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With the rise in nurse practitioner (NP) residency programs, evaluations have largely focused on retention and competency completion for residents. There is a need for expanded evaluation to ensure the sustainability of NP residency programs, to ensure timely adaptations to address resident satisfaction, and to solidify a long-term pathway of NPs well prepared for rural practice. We created a family nurse practitioner (FNP) residency program with a comprehensive evaluation framework to prepare residents for practice in rural settings. The evaluation framework was developed through collaborative engagement of an external evaluation team, program leadership, and clinical site representatives. The evaluation framework of the FNP residency program combined resident assessment and holistic program evaluation, using a rapid continuous quality improvement (QI) approach. The evaluation considered three distinct perspectives: the resident, the peer coach, and the clinical site. The rapid continuous QI approach allowed program leadership to respond swiftly to programmatic challenges, improve the residency program in response to residents' reported experiences, and emphasize sustainability for continued program impact, while assessing residents' learning and performance. The program's data-driven evaluation approach has demonstrated its success in meeting the goals of the Health Resources and Services Administration funding by increasing the number of primary care providers in rural settings. The program's expansion and continued success have further validated the efficacy of this evaluation framework in assessing, improving, and ensuring the sustainability of APRN residency programs. This article calls for the adoption of similar evaluation strategies in future residency programs to promote their long-term success and impact in rural health care settings. [ABSTRACT FROM AUTHOR]

Introduction: There is evidence that a supportive male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral therapy initiation and adherence, and increases HIVfree infant survival. Most male partner engagement clinical strategies have focused on increasing uptake of couple-based HIV testing and counseling. We delivered a couple-based care and treatment intervention to improve antiretroviral therapy adherence in expectant couples living with HIV. Methods: We implemented a cluster randomized controlled trial for seroconcordant couples living with HIV, comparing retention (using a patient's medication possession ratio) in HIV care for a couple-based care and treatment intervention vs. standard of care services in rural Mozambique. The intervention included couplebased treatment, couple-based education and skills building, and couple-peer educator support. Results: We recruited 1080 couples to participate in the study. Using a linear mixed effect model with a random effect for clinic, the intervention had no impact on the medication possession ratio among women at 12 months. However, the intervention increased men's medication ratio by 8.77%. Our unadjusted logistic regression model found the odds of an infant seroconverting in the intervention group was 30% less than in the control group, but the results were not statistically significant. Discussion: Our study found no difference in maternal outcomes by study arm, but our intervention resulted in an improved medication possession ratio among male partners. We provide a community/clinic-based treatment framework that can improve outcomes among male partners. Further work needs to be done to improve social support for pregnant women and to facilitate prevention of vertical transmission to infants among couples living with HIV. [ABSTRACT FROM AUTHOR]

Introduction: In Indonesia, spine procedure including surgery was increasing in the current years. However, there was a lack of data about it in Indonesia as a developing country. We collected and described all of spine procedure that had been done in a single center in Klaten regency as a representative of the facilities at rural area in developing settings. Method: This is a retrospective study including all patients who were undergoing spine procedure in the Department of Neurosurgery Dr Soeradji Tirtonegoro Central Public hospital of Klaten during the period of study from January 2019 to December 2022. The number of spine procedures was recorded and plotted in a pie chart and bar diagram. The data consisting pathology of the spine, spinal level affected, and type of procedure were obtained from medical records. Result: In the last four years, out of 210 cases in total, there was an increasing pattern of spine procedure with degenerative condition being the most common pathology of our cases. Lumbar region is the highly affected level of spine and our procedures mainly consisted of spine instrumentation. Conclusion: Even a rural area in developing country has a huge potency to develop advanced spine procedures. [ABSTRACT FROM AUTHOR]

Purpose: The state of Montana encompasses and defines rural health care as it is known in the United States (US) today. This vast area is punctuated by pockets of health care availability with varying access to blood products for transfusion. Furthermore, timely transport is frequently challenged by weather that may limit air transportation options, resulting in multiple hours in ground transport to definitive care. Patients and Methods: The Montana State Trauma Care Committee (MT-STCC) developed the Montana Interfacility Blood Network (MT-IBN) to ensure blood availability in geographically distanced cases where patients may otherwise not survive. The index case that led to the formal development of the MT-IBN is described, followed by a second case illustrating the IBN process. Results: This process and development manuscript details the innovative efforts of MT-STCC to develop this fledgling idea unique to rural US health care. We review guidelines that have been developed to define broad aspects of the MT-IBN including the reason to share resources, proper packaging, paperwork necessary for transfer, and how to provide resources directly to the patient. Finally, we describe implementation within the state. Conclusion: The MT-IBN was developed by MT-STCC to facilitate the hand-off of lifesaving blood to patients being transported by ground to definitive care in Montana without having to stop at an intermediary facility. This has already led to lives saved in areas that are limited in blood availability due to rurality. [ABSTRACT FROM AUTHOR]

Background: The previous "one-size-fits-all" practice in resource allocation can no longer adapt to the spatial variation in population and health needs. This study aimed to investigate the spatially heterogeneous effect of medical equipment investment in the township health centres in rural China to optimize the investment strategies. Methods: Based on the national-scale stratified multistage cluster sampling, 319 township health centres from six provinces were included in the study. The retrospective data from 2013 to 2017 were collected for each sampled township health centres and the corresponding township community. The panel threshold regression model was applied to estimate the nonlinear effect of medical equipment increment on the service utilization due to the township communities' urbanization degree. The influence of township community remoteness on the effects of equipment increment was investigated through subgroup analysis. Results: Among the township health centres in the neighbouring towns of the county seat (travel time to the county seat < 1 h), the significant effect of medical equipment increment was only found in the township health centres of the towns with high urbanization degrees (the proportion of the residents living in the built-up area > 69.89%), of which the effect size was 774.81 (95% CI 495.63, 1053.98, p < 0.05). Among the township health centres in the remote towns (travel time ≥ 1 h), the effect of medical equipment increment in the township health centres of the low urbanized towns (urban ≤ 5.99%, β = 1052.54, p < 0.01) was around four times the size of that of the counterparts (urban > 5.99%, β = 237.00, p < 0.01). Conclusion: This study demonstrated the spatially heterogeneous effect of medical equipment investment in the primary care centres in rural China. The priority of the equipment investment was suggested to be given to the township health centres in the remote towns with a low urbanization degree and those in the highly-urbanized neighbouring towns of the county seats. [ABSTRACT FROM AUTHOR]

