The Health Beliefs of Migrant Farmworker Parents: An Ethnographic Exploration

The purpose of this study was to explore the health beliefs of migrant farmworkers parents by approaching and interviewing the sample population in a health clinic where they seek care for their children. It is impossible to plan, implement care, or create health care delivery models without knowledge of health beliefs. An understanding of parental health beliefs in the vulnerable population of migrant farmworkers will assure a more informed approach to health matters of their children, while also improving health care delivery and providing culturally specific health care models. Collecting data in locations historically proven to generate trust and respect supported the objectives of this research study and promoted direct engagement with a group that is often misunderstood and marginalized. Twenty migrant farmworkers parents were interviewed during growing season in the largely agricultural setting of Weld County, Colorado. Associated variables/phenomena determining health beliefs include parental decision-making regarding children's health maintenance, injury prevention, and health care. The overarching theme that emerged from the data was pride in having healthy children with major themes of respect, convenience and inhibition/suppression.

A growing geographic disparity: Rural and urban cigarette smoking trends in the United States

Rural areas of the United States have a higher smoking prevalence than urban areas. However, no recent studies have rigorously examined potential changes in this disparity over time or whether the disparity can be explained by demographic or psychosocial characteristics associated with smoking. The present study used yearly cross sectional data from the National Survey on Drug Use and Health from 2007 through 2014 to examine cigarette smoking trends in rural versus urban areas of the United States. The analytic sample included 303,311 respondents. Two regression models were built to examine (a) unadjusted rural and urban trends in prevalence of current smoking and (b) whether differences remained after adjusting for demographic and psychosocial characteristics. Results of the unadjusted model showed disparate and diverging cigarette use trends during the 8-year time period. The adjusted model also showed diverging trends, initially with no or small differences that became more pronounced across the 8-year period. We conclude that differences reported in earlier studies may be explained by differences in rural versus urban demographic and psychosocial risk factors, while more recent and growing disparities appear to be related to other factors. These emergent differences may be attributable to policy-level tobacco control and regulatory factors that disproportionately benefit urban areas such as enforcement of regulations around the sale and marketing of tobacco products and treatment availability. Strong federal policies and targeted or tailored interventions may be important to expanding tobacco control and regulatory benefits to vulnerable populations including rural Americans.

Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study

Background

Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP.

Methods

This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA.

Discussion

The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.

Obstetric Provider Maldistribution: Georgia, USA, 2011

Objectives In 2010, Georgia had the nation's highest maternal mortality rate, sixteenth highest infant mortality rate, and a waning obstetrician/gynecologist (ob/gyn) workforce. Statewide ob/gyn workforce data, however, masked obstetric-specific care shortages and regional variation in obstetric services. The Georgia Maternal and Infant Health Research Group thereby assessed each Georgia region's obstetric provider workforce to identify service-deficient areas. Methods We identified 63 birthing facilities in the 82 Primary Care Service Areas (PCSAs) outside metropolitan Atlanta and interviewed nurse managers and others to assess the age, sex, and expected departure year of each delivering professional. Using accepted annual delivery rates of 155 per obstetrician (OB), 100 per certified nurse midwife (CNM), and 70 per family medicine physician (FP) we converted obstetric providers into "OB equivalents" to standardize obstetric services available in any given area. Using facility births and computed OB equivalents (contemporary and 2020 estimates), we calculated current and projected average annual births per provider (AABP) for each PCSA, categorizing its obstetric provider workforce as "adequate" (AABP < 144), "at risk" (144 ≤ AABP ≤ 166), or "deficient" (AABP > 166). We mapped results using ArcGIS. Results Of 82 surveyed PCSAs, 52 % (43) were deficient in obstetric care; 16 % (13) had a shortage and 37 % (30) lacked obstetric providers entirely. There were no delivering FPs in 89 % (73) of PCSAs and no CNMs in 70 % (56). If Georgia fails to recruit delivering providers, 72 % (58/77) of PCSAs will have deficient or no obstetric care by 2020. Conclusions Obstetric provider shortages in Georgia hinder access to prenatal and delivery services. Care-deficient areas will expand if recruitment and retention of delivering professionals does not improve.

Maternity care access, quality, and outcomes: A systems-level perspective on research, clinical, and policy needs

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

It's more than just luck: A qualitative exploration of breastfeeding in rural Australia

It's more than just luck: A qualitative exploration of breastfeeding in rural Australia PROBLEM: Despite significant public health benefits, breastfeeding for six months continues to be challenging for women.

BACKGROUND

In the Mid North of South Australia, healthcare professionals were concerned that breastfeeding rates were lower than the national average and that a collaborative approach was needed to promote breastfeeding.

