Nerida Hyett

Methodology or method? A critical review of qualitative case study reports

Despite on-going debate about credibility, and reported limitations in comparison to other approaches, case study is an increasingly popular approach among qualitative researchers. We critically analysed the methodological descriptions of published case studies. Three high-impact qualitative methods journals were searched to locate case studies published in the past 5 years; 34 were selected for analysis. Articles were categorized as health and health services (n=12), social sciences and anthropology (n=7), or methods (n=15) case studies. The articles were reviewed using an adapted version of established criteria to determine whether adequate methodological justification was present, and if study aims, methods, and reported findings were consistent with a qualitative case study approach. Findings were grouped into five themes outlining key methodological issues: case study methodology or method, case of something particular and case selection, contextually bound case study, researcher and case interactions and triangulation, and study design inconsistent with methodology reported. Improved reporting of case studies by qualitative researchers will advance the methodology for the benefit of researchers and practitioners.Despite on-going debate about credibility, and reported limitations in comparison to other approaches, case study is an increasingly popular approach among qualitative researchers. We critically analysed the methodological descriptions of published case studies. Three high-impact qualitative methods journals were searched to locate case studies published in the past 5 years; 34 were selected for analysis. Articles were categorized as health and health services (n=12), social sciences and anthropology (n=7), or methods (n=15) case studies. The articles were reviewed using an adapted version of established criteria to determine whether adequate methodological justification was present, and if study aims, methods, and reported findings were consistent with a qualitative case study approach. Findings were grouped into five themes outlining key methodological issues: case study methodology or method, case of something particular and case selection, contextually bound case study, researcher and case interactions and triangulation, and study design inconsistent with methodology reported. Improved reporting of case studies by qualitative researchers will advance the methodology for the benefit of researchers and practitioners.

Community participation in rural health: a scoping review.

BackgroundMajor health inequities between urban and rural populations have resulted in rural health as a reform priority across a number of countries. However, while there is some commonality between rural areas, there is increasing recognition that a one size fits all approach to rural health is ineffective as it fails to align healthcare with local population need. Community participation is proposed as a strategy to engage communities in developing locally responsive healthcare. Current policy in several countries reflects a desire for meaningful, high level community participation, similar to Arnstein’s definition of citizen power. There is a significant gap in understanding how higher level community participation is best enacted in the rural context. The aim of our study was to identify examples, in the international literature, of higher level community participation in rural healthcare.MethodsA scoping review was designed to map the existing evidence base on higher level community participation in rural healthcare planning, design, management and evaluation. Key search terms were developed and mapped. Selected databases and internet search engines were used that identified 99 relevant studies.ResultsWe identified six articles that most closely demonstrated higher level community participation; Arnstein’s notion of citizen power. While the identified studies reflected key elements for effective higher level participation, little detail was provided about how groups were established and how the community was represented. The need for strong partnerships was reiterated, with some studies identifying the impact of relational interactions and social ties. In all studies, outcomes from community participation were not rigorously measured.ConclusionsIn an environment characterised by increasing interest in community participation in healthcare, greater understanding of the purpose, process and outcomes is a priority for research, policy and practice.

Community participation for rural health: a review of challenges

Internationally, community participation is highlighted in health policy reform as good for rural communities. Implicit in this policy is the message that the complexities of the rural environment are too difficult for easy solutions and that community participation will somehow build resilient, self‐determining communities capable of dealing with complex rural access and equity issues and poorer health outcomes. The underpinning proposition is that by giving decision‐making powers to community members, health care will be locally responsive, costs will be contained, and health outcomes will improve. What happens in the practice of enacting community participation in health‐care decision making is less clear.

Approaches for building community participation: A qualitative case study of Canadian food security programs:

There is increasing opportunity and support for occupational therapists to expand their scope of practice in community settings. However, evidence is needed to increase occupational therapists’ knowledge, confidence, and capacity with building community participation and adopting community-centered practice roles. The purpose of this study is to improve occupational therapists’ understanding of an approach to building community participation, through case study of a network of Canadian food security programs. Qualitative case study was utilized. Data were semistructured interviews, field observations, documents, and online social media. Thematic analysis was used to identify and describe four themes that relate to processes used to build community participation. The four themes were use of multiple methods, good leaders are fundamental, growing participation via social media, and leveraging outcomes. Occupational therapists can utilize an approach for building community participation that incorporates resource mobilization. Challenges of sustainability and social exclusion must be addressed.