Purpose: Prenatal care is important for positive outcomes for both mother and infant. The traditional one-on-one method remains the most common. This study aimed to compare perinatal outcomes of patients attending group prenatal care with traditional prenatal care. Most previously published comparisons did not match for parity, a key predictor of perinatal outcome. Description: We collected perinatal outcome data for 137 group prenatal care patients and 137 traditional prenatal care patients, matched for contemporaneous delivery and parity, who delivered at our small rural hospital during 2015–2016. We included key public health variables, including the initiation of breastfeeding, and smoking at the time of delivery. Assessment: There was no difference between the two groups for maternal age or infant ethnicity, induced or augmented labor, preterm deliveries, APGAR scores less than 7, low birth weight, NICU admissions, or cesarean deliveries. Group care patients had more prenatal visits and were more likely to initiate breastfeeding and were less likely to report smoking at the time of delivery. Conclusion: In our rural population matched for contemporaneous delivery and parity, we found no difference in traditional perinatal outcome measures and that group care was positively associated with the key public health variables of not smoking and initiating breastfeeding. If future studies in other populations have similar findings, it may be wise to provide group care more widely to rural populations. Significance: We provide a comprehensive table comparing previous studies of group care with a focus on differences in the populations studied. Ours is the first to provide perinatal outcomes from a rural population in the US and only the second to match for parity, a key predictor. Our groups were smaller than previous reports, but our complete matching on parity and contemporaneous delivery of the control group are strengths. We found no difference in traditional perinatal outcome, but group care patients reported higher rates of breastfeeding and not smoking, a difference only found in two previous urban-based reports. [ABSTRACT FROM AUTHOR]

Background: High maternal-neonatal mortality rate in the East Nusa Tenggara Timur Province, Indonesia, has raised a concern about improving quality health care and prevention. A task force team consisting of the district health office and the corresponding hospital implemented an interprofessional peer mentoring for improving maternal-neonatal health initiative involving various health professionals and community members. This study assesses the effectiveness of the interprofessional peer-mentoring program in improving health-care workers' capacity and community members' awareness of maternal-neonatal health in the primary care setting. Methods: A mixed-methods action research was conducted to measure the effectiveness of the peer-mentoring program. The task force appointed 15 personnel to be trained as peer mentors for 60 mentees from various professions. Peer mentors' perceptions of knowledge and skills improvement were measured before and after the training program. A reflective logbook was then developed to document mentoring activities. Surveys and logbook observations were performed to measure the effectiveness of the 8-month peer-mentoring program. Mentees' capacity and perception were measured before and after the mentoring program. Quantitative data were analyzed using the descriptive statistics and Wilcoxon's paired-rank test, whereas open-ended responses and log-book reflection were analyzed using the content analysis. Results: The peer-mentor training program improved peer mentors' knowledge and readiness from 3.64/5.00 to 4.23/5.00 (P < 0.001). Moreover, mentees viewed the program as effective in improving self-confidence and working capacity in maternal-neonatal health services from 3.47/5.00 to 3.98/5.00 (P < 0.001). Open-ended responses and a reflective logbook revealed that both mentees and peer mentors gained positive learning experiences. Seniority might become an obstacle to the mentoring process since peer mentors reported barriers in engaging elderly mentees due to seniority issues. Discussion: The interprofessional peer-mentoring program was effective in improving both mentors' and mentees' knowledge, self-confidence, and working capacity in maternal-neonatal primary health services and experiential learning. Further observation of the long-term outcomes of the program should be undertaken. [ABSTRACT FROM AUTHOR]

Background: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. Methods: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. Results: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round‐trip to access care if those FPs were to stop delivering. Conclusions: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families. [ABSTRACT FROM AUTHOR]

Vaccination is a vital health care initiative to prevent individual and population infection. To increase vaccination rates the federal government implemented the 'No Jab, No Pay' policy, where eligibility for several government benefits required children to be fully vaccinated by removing 'conscientious objections' and expanding the age range of children whose families receive benefits. This study assesses the impact of this policy at a local area within a single medical practice community in NSW, Australia. A retrospective clinical audit was performed between 2012 and 2017 on a single general practice's vaccination records for children ≤19 years. Catch‐up vaccinations were assessed based on age at vaccination. Incidence of catch‐up vaccinations was assessed for each of four years before and two years after the implementation of the 'No Jab, No Pay' policy in January 2016, along with the age of children and vaccination(s) given. Catch‐up vaccinations were assessed temporally either side of implementation of 'No Jab, No Pay'. Comparing the average annual vaccination catch‐up incidence rate of 6.2% pre‐implementation (2012–2015), there was an increase to 9.2% in 2016 (p <.001) and 7.8% in 2017 (p =.027). Secondary outcome measurement of catch‐up vaccination incidence rates before (2012–2015) and after (2016–2017) 'No Jab, No Pay' implementation showed statistically significant increases for children aged 8–11 years (3.2%–5.6%, p =.038), 12–15 years (7.5%–14.7%, p <.001) and 16–19 years (3.3%–10.2%, p <.001) along with a statistically significant reduction in children aged 1–3 years (11.4%–6.2%, p =.015). Also, catch‐up rates for DTPa significantly increased after program implementation. This study demonstrates that the Australian federal government vaccination policy 'No Jab, No Pay' was coincident with an increase in catch‐up vaccinations within a rural NSW community served by one medical practice, especially for older children. [ABSTRACT FROM AUTHOR]

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas. [ABSTRACT FROM AUTHOR]

Background: The aim of this article is to describe older people's perceptions of caring relations in the context of rural eHealth, as well as to explore how such relations can facilitate engagement in digital primary health care. There is an ongoing implementation of eHealth in Western health care, and rural areas and older people are specifically targeted. eHealth is said to be a solution to emergent problems and a technology that will facilitate people's opportunities to achieve good and equal health. From this perspective, it is crucial that older people engage in eHealth services, but there are barriers for use, and care providers need to adapt to the preferences of older people. Methods: Semi-structured interviews with 19 individuals aged 61-85 were conducted. The participants were using digital services at two primary healthcare centres located in northern Sweden. Qualitative content analysis was used. An important theoretical tenet was that older people's perceptions of and engagements in eHealth are affected by the specific rural conditions. Ethical approval for the study has been obtained. Results: The analysis rendered a total of three themes: inperson interaction was central to people's perceptions of good caring relations; patient--nurse relations were particularly emphasised; and caring relations in rural eHealth appeared to be multi-directional and fuelled by a shared sense of rural community. Altogether, this facilitated participants' engagement in local eHealth initiatives. Conclusions: eHealth is an opportunity for primary health care and for rural communities. However, the results provide insight into matters that can affect the quality, access, and equality of rural primary health care. Participants' engagement in eHealth was almost always facilitated by close caring relations with local Registered Nurses. Digital care needs to be approached as a combination of digital and in-person presence. Separating digital and physical task assignments among different personnel could make older people refrain from seeking health care. [ABSTRACT FROM AUTHOR]

