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Because of a shortage of health care providers, providing rehabilitation in health care facilities is difficult. Virtual reality–based rehabilitation is effective in older populations. There are only a few studies among patients with sarcopenia. This is a quasi-experimental, single-group, pretest–posttest design evaluating the clinical effectiveness of virtual reality–based progressive resistance training among residents aged over 60 years with sarcopenia in rural care facilities. The authors used Oculus Rift with headsets to provide the virtual reality–based progressive resistance training. The authors administered the program twice per week, 30 min per session, for 12 weeks. The primary outcomes were dominant handgrip strength, walking speed, and appendicular skeletal muscle mass index. Data from 30 participants were analyzed. Significant improvements in handgrip strength and walking speed were observed. Although an increasing trend in appendicular skeletal muscle mass index was observed, it did not reach statistical significance. The authors concluded that the virtual reality–based progressive resistance training is partially effective in older sarcopenic adults in health care facilities.

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.

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: in-person 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.

Surgical site infections (SSIs) in developing countries have been linked to inadequate availability of sterilising equipment. Existing autoclaves are mostly unaffordable by rural healthcare practitioners, and when they managed to procure them, the electricity supply to power the autoclaves is epileptic. The solar-powered autoclave alternatives are too bulky with a very high initial cost. Hence, low-cost biofuel-powered autoclave becomes an attractive option, and this study sought to present the design, development and clinical evaluation of the device performance. With the global drive for the adoption of green energy, biofuel will not only reduce greenhouse gas emission but also provide revenue for local producers and reduce biomass associated health complications. The theoretical energy requirement for the sterilisation process was calculated. The standard pressure and temperature needed for sterilisation were tested to be 121 °C and 15 psi. The device was also clinically tested with

Background Nurse practitioners (NPs) are being used to meet the increased demand for rural primary care. Purpose The purpose of this study was to explore the perceptions and experiences of rural NPs while they transitioned from being registered nurses to family NPs (FNPs). In addition, the study examined if and how new FNPs experienced their professional identity formation in their first year of rural primary care practice. Methodological orientation A qualitative phenomonological research design was used. Sample A sample of 12 FNPs who graduated from one of three Midwestern university programs, worked, and provided primary care at a rural health care facility located in one of four full-practice states were used within the study. Conclusions Participants experienced new nurse practitioner professional identity formation beginning in their education programs, which continued throughout their first year of practice. Four themes emerged from the data analysis: learning new knowledge, skills, roles, and responsibilities; interactions with patients, providers, and interprofessional team members; incentive to learn and practice in rural health care; and professional identity formation. Implications for practice The emerging model, The Process of Professional Identity Formation for Rural Family NPs, shows potential for use as a framework to guide rural NP curriculum and professional development programs. Policy makers must also continue the push to increase the number of states allowing NPs full independent practice. These efforts could promote rural NP support, recruitment, and retention that will be key to meeting the primary care needs of rural and vulnerable populations.

Aim: The aim of this study was to evaluate the feasibility and efficacy, in terms of overall survival, of sequential systemic therapy in patients with metastatic castration-resistant prostate cance...

ObjectiveThe treatment of patients with dementia poses a considerable challenge to regional district general hospitals, particularly in rural areas. Here we report the establishment and initial evaluation of a dementia-specific consultation service provided by a teaching hospital-based Psychiatry Department to regional district general hospitals in surrounding smaller towns.MethodsThe consultation service was provided to patients with pre-existing or newly suspected dementia, who were in acute hospital care for concurrent conditions. An evaluation of 61 consultations – 49 on-site and 12 via telemedicine – was performed to assess the needs of the participating hospitals and the specific nature of the referrals to the consultation service.ResultsSuspected dementia or cognitive dysfunction was the primary reason for consultation requests (>50% of cases). Other common requests concerned suspected delirium, behavioral symptoms, and therapeutic recommendations. During the consultations, a diagnosis of dementia was reached in 52.5% of cases, with other common diagnoses including delirium and depression. Recommendations related to pharmacotherapy were given in 54.1% of consultations. Other recommendations included referral for outpatient neurological or psychiatric follow-up, further diagnostic assessment, or assessment in a memory clinic. Geriatric psychiatric inpatient treatment was recommended in only seven cases (11.5 %).ConclusionsOur initial evaluation demonstrates the feasibility of providing a dementia-specific consultation service in rural areas. The service has the potential to reduce acute transfers to inpatient geriatric psychiatry and enables older patients with dementia or delirium to be treated locally by helping and empowering rurally-based regional hospitals to manage these problems and associated complications.

