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Clinical outreach is a crucial but understudied health care service delivery model. Physicians staffing rural outreach clinics must allocate a limited resource (i.e., their time) between caring for patients at their main sites and outreach locations. Using a unique 30-year data set of decisions made by cardiologists, the authors estimate a constrained utility maximization model of time allocations across home and outreach locations. The results show that travel distance, potential competition, and patient demand for cardiology services significantly influence allocation decisions. This structural model is used to simulate the impact of a predicted reduction in cardiologist supply. The expected impacts are unevenly distributed, with some rural locations experiencing large decreases in access. The authors evaluate two policies to restore rural access: targeted immigration and a subsidy program. A subsidy program with an estimated annual cost of $406,000 can restore outreach after a 10% reduction in cardiologist supply. This option should be preferred to recruiting and supporting five additional cardiologists under a targeted immigration strategy. This research demonstrates the value of marketing modeling in addressing limited access to health care services and evaluating alternative policies for maintaining access in the face of coming physician shortages. [ABSTRACT FROM AUTHOR]

Maintaining and improving the health and well-being of older people in rural communities through integrated care is essential to address this cohort's frailty risk. The Indigo 4Ms Tool for health workers is a rural-specific approach to providing care that addresses the common conditions of ageing. With Australian government funding, five small rural health services are implementing the tool. This paper describes the protocol for a hybrid type 2 implementation-effectiveness study to evaluate the tool's impact on multidisciplinary comprehensive care planning and the implementation strategies that enhance the adoption and sustainability of the tool across diverse rural health settings. [ABSTRACT FROM AUTHOR]

Telehealth can expand and enhance access to school-based health care, but its use has been relatively limited. Recognizing that school-based health care is still not reaching many students, the Health Resources and Services Administration (HRSA) funded the School Based Telehealth Network Grant Program to expand telehealth in rural school-based settings to help to increase the availability and use of these services. The 19 grantees delivered telehealth to over 200 schools across 17 states, choosing which services they would deliver and how. Looking across the services, these fell into three categories – primary/urgent care, behavioral health, and other more specialized services. The majority of grantees offered multiple telehealth services with the combination of behavioral health and primary/urgent care the most common. The current study adds to the literature by elucidating that telehealth in schools can address multiple clinical conditions through separate services even though doing so involves using various combinations of clinicians providing different services. [ABSTRACT FROM AUTHOR]

Background: Ayushman Bharat is a Flagship Program in India to deliver an expanded range of free health-care services to all. Despite quality health care being a fundamental human right, rural India still grapples with its accessibility. To address this, the Indian Government aims to transform government primary health-care facilities into Health and Wellness Centers (HWCs) for comprehensive health-care delivery. Aims and Objectives: This study was done to assess the implementation status of HWCs and to explore the challenges faced by service providers during service delivery in the Bhatar Community Development block of Purba Bardhaman district. Materials and Methods: A facility-based, mixed-method study was conducted in Bhatar block, West Bengal from October 22 to February 23. For quantitative component, the implementation status of 12 HWCs was assessed using the national quality assurance standard checklist. For qualitative component, in-depth interview with Community Health Officers (CHOs) was done to explore the constraints. Results: Among 12 HWCs, 8 (66.67%) scored satisfactorily (≥70%) in overall score. Service provision, clinical services, infection control, and output were among the 8 areas of concern where all HWCs scored satisfactorily (≥60%) while input scored lowest (mean [SD] - 60.58 [9.53]). Among 12 themes, elderly and palliative health care, emergency medical services, and management of mental health ailments were lowest scoring with no HWC crossing satisfactory score (≥70%). Thematic analysis revealed that inadequate infrastructure, resource constraints, administrative and managerial constraints, lack of motivation and inadequate health promotion, and community participation were major constraints faced. Conclusion: Various challenges need to be addressed, including improving infrastructure, enhancing access to medicines and supplies, providing adequate training to CHOs, and increasing community participation.