Purpose: Oral cancer risks have been shown to be modified by improving public awareness and reducing barriers to preventive care. The purpose for this study was to assess oral cancer knowledge and awareness and provide oral cancer screenings and education to a population of rural farmers in Wisconsin. Methods: Attendees 18 years of age and older at a rural farming exposition in Wisconsin were invited to complete a 12-item oral cancer awareness paper survey and to receive a visual and tactile head and neck examination/ oral cancer screening. Completing both the survey and the screening were optional. Participants also received educational materials on oral cancer. Individuals with abnormal lesions were provided with dental referrals. Results: A total of 236 attendees consented to participate either the survey or oral cancer screening (n=236). Most (72%) reported seeing a dentist in the past six months regardless of insurance status. In spite of having had recent dental encounters, only 28% of women and 46% of men were able to identify at least one risk factor associated with oral cancer. Among participants consenting to the oral cancer screening (n=194), 17% (n=33) presented with oral lesions requiring additional assessment and were recommended for follow-up care. Conclusions: Knowledge and awareness of oral cancer risk factors, signs and symptoms was low among the participants in this rural population despite high rates of dental care access. Oral cancer screenings and education provided in varied settings could improve oral cancer knowledge and awareness and early detection of malignant oral lesions in rural communities. [ABSTRACT FROM AUTHOR]

Focusing on the experiences of African medical auxiliaries belonging to rural colonial Fort Victoria province's sprawling Ndanga Native Medical Unit, this article considers the ambiguous position occupied by this front-line group who pioneered black medical care work in the former British colony of Southern Rhodesia (Zimbabwe). Although a great deal of work has been done on the histories of medical auxiliaries across colonial Africa, how they managed their incorporation into a marginal but evolving colonial healthcare system requires a fresher look. The recent emphasis on auxiliaries' cultural power and clinical acumen – two extremely important traits – has tended to overshadow the daily realities of their positioning on the margins of colonial health-care systems. Adopting a holistic approach, I reconsider the opportunities and constraints of their occupation. I argue that although African medical auxiliaries in remote rural places such as Ndanga were influential as culture brokers and providers of frontline care – a source of pride and inspiration for many – their haphazard recruitment, ad hoc training and casual conditions of service negatively exposed them to the vicissitudes of their colonial and professional subjugation. Moreover, as African medical training became more professionalised from the 1950s onwards, the once prestigious position of medical assistants was overtaken by newer categories of professionally trained African health-care personnel. [ABSTRACT FROM AUTHOR]

In low and middle-income countries, access to cancer diagnosis and treatment is suboptimal. Further, compliance to cancer treatment is a major issue due to various reasons including financial barriers, lack of family support and fear of treatment. This article discusses the determinants of treatment completion in cancer patients of a government-run hospital, in a rural part of Punjab in India. The Sangrur hospital-based cancer registry data for the year 2018 have been used. We have registered 2,969 cancer cases, out of which 2,528 (85%) cases were eligible for the analysis. Of the total 2,528 cases, 1,362 (54%) cases completed the cancer directed treatment and 1,166 (46%) did not. The data have been collected from the electronic medical record (EMR) department and entered into CanReg5 software. The bivariate and multivariate binary logistic regression analysis was performed to see the effect of variables on the treatment completion. The results indicate that the elderly age group (>60 years) (odds ratio (OR): 0.52, (95% confidence interval (CI): 0.31-0.86)), distance from hospital (OR: 0.67, (95% CI: 0.50-0.89)) and access to government health schemes (OR: 0.13, (95% CI: 0.10-0.19)] have direct correlation with the treatment completion. The educated patients (OR: 1.49, (95% CI: 1.13-1.96)) and patients who received curative treatment (OR: 2.7, (95% CI: 1.88-3.88)) have shown 58% and 84% compliance to treatment completion, respectively. The other variables like the clinical extent of disease, religion, gender and income do not have any significant effect on the treatment completion. Determinants like age (young), education, distance from the hospital, curative treatment and availability of government health schemes for financial support have shown positive effects on treatment completion. These factors have to be considered by the cancer hospitals, health departments and policymakers while planning for cancer care or control in India. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the viability of integrating acupuncture services into a Patient-Centered Primary Care Home (PCPCH) and Federally Qualified Healthcare Center (FQHC) located in a frontier community. The study had two primary aims: (1) to assess demographics, clinical characteristics, and utilization patterns of patients who accessed acupuncture services at Winding Waters Community Health Center (WWCHC), (2) to perform cost-benefit analysis using a basic revenue versus expense calculation. Design: This observational study consisted of two primary components: (1) a retrospective chart review and (2) a basic cost versus revenue assessment. Setting/Location: WWCHC, an FQHC located in frontier Northeastern Oregon. Subjects: Data from 551 charts of patients aging ≥18 years who accessed acupuncture services at WWCHC between January 2017 and December 2018. Results: Patients attended 3210 acupuncture visits. The demographics of patients utilizing acupuncture services reflected community demographics. Mean age was 54 years (±16.9) and 99 patients (18%) reported income below the federal poverty level. The prevalent chief complaint was back and neck pain (46.6% of visits). WWCHC medical providers placed 538 internal referrals for patients to receive acupuncture. Although patients are actively utilizing insurance benefits for acupuncture, reimbursement remains a challenge. Reimbursement rates ranged between 34% and 69% of billed rate. In 2018, 779 visits were paid by patients at an average rate of $48.71 per visit. Despite challenges, clinic revenue for acupuncture services exceeded costs by 4%. Conclusions: The acupuncture program at WWCHC is economically feasible and well utilized by patients. Adequate reimbursement remains a challenge, but it is not cost-prohibitive and provides a nonpharmacologic treatment option in this frontier setting. Revenue for acupuncture services exceeded costs by 4%. [ABSTRACT FROM AUTHOR]