Re-imagining occupational therapy clients as communities: Presenting the community-centred practice framework

Abstract Background: Occupational therapists’ are increasingly working with communities and providing services at the community level. There is, however, a lack of conceptual frameworks to guide this work. Aim: The aim of this article is to present a new conceptual framework for community-centered practice in occupational therapy. Material and Method: The conceptual framework was developed from qualitative multi-case research on exemplars of community participation. The first was, a network of Canadian food security programs, and the second, a rural Australian community banking initiative. Key themes were identified from across the case studies, and cross-case findings interpreted using occupational therapy and occupational science knowledge, and relevant social theory. The outcome is a four-stage, occupation-focused, community-centered practice framework. Findings: The Community-Centred Practice Framework can be used by occupational therapists to understand and apply a community-centered practice approach. The four stages are: (1) Community Identity, (2) Community Occupations, (3) Community Resources and Barriers, and (4) Participation Enablement. Conclusions: Further research is needed to trial and critically evaluate the framework, to assess its usefulness as a robust, occupation-focused, frame of reference to guide community-centered practice in occupational therapy. Significance: The proposed framework should assist occupational therapists to conceptualize community-centered practice, and to utilize and apply theory.

How can rural health be improved through community participation

Executive summary Rural Australians generally experience poorer health than their city counterparts. Rural Australia is a vast geographical region, with significant diversity, where there is good health and prosperity, as well as disadvantage. The purpose of this issue brief is to provide evidence on how the health of rural Australians can be improved through community participation initiatives, which are currently being funded and delivered by health services and networks. Rural Australians need innovative health services that are tailored to the local context and meet increasing healthcare demands, without increases to expenditure. There are community participation approaches supported by research that can improve existing practice. Avoiding duplication, including the current work of Medicare Locals and Local Hospital Networks, is important for ensuring good outcomes from community participation initiatives. The following recommendations are made to improve practice: New ways to contract and pay for health services are needed, which use ideas developed with communities, within current budgets State and federal government competitive grants and tenders should prioritise proposals that demonstrate effective community participation approaches Community-based services, such as community health centres, Medicare Locals and Local Health Networks, have an important role to play in facilitating community participation, including: Building partnerships between existing services and leveraging existing participation strategies, rather than developing new services or standalone initiatives—to leverage available funds and maximise outcomes Employment of a jointly-appointed, paid community leadership position across existing community-based health services, to avoid duplication and overcome barriers of over-consultation and volunteer fatigue Formal and robust evaluation of initiatives is necessary to guide future policy and research A national innovative online knowledge sharing portal is required to share best practice in rural community participation, save time and money on ineffective approaches, and to support the rural health workforce.

Coaching parents; enabling participation.

Dear Editor, Graham, Rodger and Ziviani (2009) present an inspiring, systematic and sparkling clear explanation of familycentred practice from an occupational therapy perspective. A refreshing change to the usual psychology viewpoint, and one that strongly identifies occupational therapists as competent and effective in providing counselling intervention. As an occupational therapist working with adolescents and their families as an Alcohol and Other Drug Counsellor, I would like to contribute to the idea of using coaching and other cognate approaches for client engagement and occupational change. From experience I agree you can aspire to family-centred practice principles and be deterred by the challenge to implement these in practice. With my particular client group, the practicality of family engagement can be challenged by role confusion (‘Are you working with me or my mum?’), limits of confidentiality (‘don’t tell my Dad about that’), and readiness for change (‘my son’s not ready to change his routine, but I think he should’). Graham et al. (2009) challenge therapists to reflect on these practice issues and to find answers through discussion and research. I read with interest the concept of using occupational performance coaching in family-centred practice, and would suggest Motivational Interviewing is a clientcentred counselling style, effective for circumstances where the client/s may be contemplative about change, do not seem to prioritise occupational therapy intervention, or present to the service through mandatory-type pathways. Thank you to the Australian Occupational Therapy Journal and Graham et al. (2009) for presenting this Feature Article. I expect it will inspire reflection and promote discussion on the use of cognate interventions in a range of different practice areas. Sincerely, Nerida Hyett Alcohol and Other Drug Counsellor (Youth Focussed) Bendigo Community Health Services Bendigo, Victoria, Australia

Trialing Virtual Intercultural Learning With Australian and Hong Kong Allied Health Students to Improve Cultural Competency

Cultural competency, in increasingly globalized and cosmopolitan societies, is key to allied health graduate employability. Internationalization at Home initiatives that use virtual technologies have potential to facilitate transformative intercultural learning experiences and build cultural competency. The purpose of this study was to trial a virtual intercultural learning activity with Australian and Hong Kong undergraduate occupational therapy and oral health students to explore cultural competency learning. We utilized a mixed methods study design with quantitative pre- and postsurveys and qualitative group interviews. Study findings illustrate how the activity enabled students to practice and learn intercultural communication skills, gain greater awareness and appreciation for diversity at home and abroad, and engage in global citizenship learning. Educators are encouraged to utilize virtual learning spaces for creating meaningful and transformative cultural learning experiences that enhance graduate intercultural capabilities.