For many living in remote areas, accessing quality health care remains a significant hurdle. Long distances, limited specialists, and transportation challenges create a gap in care that telehealth has the potential to bridge. This article explores how telehealth, the use of telecommunication technologies for health-care delivery, can revolutionize rural health care. Telehealth consultations can connect patients with specialists in distant locations, reducing travel burdens and wait times. It can also enhance preventative care through remote monitoring and medication management. However, the success of telehealth hinges on digital health literacy. Equipping rural communities with the skills to navigate these technologies is crucial for maximizing their benefits. This article delves into the challenges and opportunities presented by telehealth in rural areas. It discusses how initiatives promoting digital health literacy can empower communities and ensure equitable access to quality health care. Ultimately, it argues that by embracing technological advancements and fostering digital literacy, we can create a future where location no longer dictates the quality of health care received.

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]

Background: Given the low usage of virtual health care prior to the COVID‐19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID‐19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. Methods: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID‐19 pandemic onset. Results: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre‐ to post‐COVID‐19 onset (32.5–16.0% and 44.7–24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in‐person visits compared with the rural cohort (96.6–45.0 vs. 98.0–66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre‐ to post‐COVID‐19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. Conclusions: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits). [ABSTRACT FROM AUTHOR]

IntroductionCommunity Health Workers (CHWs) are the first contact between the community and health services in multiple rural areas in Tanzania. Therefore, Community Health Workers are set to play a crucial role in emergencies and disasters. This cross-sectional study assessed the readiness of CHWs in Itilima concerning preventing the spread of COVID-19.MethodsA total of 190 CHWs and 30 stakeholders were interviewed using quantitative and qualitative methods, respectively. Multivariate linear regression model was used for quantitative data while thematic analysis was used for qualitative data.ResultsThe study revealed that 140/190 (73%) CHWs had adequate knowledge of COVID-19, with 126/190 (66.32%) after receiving on-job training on COVID-19. There was no association between demographic characteristics and CHWs' knowledge of COVID-19. In-depth interviews (IDIs) highlighted that the majority of the CHWs were equipped with PPEs and other working tools to aid their role in response to COVID-19. Challenges such as incentive inadequacy and insufficient working tools were among the major setbacks highlighted by the CHWs during the IDIs.ConclusionCHWs appear to be adaptable and provide relevant feedback thus can take part in emergencies and disasters when capacity building is done.

Gordon M Riha,1 Alyssa Johnson,2 Sadie Arnold,3 Michael S Englehart,1 Simon J Thompson4 1Trauma & General Surgery, Billings Clinic, Billings, MT, USA; 2EMS & Trauma Systems Montana, Chronic Disease Prevention and Health Promotion Bureau, Montana Department of Public Health and Human Services, Helena, MT, USA; 3Laboratory Services, Billings Clinic, Billings, MT, USA; 4Collaborative Science & Innovation, Billings Clinic, Billings, MT, USACorrespondence: Simon J Thompson, Collaborative Science & Innovation, Billings Clinic, Billings, MT, USA, Tel +1 503 267 7314, Fax +1 406 435-1586, Email sthompson11@billingsclinic.orgPurpose: 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.Keywords: rural health care, blood transfusion, health services accessibility, trauma

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021–2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

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]

Abstract 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 69.89%), of which the effect size was 774.81 (95% CI 495.63, 1053.98, p 5.99%, β = 237.00, p

Maintaining and improving the health and well-being of older people in rural communities through integrated care is essential to address this cohort’s frailty risk. The Indigo 4Ms Tool for health workers is a rural-specific approach to providing care that addresses the common conditions of ageing. With Australian government funding, five small rural health services are implementing the tool. This paper describes the protocol for a hybrid type 2 implementation-effectiveness study to evaluate the tool’s impact on multidisciplinary comprehensive care planning and the implementation strategies that enhance the adoption and sustainability of the tool across diverse rural health settings.