Access to health care is an important issue, particularly in remote areas. Since 2010, 106 rural hospital have closed in the United States, potentially limiting geographic access to health care. The aim of this study was to evaluate the impact of these hospital closures on the proportion of the population who can reach a secondary care facility, by road, within 15, 30, 45, or 60 min. Geographical information system analysis, using population data obtained from the 2010 U.S. Census Bureau and hospital data between 2010 and 2019 from the Center for Medicare and Medicaid Services, created 15-, 30-, 45-, and 60-min drive time isochrones (areas from which a central location can be reached within a set time). Rural hospital closures resulted in 0%-0.97% of the population no longer being able to access a hospital within 15 min. The most marked changes were in the East South Central (0.97%, 178,478 residents) and West South Central (0.54%, 197,660 residents) divisions. Lesser degrees of change were noted for longer drive times. The changes were more marked when the rural population was analyzed exclusively. Recent closures of rural hospitals in the United States have impacted population access to hospital care, although the extent varies. There are regions, such as the Southern and Southeastern United States, which demonstrate greater and potentially more concerning losses in population coverage, probably because of the greater number of closures. Future work should evaluate clinical implications of hospital closures and loss of population coverage. [ABSTRACT FROM AUTHOR]

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The 'Three Delays' model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the 'Three Delays'. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the 'Mfangano Health Navigation' programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper was to use current stroke care guidelines to identify and discuss current stroke care challenges in rural Australian health care and potential solutions for delivery of evidence‐based practice. Design and setting: A review of national guidelines since 2002 for organised stroke care was undertaken to determine best practice for delivering primary stroke care. We then employed a narrative literature review strategy looking at relevant articles, based on keywords, outlining current stroke service availability in Australia, highlighting the challenges of implementing evidence‐based stroke care in rural areas in Australia based on the current guidelines. Results: Delivery of evidence‐based stroke care in rural Australia is fraught with challenges. Although national best‐practice guidelines for stroke care are well established, the recommendations made in these guidelines do not always reflect the resource availability in rural Australia. Redesigning processes and utilising available resources, such as telemedicine or local clinical pathways, can achieve an evidence‐based standard; however, ultimately better resourcing of these areas is required. Conclusion: Evidence‐based stroke care, aligned with current national standards is the key to providing adequate stroke services in rural Australia. Improved health service resourcing and better utilisation of currently available resources are options for achieving elements of evidence‐based stroke care. Implications for public health: Availability of adequate services for stroke patients directly impacts public health as it determines health outcomes for these patients. Indirect implications for public health include the effects on health professionals and the general public. [ABSTRACT FROM AUTHOR]

Physician assistants are one way to address the healthcare provider shortage in rural areas. However, recruitment and retention of physician assistants to live and work in rural communities remain a challenge. One's relationship to his or her hometown, be it rural or not, has important implications for who might be willing to live and work in a rural community. The purpose of this research was to examine factors influencing physician assistant students' desire to return to their hometowns to live and work after graduation. Data were collected in 2016 and 2017 through a survey administered to physician assistant students (n=149) in a PA program at a Midwestern University. Survey questions examined hometown connections, community features, and job expectations, as well as desire to return to one's hometown. Students who grew up in rural communities reported lower levels of community satisfaction and were less likely to perceive that jobs were available in their hometowns. A series of regression models were run to examine the impact of hometown connections, community characteristics and evaluation, and job characteristics in predicting interest in returning to hometown while controlling for the effects of age and gender. Coming from a rural, suburban, or urban hometown did not significantly predict desire to return when controlling for respondents' evaluation of their hometowns. The strongest predictor of willingness to return to one's hometown was community attachment. Understanding the factors that impact physician assistant students' post-graduation plans may inform efforts to recruit and retain rural health care providers. [ABSTRACT FROM AUTHOR]

Of the 40 patients with lower extremity wounds, 70% were deemed to be secondary to peripheral artery disease (PAD) based on noninvasive studies, abnormal Doppler physical exam, and clinical judgment. Keywords: chronic limb threatening ischemia (CLTI); diabetic foot ulcer; peripheral artery disease (PAD); Veterans Affairs; rural health care EN chronic limb threatening ischemia (CLTI) diabetic foot ulcer peripheral artery disease (PAD) Veterans Affairs rural health care 239 240 2 06/13/23 20230601 NES 230601 Chronic limb-threatening ischemia (CLTI) has a high level of morbidity and mortality if there are delays in diagnosis and revascularization. [Extracted from the article]

The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities. [ABSTRACT FROM AUTHOR]

Purpose: To examine the perceptions, proficiencies, and barriers of diabetes device use among rural clinic providers. Methods: A total of 210 surveys were sent through e-mail and/or U.S. Postal Service to rural clinics throughout Alaska, Idaho, Montana, Oregon, Washington, and Utah based on discussions with rural clinic network leadership in the states. Responses were included if the participant was 18 years of age and older, and worked at a rural clinic as a physician, physician assistant, nurse, nurse practitioner, allied health worker, or clinic manager. Results: Respondents included clinic management (13%), midlevel providers (physician assistants and nurse practitioners) and allied health workers (pharmacists, dietitians, and social workers, 30.8%), nurses (30.8%), and physicians (23.1%). We had a low response rate (20%; n = 41), but of those who said they work with patients who have diabetes, only 47.4% indicated that they use diabetes devices as part of their patients' treatment. The most common barrier reported among respondents suggested that additional medical team expertise is needed in their community or clinic to adopt insulin pumps and/or continuous glucose monitoring for qualified patients (75.9% and 80.8%, respectively). Conclusion: Lack of provider experience and having patients managed by out-of-area experts were the biggest reasons for providers not seeing or managing patients using these devices. Lack of provider access, patient satisfaction with current diabetes regimens, unsupportive health care team, patient literacy, and patient fear showed limited to negligible endorsements from survey respondents. A variety of potential solutions to this problem of limited provider experience and training are also offered. [ABSTRACT FROM AUTHOR]

Nebraska is a largely rural state with many communities defined as medically underserved by primary care providers. In 2014, the state legislature voted to eliminate the requirement for an integrated practice agreement (IPA) between nurse practitioners (NPs) and physicians. This report describes changes in access to primary health care in rural and underserved areas of Nebraska after removal of the IPA barrier to practice. The report compares the number of primary care NPs working in medically underserved areas before and after the legislation that ended the required IPA. In addition, anecdotes will be provided of NP and patient experiences in rural, NP-owned practices in Nebraska after IPA requirements were eliminated. [ABSTRACT FROM AUTHOR]