Short, longer and programmatic rural attachments have developed in a number of medical programmes around the world. However, there is limited literature on the development of the underpinning learning outcomes to guide these attachments. Rural populations are commonly under-served and the specific needs and challenges of rural health care need to be emphasised, as well as encouraging future practice in these areas. Our aim was to produce common rural-specific learning outcomes, aligned with a rationalisation of existing guiding principles and objectives, for our medical student regional-rural programmes. This was achieved through a Delphi technique involving the relevant clinical teachers and supervisors. Forty-nine consenting participants collectively provided 72 learning outcomes which were synthesised down to 16. A consensus process was used to anonymously rate and then rank to reach consensus for the top four learning outcomes. The learning outcomes were placed within the theoretical framework of a 'pedagogy of place' based on rurality and triangulated with rural learning outcomes from an Australian study. The four final outcomes were resolved around two areas of 'place': geographical and developmental. The co-design approach enabled those involved in providing the rural exposure education to generate appropriate learning outcomes.

In the United States, severe maternal morbidity and mortality is climbing—a reality that is especially challenging for rural communities, which face declining access to obstetric services. Severe m...

For the period 2007–17 rural death rates were higher than urban rates for the seven major causes of death analyzed, and disparities widened for five of the seven. In 2017 urban areas had met national targets for three of the seven causes, while rural areas had met none of the targets.

Rates of rural hospital closures have been increasing over the past decade. Closures will almost certainly restrict rural residents' access to important inpatient services, and they could also be related in important ways to the supply of physicians in the local health care system. We used data from the Area Health Resources Files for the period 1997-2016 to examine the relationship between rural hospital closures and the supply of physicians across different specialties in the years leading up to and after a closure. We observed significant annual reductions of up to 8.3 percent in the supply of general surgeons in the years leading up to a closure. We also found that rural hospital closures were associated with immediate and persistent decreases in the supply of surgical specialists and long-term decreases in the supply of physicians across multiple specialties-including an average annual 8.2 percent decrease in the supply of primary care physicians in the six years after a closure and beyond. This dynamic relationship could lead to reduced access to care for rural residents. Future policy efforts must focus on supporting and maintaining health care delivery models that do not depend on hospitals.

Supplemental Digital Content is Available in the Text., Background: Adequate medication reconciliation is related to patients' safety. Rural populations are at increased risk of adverse drug events due to errors in medication reconciliation and often receiving medical care across multiple health care entities and across long distances with separate electronic medical records. Methods: This study examined the implementation of Medications at Transitions and Clinical Handoffs Toolkit (MATCH) in a rural primary care clinic and assessed the acceptability and feasibility of implementation. Intervention: MATCH was developed as a workflow process intervention to improve medication reconciliation. Results: Findings from MATCH implementation indicate that the process improved medication reconciliation workflow. A shared definition of current medications across providers and patients was essential. Conclusions: Empowering patients and caregivers with tools and language to work with providers, particularly nurses, to conduct medication reconciliation during primary care clinic visits is key to improving patient medication reconciliation in rural settings.

This study aims at developing SuperOrder, an order recommendation system for outpatient clinics. Using the electronic health record data available at midnight, SuperOrder predicts the order contents for each upcoming appointment on a daily basis. A two-level prediction framework is proposed. At the base-level, the predictions are produced by aggregating three machine learning methods. The meta-level predictions are generated by integrating the base-level predictions with the order co-occurrence network. We used the retrospective data between 1 April 2014 and 31 March 2015 in pulmonary clinics from five hospital sites within a large rural health care facility in Pennsylvania to test the feasibility. With a decrease of 6 per cent in the precision, the improvement of the recall at the meta-level is approximately 20 per cent from the base-level. This demonstrates that the proposed order co-occurrence network helps in increasing the performance of order predictions. The implementation will bring a more effective and efficient way to place outpatient orders.

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.

The World Health Organisation policy of improving retention of rural health care practitioners recommended that continuing medical education (CME) programmes addressing their needs should be accessible and delivered where they live and work. This cross-sectional study involved a self-administered anonymous questionnaire completed by GPs attending CME small groups (CME-SGL) in Ireland. All GPs attending CME-SGL in a one-month period were invited to complete the questionnaire which examined demographic details, distance to travel to educational meetings/nearest regional hospital, barriers to accessing continuing education, whether CME-SGL met their educational needs, morale and professional isolation. A total of 1,686 responses were collected, of which 332 (19.6%) were from rural GPs. Of these, 289 (87%) reported that their educational needs were fully or mostly met by attending CME-SGL. Compared to urban doctors, rural GPs had further to travel to CME-SGL meetings, were further from the nearest regional hospital, and reported increased barriers to accessing continuing education. Rural GPs reported lower morale and greater levels of professional isolation. Despite considerable barriers to accessing continuing education, rural GPs reported that CME-SGL meets their educational needs. Future research should focus on the potential positive impact this may have on professional isolation and morale.