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]

Longitudinal integrated clerkships (LICs) are effective in promoting careers in rural primary health care environments. This model of training medical professionals involves longer clinical placements of medical students and a different approach to learning which better prepares them for primary health care practice. Stellenbosch University created a LIC in 2011 for this purpose and has trained almost 100 doctors in their yearlong LIC since then. The past 12 years have brought about a lot of learning as this model of training was implemented, developed, and refined to suit the needs of students and the clinical environments. Contribution: Countries across the globe face challenges in recruiting and retaining doctors in rural primary health care environments. Longitudinal integrated clerkships have several educational benefits in addition to increase recruitment and retention of rural doctors, and 12 years of experience have led to a greater understanding regarding implementation and outcomes of an LIC in the South African context.

In a globalized world where pathology and risk can flow freely across borders, the discipline of global health equity has proposed to meet this challenge with an equal exchange of solutions, and people working toward those solutions. Considering the history of colonialism, ongoing economic exploitation, and gaping inequities across and within countries, these efforts must be taken with care. The Partners In Health program in Chiapas, Mexico was founded in 2011 by a team of leaders from both the United States and Mexico to strengthen the public health and care delivery systems serving impoverished rural populations. Key to the strategy has been to marshal funding, knowledge, and expertise from elite institutions in both the United States and Mexico for the benefit of an area that previously had rarely seen such inputs, but always in close partnership with local leaders and community processes. With now over a decade of experience, several key lessons have emerged in both what was done well and what continues to present ongoing challenges. Top successes include: effective recruitment and retention strategies for attracting talented Mexican clinicians to perform their social service year in previously unappealing rural placements; using effective fund-raising strategies from multinational sources to ensure the health care delivered can be exemplary; and effectively integrating volunteer clinicians from high-income contexts in a way that benefits the local staff, the foreign visitors, and their home institutions. A few chief ongoing challenges remain: how to work with local communities to receive foreign visitors; how to hire, develop, and appropriately pay a diverse workforce that comes with differing expectations for their professional development; and how to embed research in non-extractive ways. Our community case study suggests that multinational global health teams can be successful if they share the goal of achieving mutual benefit through an equity lens, and are able to apply creativity and humility to form deep partnerships.

Introduction: Tamil Nadu has a well-established public health-care delivery system with the Auxiliary Nurse and Midwifery (ANM) or Village Health Nurses. They learn and qualify for their job from ANM institutes and become the key field level functionary who interacts directly with the community. Their ability to provide quality community care is largely determined by the quality of ANM education they receive during their training. Hence, this study aimed to assess the perception of these students to facilitate a conducive educational environment. Methods: A descriptive study was carried out among 244 ANM students from across 10 randomly selected government ANM schools in Tamil Nadu. A self-administered Dundee Ready Educational Environment Measure (DREEM) questionnaire was used for assessment. The data was analyzed using EpiData. Results: Among the 244 students enrolled in the study, the mean (standard deviation) global DREEM score was 167.39 (±18.06). Student's academic perception was the highest (91%), followed by student's perception of atmosphere (84.2%), learning (84%), and teachers (83.5%), and the least average score was from student's social self-perception (74%). Conclusion: The study showed the nursing students' view on their academic learning environment as “more positive than negative,” Centers were also considered excellent, and this assessment would provide an useful guide into the areas that students felt “good” about, which should be reinforced and the weaker areas that need to be strengthened for better services.