AIM

To explore the experiences of women and health professional in the Mid North, to inform interventions to improve breastfeeding longevity.

METHOD

Two focus groups were conducted to examine breastfeeding experience in the region. Focus group one included nine mothers who had breastfed more than six months and focus group two consisted of ten health professionals from the Mid North. Thematic analysis was used to analyse the data.

FINDINGS

Two overarching themes were identified; 'breastfeeding: It's more than just luck' represented the voices of the mothers and 'breastfeeding: It's everybody's business' captured the discussion between the health professionals. Women described themselves as lucky while acknowledging that their own persistence, as well as positive support was vital. Health professionals identified education and support as key foci, and a need for a holistic approach to improve breastfeeding rates.

DISCUSSION

Breastfeeding should be understood as a relationship, in which broadly applied solutions do not necessarily influence longevity, particularly in rural communities. Strategies should also reflect a realistic picture of breastfeeding and safeguard against idealistic expectation of the experience.

CONCLUSION

A holistic approach to improve breastfeeding rates is imperative. One of the most promising antidotes to the breastfeeding dilemma is the provision of midwifery continuity of care.

General practitioners' experiences and perceptions of mild moderate depression management and factors influencing effective service delivery in rural Australian communities: a qualitative study

BACKGROUND

Rural communities in Australia face significant disadvantages relating to geographical isolation and limited access to mental health services. Documenting general practitioners' (GP) experiences and perception of mental health services in rural Australia may be useful to gain insight into rural GP management of mild to moderate depression.

AIMS

To explore GPs' experience and views on which factors influence access to mental health services for mild to moderate depression.

METHOD

This qualitative study was conducted in 2014 in the Northern Rivers, NSW, Australia. Data were obtained from semi-structured in-depth face-to-face interviews with ten GPs, and analyses were performed using a general inductive method of thematic analysis.

RESULTS

Most GPs believed that the current services for managing mild-moderate depression were adequate, however they also identified the need for better access and more services that were free for patients. GPs had a positive perception of management of depression in a rural setting, identifying advantages including better doctor-patient relationships, continuity of care and the proximity of services. However, GPs also identified several barriers to access to mental health services in a rural setting, including long waiting-times, inadequate patient rapport with referred professionals, cost of treatment, transportation, geographical location, stigma, and lack of education about available mental health services. As a result, GPs frequently self-managed patients in addition to referring them to other community mental health service providers where possible.

CONCLUSION

Overall, GPs appeared relatively satisfied with the resources available in their communities but also identified numerous barriers to access and room for improvement. Rural GPs often self-managed patients in addition to referring patients to other mental health services providers. This should be taken into account when designing mental health policies, developing new services or re-designing current services in rural communities.

Feasibility of a low-cost hearing screening in rural Indiana

Background

Hearing loss remains a neglected public health issue in the rural and agricultural communities in the United States and therefore, promotion of a low-cost hearing screening may be important for these underserved populations. The major objectives of our study were to assess feasibility of a low-cost telephone-administered hearing test in rural Indiana and to identify the challenges, barriers and viable implementation strategies associated with this test. Also, we evaluated whether a focus group session could change the hearing health attitude of rural residents.

Methods

We recruited 126 adults from six rural Indiana counties who participated in study activities in the following order: 1) a pre-focus group demographic, knowledge and attitude survey, 2) a focus group for discussing the feasibility of a telephone-administered hearing screening, 3) a post focus group attitude survey and 4) hearing was screened using an audiometer and self-assessment scale. These activities generated both qualitative and quantitative data, which were subsequently analyzed.

Results

Hearing impairment was perceived as an important public health issue. Many participants expressed interests to try the low-cost National Hearing Test (NHT). However, participants recommended NHT to be facilitated by community organizations to provide access to landline phones. The focus group turned out to be an excellent awareness building activity producing significant improvement in hearing health attitudes. Comparison of self and audiometric evaluations indicated underestimation of hearing handicap in our rural study population.

Conclusions

The study results underscore the urgent need for an effective strategy to promote low-cost hearing screening in rural US communities.