Supplemental Digital Content is available in the text., Background: In the unique context of rural Veterans’ health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. Objectives: We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. Research Design: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. Results: Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. Conclusions: This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners’ efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.

The paper presents a review of publications concerning issues of development of telemedicine in rural health care of the USA during in conditions of COVID-19 pandemic and expediency of extensive application of telemedicine technologies during "post-COVID" period. The issues, aspects, prospects and required conditions for extensive diffusion of telemedicine services to the rural population are considered.

Background Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or “secret shoppers” with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. Methods We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles—one white and one AI—to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. Discussion The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Critical care nursing and medicine have evolved significantly over the past few decades. Critical care in India began the major urban hospitals and has not yet become established in rural health care facilities. The formation of Indian critical care nursing and medical societies led to emerging regular conferences, updates, continuing nursing and medical education, workshops, and training programs for the further training of nurses and doctors. Future challenges include development of guidelines and consolidation of research activities on the outcome of patients with critical illness. This article describes the organization and practice of critical care nursing in India.

Refereed/Peer-reviewed We are pleased to introduce this special edition of the Australian Journal of Rural Health that focuses on rural health workforce. It is an opportune and timely edition as rural health and the rural health workforce face a precipice borne, in part, by the COVID‐19 pandemic. There has never been a more important time to consider appropriately and effectively rural communities to improve health outcomes.

To respond to an urgent community and educational need, we rapidly created a medication-assisted treatment program for opioid use disorder within our family medicine residency practice. We did this by transitioning a large group of established patients from a single family physician (G.K.) who was

This paper leverages the expansion of the United States' Community Health Center program over the 21st century to investigate whether improved access to health care reduces disability insurance (DI) participation at the county level. I find that the introduction of a health center that specializes in mental health and substance abuse services is associated with a 0.09 to 0.40 percentage point reduction in working-age DI enrollment in rural counties. A cost-benefit analysis indicates that the money saved from reduced program participation can account for more than a third of the cost the federal government faces in funding well-targeted health care access initiatives.

Background: Health care service is worsening in the remote villages due to less complete and further away of healthcare facilities and service and makes this service costs compared to those of urban people. Telemedicine service provides a potential solution regarding this particular issue. This study provides empirical evidence of the benefits package consists of hypothetical telemedicine service and evaluates the economic benefit of telemedicine service. Methods: The study measures marginal willingness-to-pay (MWTP) responses to policy change on a sample (n = 203) observations. A randomized conjoint experiment has conducted in 7 remote villages of 3 coastal districts of the southwest coastal region of Bangladesh. Each respondent ranks 3 options-two hypothetical alternatives and the telemedicine status quo scheme. The level of attributes-payment for telemedicine service, sample collection from home, medicine delivery to home, capitation through online technology, service delivery frequency, and blood pressure and glucose measure at home-are randomly and jointly assigned to the 2 alternatives. Results and Conclusions: Coastal villagers would like to pay more in option 4 and above. The lower payment for telemedicine service does not necessarily imply low demand for telemedicine, as the findings from MWTP illustrate potential demand for telemedicine in coastal villages in Bangladesh.

Filtering facepiece respirators (FFR) are critical for protecting essential personnel and limiting the spread of disease. Due to the current COVID-19 pandemic, FFR supplies are dwindling in many health systems, necessitating re-use of potentially contaminated FFR. Multiple decontamination solutions have been developed to meet this pressing need, including systems designed for bulk decontamination of FFR using vaprous hydrogen peroxide or UV-C radiation. However, the large scale on which these devices operate may not be logistically practical for small or rural health care settings or for ad hoc use at points-of-care. Here, we present the Synchronous UV Decontamination System (SUDS), a novel device for rapidly deployable, point-of-care decontamination using UV-C germicidal irradiation. We designed a compact, easy-to-use device capable of delivering over 2 J cm−2 of UV-C radiation in one minute. This short decontamination time should enable care-providers to incorporate decontamination of FFR into a normal donning and doffing routine following patient encounters. Disclaimer This article does not represent the official recommendation of the Cleveland Clinic or Case Western Reserve University, nor has it yet been peer reviewed. License This work is licensed under a Creative Commons Attribution Non-Commercial Share-Alike Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/legalcode.