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]

Introduction: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. Methods: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. Results: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. Conclusion: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs. [ABSTRACT FROM AUTHOR]

Adolescents living in rural areas are less likely to be up to date on the human papillomavirus (HPV) vaccine, which can prevent cervical cancer. We administered a telephone survey to 27 clinics in rural East Texas to assess perceived barriers to HPV vaccination and current use of evidence-based interventions to promote HPV vaccination. Perceived barriers were assessed using a 5-point Likert scale and clinical implementation of evidence-based practices was determined. Findings are reported using descriptive statistics. The most commonly reported barriers were missed vaccination opportunities due to the pandemic (66.7%), followed by vaccine hesitancy due to the pandemic (44.4%) and due to the HPV vaccine specifically (33.3%). Fewer than a third of clinics reported using the evidence-based strategies of use of a "refusal to vaccinate" form (29.6%), having an identified HPV vaccine champion (29.6%), and recommending the HPV vaccine at age 9 (22.2%). While many clinics surveyed currently implement evidence-based practices to promote HPV vaccination, there is a need and desire for additional HPV vaccination interventions in East Texas clinics. [ABSTRACT FROM AUTHOR]

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.

Introduction: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. Methods: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. Results: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. Conclusion: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

At least half of the world’s population still do not have full coverage of essential health services and the available health-care services are also not equitably distributed, the rural areas being the generally underserved ones. Several factors influence attraction and retention of doctors in rural areas which are related to international and national contexts, work-related factors, environmental and living conditions, and individual or personal factors which includes family and social support, in addition to personal aspirations. Innovative strategies have been worked out and implemented to address these problems and fill the gaps in the areas of educational, regulatory, financial and professional and personal support. This review discusses the educational strategies which are targeted at all levels viz. selection of candidates for admission, and subsequent undergraduate, internship, and postgraduate teaching and training that can be oriented toward rural health and health-care services

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 %).ConclusionOur 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.

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]

Social workers and other health care researchers have examined benefits and challenges of telehealth in rural communities before the COVID-19 pandemic. Yet, experience with virtual platforms and other technologies have rapidly evolved during the pandemic. The research team interviewed 14 health care providers and 17 patients after the onset of the pandemic in a predominantly rural state to examine perceptions of telehealth. MaxQDA analytic software was used to identify benefits and challenges in the use of telehealth. Findings identified commonly discussed benefits of telehealth including convenience for patients, increasing patient access to care, improved patient experience of care, and ability of telehealth to attract/retain patients. Challenges identified in this study included concerns about quality of care being compromised, patients' comfort and access to technology, policy challenges for providers, and the impersonal nature of telehealth visits. Persistent issues warrant research, education, and policy advocacy to improve access for rural populations. Social workers should play a key role in educating the emerging and existing workforce around barriers such as quality of care and patient comfort with technology, convening professionals and patients to establish sustained and effective reimbursement models, and advocating for structural access via enhanced broadband and other resource allocations. [ABSTRACT FROM AUTHOR]

Background: Families increasingly desire to bring their children home from the acute care setting at end of life. This transition includes home to rural or remote areas. Little is known about the end-of-life care for children who reside in rural areas. Objective: The purpose of this study was to comprehensively review and summarize the evidence regarding end-of-life care for children living in rural areas, identify key findings and gaps in the literature, and make recommendations for future research. Methods: A systematic review was conducted from 2011 to 2021 using MEDLINE and CINAHL databases. Results: Nine studies met inclusion criteria. Key themes from the literature included: barriers, facilitators, and needs. Three articles identified barriers to end-of-life care for children in rural communities, which included access to end-of-life care and clinicians trained to provide pediatric care. Three studies identified and evaluated the facilitators of end-of-life care for rural children. The articles identified technology and additional training as facilitators. Four studies reported on the needs of rural children for end-of-life care with serious illness. Conclusions: We found major barriers and unmet needs in the delivery of rural pediatric end-of-life care. A few facilitators in delivery of this type of care were explored. Overall research in this area was sparse. Future studies should focus on understanding the complexities associated with delivery of pediatric end-of-life care in rural areas. [ABSTRACT FROM AUTHOR]