Background: Researches have shown highest awareness but low utilization of contraceptives making the situation a serious challenge. Most of women in reproductive age group know little or have incorrect information about family planning methods. Even when they know the name of some of the contraceptives, they do not know where to get them or how to use it. These women have negative attitude about family planning, whereas some have heard false and misleading information, the current study aimed in assessing the knowledge, attitude, and practice of family planning among female healthcare workers in Kashmir valley. Method: A self-administered questionnaire was served to the female multipurpose health workers of District Anantnag and Baramulla at a training conducted in Department of Community Medicine, Government Medical College, Srinagar, Kashmir. Result: All the participants had heard about family planning methods. The major sources of information were trainers (78.8%). About 90.4% of the study participants gave correct response regarding the types of family planning. About 80.1% of the respondents had a favorable attitude toward family planning. Around three-fourths of the study participants practiced one or other method of family planning. Conclusion: Our study lead to the conclusion that the level of knowledge and attitude toward family planning was relatively low and FP utilization was quite low among the healthcare workers. In order to imbibe positive attitude among general public, the health workers need to be trained so as to inculcate the positive attitude in them leading to increased awareness among general public with regard to family planning. [ABSTRACT FROM AUTHOR]

In light of the rising regional inequalities in primary care provider supply, to ensure equitable access is a pressing issue in health policy. Most policy approaches fall short in considering the patient perspective when defining shortage areas. As a consequence, implementations of new service delivery models might fail to be responsive to patients' expectations. To explore regional differences in the relative importance of structure and process attributes as drivers of patient satisfaction with local primary care, we collected data from residents of three objectively well-supplied urban and six objectively worse-supplied rural areas in Germany and tested a multi-group structural equation model. The results suggest that the relative importance of care attributes is different among the regional conditions rural and urban. Regardless of regional constraints, the strongest determinants of satisfaction are not related to structural aspects but are concerned with the quality of the doctor-patient relationship. A lack of available choices and a higher tolerance in terms of distances provide possible explanations for the results. The high importance rural residents attribute to the interpersonal relation should not be neglected in the re-organization of traditional service delivery in rural areas. [ABSTRACT FROM AUTHOR]

Background: Studies demonstrate that the CME/CPD (continuing medical education/continuing professional development) needs of rural general practitioners (GPs) are unique. Little research has focused specifically on the effectiveness of CME/CPD programmes for rural practice. Aims: To review the literature on CME/CPD for GPs in rural areas, focussing on studies which examined impact on doctor performance or patient outcomes. Methods: A search of peer-reviewed English language literature and relevant grey literature was conducted: identified literature was reviewed. Results: Nineteen articles met the pre-specified inclusion criteria. Educational delivery approaches examined include regional CME/CPD small-group learning programmes, workshops and distance learning. Most articles report on participant experience or satisfaction while doctor performance and patient outcomes are seldom reported. Distance learning programmes found it difficult to recruit or engage doctors, two out of six studies found improvements in self-reported knowledge or performance, while none reported measurable changes in doctor performance/patient care. [ABSTRACT FROM AUTHOR]

This article reviews the condition and challenges of health care in rural areas. A particular emphasis is made on assessing the process of reforming health care and its impact on the health of residents of Russian villages by analyzing infrastructure, staffing, and the relationship between the population and medical and preventive care facilities. The article concludes that negative processes predominate: There are trends toward a total reduction in hospitals and ambulatory clinics, which exacerbates the already difficult social situation of residents of rural areas. Statistical data characterizing the state of their health and the demographic situation in rural areas provide evidence of widespread socially significant illnesses and an increase in disability and the mortality rate. [ABSTRACT FROM AUTHOR]

Traditional medicine is widespread in Ghana, with 80% of Ghanaians relying on its methods for primary health care. This paper argues that integrating traditional and biomedical health systems expands the reach and improves outcomes of community health care. Moving beyond literature, it stresses the importance of trust-relationships between healers and biomedical staff. Insights are based on qualitative research conducted in Ghana's Northern Region (2013-2014). Five challenges to integration emerged out of the data: a lack of understanding of traditional medicine, discrimination, high turnover of biomedical staff, declining interest in healing as a profession, and equipment scarcity. Besides challenges, opportunities for integration exist, including the extensive infrastructure of traditional medicine, openness to collaboration, and grassroots initiatives. Contemplating challenges and opportunities this paper provides recommendations for integration, including: identify/select healers, promote best practices, institute appropriate forms of appreciation/recognition of healers, provide aid and equipment, use communication campaigns to promote integration and steer attitudinal change towards healers among biomedical staff. Most crucial, we argue successful implementation of these recommendations depends on a concerted investment in relationships between healers and biomedical staff. [ABSTRACT FROM AUTHOR]

Health care delivery and payment systems are moving rapidly toward value-based care. To be successful in this new environment, providers must consistently deliver high-quality, evidence-based, and coordinated care to patients. This study assesses whether Project ECHO® (Extension for Community Healthcare Outcomes) GEMH (geriatric mental health)-a remote learning and mentoring program-is an effective strategy to address geriatric mental health challenges in rural and underserved communities. Thirty-three teleECHO clinic sessions connecting a team of specialists to 54 primary care and case management spoke sites (approximately 154 participants) were conducted in 10 New York counties from late 2014 to early 2016. The curriculum consisted of case presentations and didactic lessons on best practices related to geriatric mental health care. Twenty-six interviews with program participants were conducted to explore changes in geriatric mental health care knowledge and treatment practices. Health insurance claims data were analyzed to assess changes in health care utilization and costs before and after program implementation. Findings from interviews suggest that the program led to improvements in clinician geriatric mental health care knowledge and treatment practices. Claims data analysis suggests that emergency room costs decreased for patients with mental health diagnoses. Patients without a mental health diagnosis had more outpatient visits and higher prescription and outpatient costs. Telementoring programs such as Project ECHO GEMH may effectively build the capacity of frontline clinicians to deliver high-quality, evidence-based care to older adults with mental health conditions and may contribute to the transformation of health care delivery systems from volume to value. [ABSTRACT FROM AUTHOR]

Purpose:Traumatic brain injury (TBI) is prevalent in Kentucky and comes with a high cost in care and quality of life for individuals and caregivers affected. Many people living with the condition of TBI have unmet needs. Research among people living with TBI in rural areas is limited. The purposes of this study were to (1) increase understanding of the lived experience of people with TBI and caregivers in rural regions of Kentucky across the continuum of their care and (2) provide their perspectives on barriers and facilitators of optimal function and well-being. Methods:A qualitative descriptive interview study was conducted by a multidisciplinary team. Content analysis was completed with data-derived coding and iterative modifications to analysis, coalescing codes into categories and themes. Results:Thirteen people with TBI and six caregivers participated in the interview. Categories that emerged in analysis included the experiences under each locus of care; themes included relationships, functional competence, and participation in meaningful activity. Conclusion:Relationships represented both barriers and facilitators of well-being. Major unmet needs persisted in terms of medical problems, support for caregivers, community linkages, and participation in meaningful activities. Recommendations are made regarding avenues for addressing unmet needs.Implications for RehabilitationPeople with TBI are living with chronic conditions and may need intensive rehabilitation after the injury and intermittent rehabilitation throughout life to develop and maintain functional competence.Rehabilitation providers need to understand the unique aspects of the rural home environment to which a patient will be discharged (e.g., mountainous terrain, lack of transportation, dimensions of home) and communicate with rural providers directly.Rehabilitation providers need additional focus on improving patient’s and caregiver’s abilities to advocate for themselves.Patients with TBI should be referred to vocational rehabilitation as soon as possible to make the transition to meaningful activity at home more of a possibility. [ABSTRACT FROM AUTHOR]