Older adults in rural areas of the U.S. face unique risks related to COVID-19. Rural areas are older, on average, than urban areas, and have more underlying health conditions and fewer economic resources. Rural health care is more limited, as is access to technology and online connectivity. Altogether, this puts rural older adults at risk of not only the virus, but of not being able to meet their health care, social, and basic needs. Rural/urban inequities, combined with within-rural inequities in health, health care, and financial resources cause particular challenges to health and well-being from COVID-19 for some older adults.

Background The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. Methods Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. Results In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. Conclusions Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.

Among the many trends influencing health and health care delivery over the next decade, three are particularly important: the transition to value-based care and increased focus on population health; the shift of care from acute to community-based settings; and addressing the vulnerability of rural health care systems in North Carolina.

Although telepsychiatry has emerged as an innovative tool for increasing access to behavioral health services, few studies have examined the complexities associated with designing and implementing telepsychiatry programs. This column examines a multisite, multimodal telepsychiatry program that has been providing direct care, synchronous consultation, and asynchronous consultation services in rural Illinois since 2016. The program used quality improvement metrics and implementation science strategies to improve its long-term impact and sustainability. Program impact was assessed through satisfaction surveys of patients and primary care physicians, chart reviews, wait times, and volume of patients served. Results indicate that the design and implementation of this telepsychiatry program improved access to behavioral health services and effectively supported primary care providers, with high degrees of patient and provider satisfaction.

People living in rural areas have worse health outcomes than their urban counterparts do. Understanding what factors account for this could inform policy interventions for reducing rural-urban disparities in health. We examined a nationally representative survey of Medicare beneficiaries with one or more complex chronic conditions, which represented 61 percent of rural and 57 percent of urban Medicare beneficiaries. We found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate, compared to urban residence. Having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate for people with chronic conditions, after we controlled for having one or more primary care provider visits. Access to specialists accounted for 55 percent and 40 percent of the rural-urban difference in preventable hospitalizations and mortality, respectively. Medicare should consider interventions for rural beneficiaries who lack access to specialist care to reduce rural-urban disparities in health outcomes.

Growing up in a rural setting is a strong predictor of future rural practice for physicians. This study reports on the fifteen-year decline in the number of rural medical students, culminating in rural students' representing less than 5 percent of all incoming medical students in 2017. Furthermore, students from underrepresented racial/ethnic minority groups in medicine (URM) with rural backgrounds made up less than 0.5 percent of new medical students in 2017. Both URM and non-URM students with rural backgrounds are substantially and increasingly underrepresented in medical school. If the number of rural students entering medical school were to become proportional to the share of rural residents in the US population, the number would have to quadruple. To date, medical schools' efforts to recognize and value a rural background have been insufficient to stem the decline in the number of rural medical students. Policy makers and other stakeholders should recognize the exacerbated risk to rural access created by this trend. Efforts to reinforce the rural pipeline into medicine warrant further investment and ongoing evaluation.

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008–16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.

Background and Objectives: Despite the efforts of many organizations to increase the volume of rural health care providers, rural communities continue to experience a shortage of physicians. To address this shortage, more information is needed as to how specific factors contribute to family physicians’ choice to purse rural full-spectrum practice. Methods: Interviews with 21 key informants guided a grounded theory analysis around the question of “What factors contribute to the decision to, and maintenance of, practicing full-spectrum rural medicine?” Results: Analysis revealed two categories of factors that influenced choice of scope and maintenance of scope across a career: contextual and developmental factors. Contextual factors included the national health care landscape, the local setting, and personal factors. The developmental factors pertained to the point in the physician’s career, and include preprofessional envisioned scope, current scope, and ideal future scope of practice. Conclusions: Results describe how a rural physician’s scope of practice generally narrows as her/his career progresses. The results elaborate on how the larger health care landscape, local community, and personal factors all intersect to inform a physician’s decision to pursue and/or continue practice. Results of the study were consistent with preexisting literature, but provide additional depth and suggest a theoretical relationship among factors.

Do health care costs differ between rural and urban populations, and if so, why might that be? Rural Americans are more vulnerable than their urban counterparts, which could lead us to suspect rural health care costs are higher. However, the answer may differ depending on how costs are measured and who is paying.

