, disseminate or otherwise catalyze financially unsupported community-based research in NNCL. In so doing, it strives to cultivate partnerships with healthcare providers and direct research, resources and services toward addressing rural healthcare needs. While educational programs that support rural physician-led health research are rare [16,17], to our knowledge Rural360 is the first university-based program to provide funds, resources and expertise to forge faculty-rural physician research partnerships that address healthcare issues. Here we describe the Rural360 program, its structure and processes, and results to date.

Rural360 program structure

Overview

Rural360 is an “incubator” for rural health research, facilitating access to resources (funding, expert feedback on proposals, facilitated collaborations with content experts) that allow rural physicians to bypass the barriers to research in NNCL. Rural360 is designed to nurture early proposals into full-fledged grant applications. This process favors continuous revision and approval over rejection, so the adjudication process is encouraging and helps participants learn and gain momentum as opposed to investing their limited time into an application that is outright denied. Rural360 is structured as a three-year initiative, which based on our experience delivering 6for6, is the right duration for a rural-focused research program to gain momentum and build brand-familiarity within the medical community.

Conceptual approach

The process begins with participants (NNCL physicians) having a question about a health issue or an idea about health system change that they have identified via their patients and/or community. Through 6for6, we assist them to each formulate a research question around their own concept. Participants become familiar with principles of community and patient engagement to ensure these elements are integrated into their projects. The capstone project for 6for6 is a research proposal. Rural360 is designed to pick up exactly at this point, providing candidates with resources (e.g. graduate assistant, librarian, faculty experts) to refine their proposal for eventual funding upon reaching an acceptable level of scientific rigour (as determined by a panel of experts). Rural360 links directly with 6for6, advancing ideas into fully realised projects through a “pathway” of support that covers all 360 degrees of the research process. This pathway ranks as highly socially accountable on the social obligation scale, [9] empowering participants to become change-makers who investigate contextually important issues defined alongside rural society. A positive impact on rural community health as evaluated by local health partners is ultimately the measure for success [9].

Eligibility

Rural360 is exclusively for physicians practicing in NNCL who are interested in conducting healthcare research for and about communities in these regions. Our program is open to any projects related to patient or system level health issues, although projects tend to align with the following subthemes, united by the common theme of social accountability – research for and about the health, healthcare and wellbeing of NNCL people and communities. These subthemes are:

• Indigenous Health: Projects (research, quality improvement or knowledge translation) pertaining to the health, healthcare and/or general wellbeing of Indigenous and/or First Nations, Métis, and Inuit people in NNCL.

• Community Engagement: Projects that meaningfully engage communities and citizens as partners in socially accountable research, aligned with local needs.

• Knowledge Translation: Projects focused on imparting research findings for the betterment of health, healthcare and/or wellbeing in NNCL.

• Healthcare Innovation & Outcomes: Projects examining novel approaches to healthcare delivery (e-health, telehealth, group medical appointments, etc.) related to the health of NNCL patients.

• Medical Education: Projects involving the study of medical education in the NNCL setting.

• Emerging Issues in Northern Health: Projects that address current and significant issues in NNCL health, but do not fit under the other five subthemes.

Application process

Letters of intent may be submitted any time but submissions and grants are limited to one per candidate. Once received, a committee provides feedback on each letter of intent to improve the submission. Rarely, a letter will be rejected due to an ineligible project or inadequately developed idea (for the latter, substantial feedback and an invitation to revise and resubmit accompanies the rejection). All other letters are returned to the applicants with feedback and an invitation to submit a full proposal. We also liaise applicants with academic faculty to form research teams around the projects, and with a graduate assistant to help develop the proposal, patient/community engagement strategy, and knowledge translation plan. Submitted proposals are sent to a panel of subject-matter experts for review, and from here reviews loop, with the review team returning comments to the candidate, who (with the help of academic faculty supported by a graduate assistant) addresses comments and returns an improved proposal to the review team. This continues until there are no further revisions. Once all feedback is addressed and the project obtains ethics approval, funds are released. All projects have a one-year scope, must include a citizen on their research team, and must translate their findings back to the community. We also require a progress report mid-way through the grant, and a final report. At the end of the project, Rural360 offers a second, smaller opportunity for funding to facilitate knowledge translation. To access this funding, participants must submit a new application describing their knowledge translation plan.