Purpose: Traumatic brain injury (TBI) is prevalent in Kentucky and comes with a high cost in care and quality of life for individuals and caregivers affected. Many people living with the condition of TBI have unmet needs. Research among people living with TBI in rural areas is limited. The purposes of this study were to (1) increase understanding of the lived experience of people with TBI and caregivers in rural regions of Kentucky across the continuum of their care and (2) provide their perspectives on barriers and facilitators of optimal function and well-being. Methods: A qualitative descriptive interview study was conducted by a multidisciplinary team. Content analysis was completed with data-derived coding and iterative modifications to analysis, coalescing codes into categories and themes. Results: Thirteen people with TBI and six caregivers participated in the interview. Categories that emerged in analysis included the experiences under each locus of care; themes included relationships, functional competence, and participation in meaningful activity. Conclusion: Relationships represented both barriers and facilitators of well-being. Major unmet needs persisted in terms of medical problems, support for caregivers, community linkages, and participation in meaningful activities. Recommendations are made regarding avenues for addressing unmet needs. [ABSTRACT FROM AUTHOR]

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial Registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009. [ABSTRACT FROM AUTHOR]

Introduction Timely, appropriate intervention is key to improving outcomes in many emergent conditions. In rural areas, it is particularly challenging to assure quality, timely emergency care. The TelEmergency (TE) program, which utilizes a dual nurse practitioner and emergency medicine-trained, board-certified physician model, has the potential to improve access to quality emergency care in rural areas. The objective of this study was to examine how the implementation of the TE program impacts rural hospital Emergency Department (ED) operations. Methods Methods included a before and after study of the effect of the TE program on participating rural hospitals between January 2007 and December 2008. Data on ED and hospital operations were collected one year prior to and one year following the implementation of TE. Data from participating hospitals were combined and compared for the two time periods. Results Nine hospitals met criteria for inclusion and participated in the study. Total ED volumes did not significantly change with TE implementation, but ED admissions to the same rural hospital significantly increased following TE implementation (6.7% to 8.1%, p-value = 0.02). Likewise, discharge rates from the ED declined post-initiation (87.1% to 80.0%, p-value = 0.003). ED deaths and transfer rates showed no significant change, while the rate of patient discharge against medical advice significantly increased with TE use. Discussion In this analysis, we found a significant increase in the rate of ED admissions to rural hospitals with TE use. These findings may have important implications for the quality of emergency care in rural areas and the sustainability of rural hospitals' EDs. [ABSTRACT FROM AUTHOR]

Background: Community service doctors (CSDs) are often expected to administer anaesthesia after minimal training and with very little support, especially in rural hospitals. This leads to unnecessary stress on these junior doctors and may lead to poor anaesthesia outcomes. Objectives: The aim of this study was to understand the experiences of CSDs administering anaesthesia. This feedback will be used to improve the current intern training programme for anaesthesia and to structure the rotation according to their needs. Methods: A questionnaire was sent to Pietermaritzburg (PMB) interns who completed their anaesthesia intern rotation between 2008 and 2010. Two data sets were collected: quantitative data (this will be reported on in another paper) and qualitative data. The qualitative data included five open-ended questions about the intern rotation in anaesthesia. Results: Between 2008 and 2010, 298 interns completed an anaesthetic rotation. The survey was sent to 259 doctors of whom 189 responded (73%). The first three questions were about the structure of the intern rotation in anaesthesia. The responses were analysed together. The following feedback was common: more autonomy, longer duration of the anaesthesia rotation and more practical exposure during the rotation. Questions 4 and 5 were about the impact of internship and community service on future career choice. Community service had a greater impact on career choice than internship. Conclusion: Intern training in anaesthesia is essential to create confident CSDs. Feedback from previous interns should be used to improve intern training programmes. [ABSTRACT FROM AUTHOR]

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice. [ABSTRACT FROM AUTHOR]

Objective: To describe the distribution of Veterans in areas of the United States where there are potentially inadequate supplies of health professionals, and to explore opportunities suggested by this distribution for fostering health workforce flexibility.Data Sources: County-level data from the 2015-2016 Health Resources and Services Administration's (HRSA's) Area Health Resources Files (AHRF) were used to estimate Veteran populations in HRSA-designated health professional shortage areas (HPSAs). This information was then linked to 2015 VA health facility information from the Department of Veterans Affairs.Study Design: Potential Veteran populations living in Shortage Area Counties with no VHA facilities were estimated, and the composition of these populations was explored by Census division and state.Principal Findings: Nationwide, approximately 24 percent of all Veterans and 23 percent of Veterans enrolled in VHA health care live in Shortage Area Counties. These estimates mask considerable variation across states.Conclusions: An examination of Veterans residing in Shortage Area Counties suggests extensive maldistribution of health services across the United States and the continued need to find ways to improve health care access for all Veterans. Effective avenues for doing so may include increasing health workforce flexibility through expansion of nurse practitioner scopes of practice. [ABSTRACT FROM AUTHOR]

Objective: To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers.Data Sources: Experimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services.Study Design: We generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates' sensitivity to the inclusion of control variables.Data Collection: The primary data are from a large field study.Principal Findings: Approximately 80 percent of Medicaid callers receive an appointment in rural areas-a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment.Conclusions: Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees. [ABSTRACT FROM AUTHOR]

Objective: To identify and compare the factors affecting the knowledge of, attitude towards and use of antibiotics between urban and rural residents in China.Methods: A total of 3631 urban and rural residents in Heilongjiang Province, China, were selected using random sampling. Questionnaires recorded demographic characteristics and participant knowledge of, attitude towards and use of antibiotics. The responses of rural and urban residents were compared, and logistic regression analysis was applied to identify the factors that may contribute to the knowledge of, attitude towards and use of antibiotics.Results: The majority of the participants (>60%) were aware that antibiotics could be used to treat bacterial infections and that bacteria could be resistant to antibiotics. However, only roughly half (40-60%) of the participants were aware that bacterial resistance to antibiotics had become a problem in China. Urban participants reported a more adequate knowledge of, attitude towards and use of antibiotics than rural participants. Logistic regression analysis indicated that urban residency, female gender and level of education were associated with knowledge of, attitude towards and use of antibiotics.Conclusions: Within our sample in Heilongjiang Province, the knowledge of, attitude towards and use of antibiotics were suboptimal in roughly half of all urban and rural residents, but better in urban than in rural residents. Targeted interventions to educate rural residents in particular may reduce the misuse of antibiotics. [ABSTRACT FROM AUTHOR]