Safe and sufficient water, sanitation, and hygiene (WaSH) prevent the spread of disease in health-care facilities (HCFs). Little research has been conducted on WaSH in HCF in sub-Saharan Africa. We carried out a cross-sectional study of WaSH in 1,318 randomly selected rural HCF (hospitals, health centers, health posts, and clinics) in regions throughout Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Methods included questionnaires with head doctors and nurses to document WaSH access, continuity, quality, quantity and reliability, and analysis of drinking water samples for Escherichia coli. We found that fewer than 50% of rural HCFs had access to improved water sources on premises, improved sanitation, and consistent access to water and soap for handwashing (Ethiopia [7%), Kenya [30%], Mozambique [29%], Rwanda [50%], Uganda [30%], and Zambia [21%]). Adequate hand hygiene reduces disease transmission and health-care-acquired infections, but fewer than 25% of HCF in each country reported that a combination of water, soap, and hand-drying materials were always available. Our research points to a lack of basic WaSH services in rural HCFs in regions of sub-Saharan Africa, which poses a threat to the health of patients and health-care workers in these settings.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

Background This project is part of the prospective quasi experimental proof-of-concept investigation of clinical pharmacist intervention study to reduce drug-related problems among people admitted to a ward in a rural hospital in northern Sweden. Objective To explore doctors’ and nurses’ perceptions and expectations of having a ward-based pharmacist providing clinical pharmacy services. Setting Medical ward in a rural hospital in northern Sweden. Method Eighteen face-to-face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward where the clinical pharmacy service was due to be implemented. Semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. Main outcome measure Perceptions and expectations of nurses and doctors. Results Doctors and nurses had limited experience of working with pharmacists. Most had a vague idea of what pharmacists can contribute within a ward setting. Participants, mainly nurses, suggested inventory and drug distribution roles, but few were aware of the pharmacists’ skills and clinical competence. Different views were expressed on whether the new clinical pharmacy service would have an impact on workload. However, most participants took a positive view of having a ward-based pharmacist. Conclusion This study provided an opportunity to explore doctors’ and nurses’ expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. To successfully implement a clinical pharmacy service, roles, clinical competence and responsibilities should be clearly described. Furthermore, it is important to focus on collaborative working relationships between doctors, nurses and pharmacists. Electronic supplementary material The online version of this article (doi:10.1007/s11096-017-0488-5) contains supplementary material, which is available to authorized users.

The changes in social and economic life that took place in Russia during last decades resulted in significant reduction in agricultural production, deterioration of life of rural population, limitation of accessibility and decreasing of quality of medical care that negatively impacted health of rural residents. The results of research studies testify low level of rural population health, which by many indices is worse as compared with urban population. The persistent tendency of its deterioration is established. These processes occur against the background of implementation of the Federal target program "The sustainable development of rural areas in 2014-2017 and until 2020" which is a logical continuation of the program "The social development of rural areas until 2013". The programs determine main directions of regulating integrated development of rural areas including such an integrated section as development of rural health care. The study was targeted present proposals concerning reformation and prospects of development of rural health care on the basis of analysis of key indices of medical organizations functioning, supporting rural population, with consideration of morbidity and accessibility of medical care to rural areas residents.

Rural hospitals differ from urban hospitals in many ways. For example, rural hospitals are more reliant on public payers and have lower operating margins. In addition, enrollment in the health insurance Marketplaces of the Affordable Care Act (ACA) has varied across rural and urban areas. This study employed a difference-in-differences approach to evaluate the average effect of Medicaid expansion in 2014 on payer mix and profitability for urban and rural hospitals, controlling for secular trends. For both types of hospitals, we found that Medicaid expansion was associated with increases in Medicaid-covered discharges. However, the increases in Medicaid revenue were greater among rural hospitals than urban hospitals, and the decrease in the proportion of costs for uncompensated care were greater among urban hospitals than rural hospitals. This preliminary analysis of the early effects of Medicaid expansion suggests that its financial impacts may be different for hospitals in urban and rural locations.

Community paramedicine (CP) uses emergency medical services (EMS) providers to help rural communities increase access to primary care and public health services. This study examined goals, activities, and outcomes of 31 rural-serving CP programs through structured interviews of program leaders and document review. Common goals included managing chronic disease (90.3%); and reducing emergency department visits (83.9%), hospital admissions/readmissions (83.9%), and costs (83.9%). Target populations included the chronically ill (90.3%), post-hospital discharge patients (80.6%), and frequent EMS users (64.5%). Community paramedicine programs engaged in bi-directional referrals most often with primary care facilities (67.7%), hospitals (54.8%), and home health (38.7%). Programs provided assessment, testing, preventive care, and post-discharge services. Reported outcomes were promising, but few programs used rigorous evaluation methods. Rural-serving CP programs provided services to shift costs to less expensive settings and provide appropriate care where vulnerable patients live, but more evidence is needed that care is safe, effective, and economical.