Funding route

Grants are available in two amounts: $15,000 (CAD) for a research project, and $7500 (CAD) for a knowledge translation project. This funding is in addition to the help we provide participants to develop publications and other materials for scholarly dissemination (e.g. posters, presentations). Rural360 is funded by the International Grenfell Association, a non-profit organization with a mandate of supporting initiatives that serve NNCL communities [18]. The 6for6 program, funded by Memorial’s Dean of Medicine, was instrumental to our funding proposal as it is a case in point that rural research capacity building is possible and can be highly successful. Together, our teams continue to champion rural, remote and Northern research within Memorial and beyond.

Evaluation

We will evaluate Rural360 after 3 years of delivery, using a logic model to map how the program uses inputs (e.g. money, time, staff effort) to drive activities, outputs and outcomes around NNCL research capacity, and an evaluation matrix to plan specific questions to be addressed with evidence. There will also be a particular focus on gauging the value of Rural360 in terms of research outcomes (e.g. publications, other grants, continued research education, etc. achieved by participants).

Outcomes

To date, Rural360 has committed $60,000 (CAD) to five projects led by NNCL physicians, two of whom have used their grants to leverage a cumulative $22,500 from an external funder.

Recommendations & lessons learned

Although Rural360 is in its formative years, we have identified some early lessons learned and recommendations. First, a prerequisite research education initiative (in our case, 6for6) is essential, ensuring applicants have a baseline knowledge of research fundamentals before applying for funding. Second, linking participants with other experts is crucial. Multidisciplinary teamwork and partnerships are essential in rural [19] and health science research [20], and improving healthcare in circumpolar areas [5]. Finally, funding can be obtained from many sources (e.g. grants, internal medical school/institutional funding, private donations, etc.). More important is how participants obtain that funding, and fostering an adjudication system that caters to the needs of rural physicians. Rural360’s processes were specifically created to accommodate rural and remote physicians’ substantial clinical commitments and position as nascent researchers.

Discussion

Scholars have been largely silent on the issue of funding for rural, remote and Northern health research. Rural360 makes a strong case for change so that rural and remote health research can thrive. Specifically, the nurturing approach to review juxtaposes strongly against the infamously competitive adjudication processes of major funding agencies that are intimidating even to seasoned researchers. In fact, the major Canadian funder for health research (Canadian Institutes of Health Research – CIHR) has acknowledged the need for a dedicated initiative to fund research in Northern, rural and remote Canada, and one delivered in ways outside the traditional rules of research funding [21]. While such an initiative has not yet been instituted by CIHR, Rural360 is trailblazing this vision by “promot[ing], coordinat[ing] and fund[ing] [rural health research] … ensur[ing] research excellence through a rigorous peer review process … further enhance[ing] research capacity and … translat[ing] research into usable knowledge.” [21]

Rural360 also makes research resources available with a delivery model that represents a paradigm shift in terms of how projects typically secure funding. In one of the few studies on the topic, Barclay, Phillips and Lyle [22] identified a striking deficiency in investment in Australian rural health research from 2005 to 2014 that paled in comparison to the continued health disparities and challenges faced in these regions. A similar disparity has also been identified in Canada’s Northern, circumpolar areas [5]. The Rural360 program represents a considerable injection of resources into NNCL research, contrasting the globally-reported shortcoming. Additionally, the secondary funding that participants can receive makes the presentation of NNCL research more feasible. Not only is it an opportunity to create and share research, but a way to make meaningful and impactful change in NNCL communities.

The Rural Road Map co-developed by the College of Family Physicians of Canada and the Society of Rural Physicians of Canada emphasises the need to increase the currently limited rural research in Canada with a well-coordinated and adequately funded national rural research network [23]. They recommend to: “Create and support a Canadian rural health services research network with the goal of connecting existing rural health research initiatives, and coordinating and strengthening research that enhances the health care of rural Canadians” [23]. In their pre-budget submission to the Canadian government both organizations requested federal funding to develop and support programs like Rural360 across Canada.

Acknowledgments

Thank you to the International Grenfell Association for providing funds for Rural360, and to Dean Margaret Steele for her continued enthusiasm and support of 6for6.

Disclosure statement

Mr. Thomas Heeley is a salaried project manager for Rural360. His position is paid for by the same grant that supports the program. All other authors received no financial benefit from this initiative.

Additional information

Funding

Rural360 is supported by the International Grenfell Association under grant [2017-024].