The purpose of the study was to evaluate the qualitative aspect and global impact of surgery in a district hospital (DH) since the launching of the surgery at the district level. Surgical care was provided by general practitioners (GP) who received 12-month training in surgery, certified by a 'Capacity of District Surgery' (CDS) diploma. It was a prospective study during 4 years from 2007 to 2010. Of the 34 DHs, only 21 were functional and included in this study. Most of the DHs had two or more CDS ( n = 15). The majority of the DHs had one nurse surgical aid ( n = 16) and one nurse anesthetist ( n = 17). The total number of surgical operations was 18,441 cases; emergency cases represented 51.8 % and elective surgery 48.2 %. Regarding emergency surgery, cesarean sections revealed the most common surgical procedure (37.21 %), followed by wound debridement (19.42 %). In elective surgery, hernia repair and hydrocelectomy were the most common surgical procedures (69.60 %), followed by gynecologic procedures in 12.74 % of the cases. The global complication rate was 4.34 %. The global mortality rate was 1.04 % ( n = 192), 102 deaths following cesarean section (2.87 %). No death was encountered in elective surgery. Nine hundred and fifty-five patients (5.17 %) were transferred to a higher-level facility of whom 598 patients (62.61 %) were admitted for fracture treatment. The concept of district surgery has proven to be an effective tool to counter skilled medical manpower shortage to perform emergency and elective basic surgery at the rural level and could be adopted by developing countries facing similar health challenges. [ABSTRACT FROM AUTHOR]

Rationale and Aim While interprofessional practice has been promoted as a solution to the challenges besetting rural health services, current evidence does not offer a clear explanation as to why it is effective in some domains and yet is not successful in others. At the same time, rural clinicians are frequently faced with major workforce pressures and this has a significant influence on professional practice. The aim of this study was to explore how these pressures impact on rural interprofessional practice. Method This study is part of a larger project investigating factors that enhance and detract from effective interprofessional working. We utilised a modified realistic evaluation approach to analyse the context, mechanisms and outcomes of rural interprofessional practice. Approval for this study was granted by an accredited research ethics committee. Semi-structured interviews were conducted with 22 rural clinicians who were purposively recruited from a range of settings, roles, locations and professions. Findings and Discussion We found that clinicians often invested in interprofessional practice because of the need to manage intense workloads and this necessitated sharing of responsibilities across disciplines and blurring of role boundaries. Paradoxically, participants noted that workload pressures hampered interprofessional working if there were long-term skill shortages. Sharing workload and responsibility is an important motivator for rural practitioners to engage in interprofessional practice; however, this driver is only effective under circumstances where there are sufficient resources to facilitate collaboration. In the context of intransient resource challenges, rural health service managers would be best to focus on enabling IPP through facilitating role understanding and respect between clinicians. This is most feasible via informal workplace learning and allowing time for teams to reflect on collaborative processes. [ABSTRACT FROM AUTHOR]

Background In 2005, the Indian government launched the National Rural Health Mission (NRHM) to improve the quality of and access to rural public health care. Despite these efforts, recent evidence shows that the rural poor continue to primarily consult private non-degree allopathic practitioners (NDAPs) for acute illness episodes. To examine this phenomenon, we explore the rural poor's perception and utilization of the rural health care system and the role and accessibility of NDAPs therein. Methods Our study is based on qualitative data from focus group discussions conducted in three rural districts in Bihar and Uttar Pradesh, two high-focus states of the NRHM in northern India, in 2009/2010. Our study population consists of female micro-credit self-help group members and their male household heads. We apply a directed content analysis and use a theoretical framework to differentiate between physical, financial and cultural access to care. Results Our study population distinguishes between "home treatment" (informal self-care), "local treatment" (formally unqualified care) and "outside treatment" (formally qualified care). Because of their proximity, flexible payment options and familiarity with patients' belief systems, among other things, local NDAPs are physically, financially and culturally accessible. They are usually the first contact points for patients before turning to qualified practitioners, and treat minor illnesses, provide first relief, refer patients to other providers and administer formally prescribed treatments. Conclusion Our findings are similar for all three study sites and reinforce recent findings from southern and eastern India. The poor's understanding and utilization of the rural health system deviates from governmental ideas. Because of their embeddedness in the community, private NDAPs are the most accessible medical providers and first contact points for acute illness episodes. Thus, they de-facto fulfill the role envisaged by the Indian government for accredited social health activists introduced as part of the NRHM. We conclude that instead of trying to replace NDAPs with public initiatives, the Indian government should regulate, qualify and integrate them as part of the existing public health care system. This way, we argue, India can improve the rural poor's access to formally qualified practitioners. [ABSTRACT FROM AUTHOR]

Little is known about the views of rural family physicians (FPs) regarding collaborative care models for patients with dementia. The study aims were to explore FPs’ views regarding this issue, their role in providing dementia care, and the implications of providing dementia care in a rural setting. This study employed an exploratory qualitative design with a sample of 15 FPs. All rural FPs indicated acceptance of collaborative models. The main disadvantages of practicing rural were accessing urban-based health care and related services and a shortage of local health care resources. The primary benefit of practicing rural was FPs’ social proximity to patients, families, and some health care workers. Rural FPs provided care for patients with dementia that took into account the emotional and practical needs of caregivers and families. FPs described positive and negative implications of rural dementia care, and all were receptive to models of care that included other health care professionals. [ABSTRACT FROM PUBLISHER]