Strengthening occupational therapy practice with communities after traumatic events

Occupational therapists have immense potential to strengthen their role in supporting communities to recover from collective trauma. After traumatic events, a community-centred practice approach can be used by occupational therapists to improve health, safety, security and wellbeing at a population level. Three strategies to strengthen the role of occupational therapy in this critical area of practice are proposed: (a) work collaboratively with communities to design programmes centred on community strengths and needs; (b) select and use therapeutic occupations to support community recovery; and (c) develop strong networks to enhance community partnerships and sustainability of services.

Reconceptualising community participation in primary health

Internationally, there is a push to involve communities and community members in all stages of healthcare design, delivery and evaluation. Proponents argue that, by involving community members, self-determining empowered communities will emerge and contribute to locally responsive healthcare delivery and improved health outcomes. Critics of the community participation agenda cite neoliberal underpinnings and argue that shifting the responsibility to ordinary people is an attempt to absolve the responsibilities of the State. In these debates, there is, of course, always a middle ground. It is clear that the idealised notion of actively engaged, well-behaved community members, passionate about shaping primary healthcare, is far from reality. When the public do become involved in driving healthcare, many within the health system are pushed into a very uncomfortable space. When discussing and operationalising the notion of community participation, many fall back on the tokenistic consumer on an advisory board or the advisory board of community members who offer advice, but have little direct power in decision making. Well-meaning people seek ways to engage with the ‘hard to reach’. Few step back and question whether it is the health system and health professionals that are hard to reach. On a recent trip to a Canadian conference it was intriguing to be introduced to a person who was described as ‘our patient’. The person’s name was not used and there was a lack of acknowledgement that everyone in the room would interact with the health system at some point. The description of the person as ‘the patient’ came from a well-meaning and genuine place, but it highlighted the struggle that we have to really understand how the public should be involved in primary healthcare design, delivery and evaluation; for what purpose and for what outcomes. In this special issuemany of the advantages, challenges, issues and quandaries in the community participation space are highlighted. Pagatpatan and Ward (2017) describe their realist synthesis approach to critical analysis of the concept of ‘effective’ public participation, and they examine the factors that make public participation effective. In this article, questions are asked about the techniques of public participation and whether people must only engage in methods developed and driven by those in the health system. The ability of those in positions of power to listen to the public is questioned. Farmer et al. (2017) emphasise the importance of differentiating between types of participation and identifying those accountable for outcomes. Case studies of Primary Health Networks (PHN) and their engagement with consumers are presented in the papers by McClean and Trigger (2017) and Blignault et al. (2017). We pondered whether there are examples where Community Advisory Councils have directly affected PHN outcomes and whether decisions and actions were evaluated to see if primary health services were improved. These articles prompted us to have a robust discussion about whether there is greater opportunity for Community and Clinical Advisory Councils to work together in co-design and co-production activity. The disparate operation of these groups prompts the question, are those in the health system really ready to participate? Kelly et al.’s (2017) description of co-creation of patient journey mapping tools is an interesting example of people with different but complementary expertise working together. The need for different but complementary expertise is reinforced by the work of Guzys et al. (2017). In their study they challenge the emphasis on fiduciary responsibilities in boards and advisory committee’s and reinforce the fundamental importance of participation by directors or advisory committee members who have strong understanding of health and community needs and who use this knowledge in decision making. Pagatpatan and Ward (2017) highlight that effective participation in policy making is characterised by political commitment, partnership synergy, inclusiveness and deliberativeness. There are examples of these factors in this special issue. A study by Bovill et al. (2017) on the design of a culturally responsive smoking intervention for Aboriginal mothers, provides new insights on these. Spurling et al. (2017) reinforces how investigator driven research may represent ‘an extension of colonial control’ and that much can be learned by asking people about their priorities. The theme of participation and research priority setting is picked up by Ball et al. (2017). Hesson et al. (2017) argue that parents are rarely involved in the development of child and family services and stresses the importance of timely, integrated, continuous participatory mechanisms driven by consumers. In reading this article, we thought about the concept of defensive reasoning, where those working in primary health may engage in defensive behaviours when their work or views are challenged. There is a need to support those in the health system to accept and better respond to the views of those interested in or accessing primary care. We have really enjoyed reading the papers in this special edition and it has challenged us to think in new and different ways. This issue made us wonder where we sit on the spectrum between zealous promotion of community participation, as almost a panacea to the woes of primary healthcare delivery, and the neoliberal cynicism that sees community participation as a transfer of responsibility to communities who are expected to have the capacity and willingness to participate, often with no funding and no support. Perhaps we have a slightly utopian view, but when thinking about wicked challenges in primary health, we argue that siloed thinking that perpetuates the notion of groups of consumers and groups of primary health professionals working independently, or the tokenistic consumer in an advisory capacity, represents a missed opportunity for working together. Real gains will only be achieved when we push the agenda and reconceptualise