The U.S. government has supported rural hospitals through direct subsidies and staff recruitment programs. However, little is known about the long-run impact of large-scale changes to rural health care. The authors explore the long-run trajectory of Appalachian counties where a coal mining union introduced a pioneering rural health care program in the 1950s, anchored by a chain of high-quality hospitals. Hospital beds per capita in counties where the union built its hospitals are persistently high through 2006, even when compared to similar counties and accounting for a variety of supply- and demand-side factors. In particular, union counties defied a national hospital consolidation trend starting in the 1980s. Results are consistent with a supply-side explanation where the scale and/or innovation of the union's investment allowed hospital markets to thrive and attract patients from a broad geography. [ABSTRACT FROM AUTHOR]

Introduction: Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. Methods: Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. Results: The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. Conclusion: It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process. [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]

Abstract 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.

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.

Adolescents living in rural areas are less likely to be up to date on the human papillomavirus (HPV) vaccine, which can prevent cervical cancer. We administered a telephone survey to 27 clinics in rural East Texas to assess perceived barriers to HPV vaccination and current use of evidence-based interventions to promote HPV vaccination. Perceived barriers were assessed using a 5-point Likert scale and clinical implementation of evidence-based practices was determined. Findings are reported using descriptive statistics. The most commonly reported barriers were missed vaccination opportunities due to the pandemic (66.7%), followed by vaccine hesitancy due to the pandemic (44.4%) and due to the HPV vaccine specifically (33.3%). Fewer than a third of clinics reported using the evidence-based strategies of use of a “refusal to vaccinate” form (29.6%), having an identified HPV vaccine champion (29.6%), and recommending the HPV vaccine at age 9 (22.2%). While many clinics surveyed currently implement evidence-based practices to promote HPV vaccination, there is a need and desire for additional HPV vaccination interventions in East Texas clinics.

No abstract available.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

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]

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Purpose: Rural areas of the United States have experienced outbreaks of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among people who use drugs (PWUD). Pharmacy‐based interventions may play a crucial role in prevention and entry into care, especially when traditional health care access is limited. The willingness of rural PWUD to use pharmacies for HIV/HCV‐related services remains unknown. The purpose of this study was to describe the factors associated with the perceived likelihood of participating in free pharmacy‐based HIV and HCV testing among PWUD living in rural Kentucky. Methods: Baseline data from the CARE2HOPE study in five Appalachian counties in eastern Kentucky were used. Participants were recruited using respondent‐driven sampling and completed interviewer‐administered surveys. Guided by the Andersen and Newman Framework of Health Services Utilization, we examined distributions and correlates of items regarding willingness to participate in free pharmacy‐based HIV/HCV testing using logistic regression. Analyses included individuals who reported being HIV (N = 304) or HCV (N = 185) negative. Findings: Seventy‐five percent of PWUD reported being "very likely" to participate in free pharmacy‐based HIV testing and 80% for HCV testing. Two factors were associated with being less willing to participate in free HIV testing: PWUD who previously tested for HIV (OR: 0.47, CI: 0.25–0.88) and PWUD who obtained a high school diploma or equivalent compared to those who completed less (OR: 0.50, CI: 0.26–0.99). Conclusion: Free pharmacy‐based HIV and HCV testing was invariably acceptable among most of the rural PWUD in our sample, suggesting that pharmacies might be acceptable testing venues for this population. [ABSTRACT FROM AUTHOR]

At least half of the world's population still do not have full coverage of essential health services and the available health-care services are also not equitably distributed, the rural areas being the generally underserved ones. Several factors influence attraction and retention of doctors in rural areas which are related to international and national contexts, work-related factors, environmental and living conditions, and individual or personal factors which includes family and social support, in addition to personal aspirations. Innovative strategies have been worked out and implemented to address these problems and fill the gaps in the areas of educational, regulatory, financial and professional and personal support. This review discusses the educational strategies which are targeted at all levels viz. selection of candidates for admission, and subsequent undergraduate, internship, and postgraduate teaching and training that can be oriented toward rural health and health-care services. [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]