Aim To describe the research protocol that will be used to investigate factors contributing to effective interprofessional practice in a rural context in Australia. Background Interprofessional practice is a key strategy for overcoming rural health challenges; however, our knowledge of interprofessional initiatives and consequences in rural areas is limited. Design A modified realistic evaluation approach will be used to explore the structures, systems, and social processes contributing to effective interprofessional outcomes. This 'context-mechanism-outcome' approach provides a useful framework for identifying why and how interprofessional practice works in rural contexts. Method Initial propositions regarding the factors that explain effective collaborative practice will be generated through interviews with lead clinicians, policy-makers, and clinician managers. Clinician interviews, document analysis, and multi-participant focus groups will be used as evidence to support, refine, or redevelop the initial propositions. This will allow the development of a model of rural interprofessional practice that will explain how and why collaborative approaches work in rural environments. This study is funded by an Institute of Rural Clinical Services and Teaching grant (January 2010). Discussion Rural healthcare challenges are well documented; however, studies investigating the nature of interprofessional practice in rural contexts are not common. Rural contexts also present research design, particularly data collection, challenges. This proposed research is one of the first to identify the factors that facilitate or constrain effective interprofessional work in rural settings. This is particularly important, given the continuing workforce shortages and maldistribution and poorer health outcomes in rural communities globally. [ABSTRACT FROM AUTHOR]

Background: Admission to a nursing home is generally regarded as a stressful time for older people and their carers. Although the choice of home is significant in facilitating a more positive transition, few studies have explored this issue in detail, particularly in the context of rural communities. With a worldwide ageing population and an increasing demand for long-term care facilities, it is important to highlight the factors that can improve the experience of entry to long-term care and the role of nursing home staff in facilitating a more positive transition for older people and their families. Methods: The overall aim of this qualitative study was to explore rural family carers’ experience of the nursing home placement of an older relative. Semi structured interviews were conducted with 29 relatives of nursing home residents. Participants were selected from a large health and social care trust in the United Kingdom. Data were analysed using grounded theory principles and procedures and NVivo software. Results: Rural family carers had a strong sense of familiarity with the nursing homes in their area and this appeared to permeate all aspects of their experience. Carers who reported a high degree of familiarity appeared to experience a more positive transition than others. This familiarity was influenced by the high degree of social capital that was present in the rural community where the study was conducted. This familiarity, in turn, influenced the choice of nursing home and the responses of family carers. The theory that emerged suggests that familiarity was the key factor influencing rural family carers’ experience of the nursing home placement of an older relative. Conclusions: The population of the world is ageing and nursing homes are increasingly providing care to older people with multiple and complex needs. This study makes an important contribution to the ways in which the move to long term care can be managed more effectively by increasing awareness of the importance of familiarity, stability and social capital in the lives of older people and their carers. [ABSTRACT FROM AUTHOR]

Abstract: Global inequalities in health have long been associated with disparities between rich and poor nations. The middle-income countries of the Levant (Lebanon, Syria and Jordan) have developed models of health care delivery that mirror the often complex make-up of their states. In Lebanon, which is characterized by political clientelism and sectarian structures, access to health care is more contingent on ethnicity and religious affiliation than on poverty. This case study of the Bedouin of the Middle Bekaa Valley of Lebanon is based on interviews with policymakers, health care providers and the Bedouin as part of a study funded by the European Commission between 2006 and 2010. The study explores the importance of considering social discrimination and political exclusion in understanding compromised health care. Three decades after the Declaration of Alma Ata (1978), which declared that an acceptable level of health care for all should be attained by the year 2000, the Bedouin community of Lebanon remains largely invisible to the government and, thus, invisible to national health care policy and practice. They experience significant social discrimination from health practitioners and policymakers alike. Their unfair treatment under the health system is generally disassociated from issues of wealth or poverty; it is manifested in issues of access and use, discrimination, and resistance and agency. Overcoming their political exclusion and recognizing the social discrimination they face are steps that can be taken to protect and promote equal access to basic reproductive and child health care. This case study of the Bedouin in Lebanon is also relevant to the health needs of other marginalized populations in remote and rural areas. [Copyright &y& Elsevier]

Community research and action projects undertaken by community-university partnerships can lead to contextually appropriate and sustainable community improvements in rural and urban localities. However, effective implementation is challenging and prone to failure when poorly executed. The current paper seeks to inform rural community-university partnership practice through consideration of first-person accounts from five stakeholders in the Rural Embedded Assistants for Community Health (REACH) Network. The REACH Network is a unique community-university partnership aimed at improving rural health services by identifying, implementing, and evaluating innovative health interventions delivered by local caregivers. The first-person accounts provide an insider's perspective on the nature of collaboration. The unique perspectives identify three critical challenges facing the REACH Network: trust, coordination, and sustainability. Through consideration of the challenges, we identified several strategies for success. We hope readers can learn their own lessons when considering the details of our partnership's efforts to improve the delivery infrastructure for rural healthcare. [ABSTRACT FROM AUTHOR]

Objective. One approach to solving mental health care disparity issues in rural areas is by establishing a telepsychiatry consultation practice for children, in which a psychiatrist sees a child via videoconferencing for a limited number of sessions and then provides a treatment plan to that child’s primary care physician and family. Method. The present study offered a 2-session telepsychiatry consultation clinic, consisting of a psychiatric evaluation session and a recommendation session, with patients located remotely in rural Georgia. Results. Fifteen consultations with children aged 4 to 18 years (M = 9.73, SD = 3.39) with varying diagnoses were completed. Parental satisfaction with the telepsychiatry consultation model was high, overall mean of 4.58 (SD = 0.63) on a 5-point scale (n = 11). Conclusion. Establishing a child telepsychiatry consultation practice is feasible in rural areas. This report describes the benefits and challenges of our telepsychiatry consultation clinic with rural pediatric patients. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Rurality adversely impacts the continuum of cancer care. However, investigations of rural cancer surgery are notably absent. We examined patterns and outcomes of oncologic resections at rural US hospitals. Methods: We identified 928,370 hospital admissions in which 1 of 20 oncologic resections was performed using the 1998 to 2009 Nationwide Inpatient Sample. Logistic regression examined predictors of rurality and the adjusted likelihood of in-hospital mortality at rural and urban hospitals. Results: The fraction of procedures performed at rural hospitals decreased from 12% to 6%. Older age, non-Hispanic white race, and fewer comorbidities predicted rurality. Rural hospitals did not have worse mortality, however, rurality significantly augmented mortality among recipients of complex cancer surgery. Conclusions: Rural hospitals had comparable mortality overall, but delivered poorer outcomes for certain groups. Future research should explore these variations as cancer care is increasingly centralized. [Copyright &y& Elsevier]

This article explores factors that influence a nurse's choice between working in a rural and an urban area. Understanding how nurses make the choice of which type of environment is critical to addressing this shortage, especially in these hardest hit rural areas. A comprehensive literature review suggested a number of factors worthy of investigation. These factors were assessed through six focus groups and a survey. Results suggest that native geographic preferences dominate, but that value congruence, economics, work facilities and stress all play a significant role in the decision when choosing between an urban and rural work environment. [ABSTRACT FROM AUTHOR]