Evaluation of Healthy2Go: A country store transformation project to improve the food environment and consumer choices in Appalachian Kentucky

Rates of obesity and type 2 diabetes in Kentucky's Cumberland Valley region are among the highest in the United States and limited access to healthy food contributes to these epidemics. The aim of Healthy2Go (H2G), a country store transformation project launched by Spread the Health Appalachia (STHA), was to improve awareness and availability of healthy options in small, rural stores. Ten country stores participated in H2G and received training and technical assistance to increase availability and awareness of healthy foods. Stores made inventory changes; installed point-of-purchase educational and in-store marketing materials directing shoppers to healthier options; provided nutrition education such as healthy recipes; and altered the display and location of healthy items. To measure changes within stores and the potential impact on resident eating and purchasing habits, STHA used four instruments: a modified version of the Nutrition Environs Measures Survey - Corner Stores at baseline and follow-up, a bimonthly store inventory assessment, a final store owner survey, and a Community Nutrition Survey at baseline (n = 287) and follow-up (n = 281). The stores in the H2G program (n = 10) had a 40% increase in stocking fresh produce, a 20% increase in produce variety, and trends towards increasing healthy inventory. During the same period, surveyed residents reported a statistically significant increase in the frequency of healthy food consumption. Small store transformation programs can improve availability of and access to healthy food in rural settings and influence local purchasing patterns.

Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India

Background

Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities.

Methods

An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention.

Results

In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (β) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: β = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: β = 11.66; 95% CI = 10.06, 13.27. Adjusted: β = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: β = 15.74; 95% CI = 14.39, 17.08; Adjusted: β = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time.

Conclusions

Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1452-z) contains supplementary material, which is available to authorized users.

Colorectal cancer screening in rural and poor-resourced communities

To test the efficacy of a community-based intervention, Empowering Communities for Life (EC4L), designed to increase colorectal cancer (CRC) screening through fecal occult blood test (FOBT) in rural underserved communities in a randomized controlled trial. Participants were randomized into 3 groups (2 interventions and 1 control). Interventions were delivered by community lay health workers or by academic health professionals. The main outcome of interest was return rate of FOBT screening kit within 60 days. Participants included 330 screening-eligible adults. The overall return rate of FOBT kits within 60 days was 32%. The professional group (Arm 2) had the highest proportion of returned FOBTs within 60 days at 42% (n = 46/110), a significantly higher return rate than the lay group (Arm 1) [28%(n = 29/103);P = 0.0422] or control group (Arm 3) [25%(n = 29/117);P = 0.0099]. Thus, one arm (Arm 2) of our intervention produced significantly higher CRC screening through FOBT. Community-based participation partnered with academic health professionals enhanced CRC screening among rural and poor-resourced communities.

Exploring the determinants of health and wellbeing in communities living in proximity to coal seam gas developments in regional Queensland

Background

There is some concern that coal seam gas mining may affect health and wellbeing through changes in social determinants such as living and working conditions, local economy and the environment. The onward impact of these conditions on health and wellbeing is often not monitored to the same degree as direct environmental health impacts in the mining context, but merits attention. This study reports on the findings from a recurrent theme that emerged from analysis of the qualitative component of a comprehensive Health Needs Assessment (HNA) conducted in regional Queensland: that health and wellbeing of communities was reportedly affected by nearby coal seam gas (CSG) development beyond direct environmental impacts.

Methods

Qualitative analysis was initially completed using the Framework Method to explore key themes from 11 focus group discussions, 19 in-depth interviews, and 45 key informant interviews with health and wellbeing service providers and community members. A key theme emerged from the analysis that forms the basis of this paper. This study is part of a larger comprehensive HNA involving qualitative and quantitative data collection to explore the health and wellbeing needs of three communities living in proximity to CSG development in regional Queensland, Australia.

Results

Communities faced social, economic and environmental impacts from the rapid growth of CSG development, which were perceived to have direct and indirect effects on individual lifestyle factors such as alcohol and drug abuse, family relationships, social capital and mental health; and community-level factors including social connectedness, civic engagement and trust.

Conclusions

Outer regional communities discussed the effects of mining activity on the fabric of their town and community, whereas the inner regional community that had a longer history of industrial activity discussed the impacts on families and individual health and wellbeing. The findings from this study may inform future health service planning in regions affected by CSG in the development /construction phase and provide the mining sector in regional areas with evidence from which to develop social responsibility programs that encompass health, social, economic and environmental assessments that more accurately reflect the needs of the affected communities.

Adolescent Tobacco Use in Urban Versus Rural Areas of the United States: The Influence of Tobacco Control Policy Environments

PURPOSE

Adults and adolescents who reside in rural areas of the United States are traditionally more likely to be tobacco users. This urban-rural disparity remains largely unexplained and, more recently, it is unclear what impact the emergence of electronic cigarettes (e-cigarettes) has had on adolescent tobacco use in urban and rural areas. Our objective is to evaluate the influence of sociodemographics and tobacco control policy environments on adolescent tobacco use in urban versus rural areas, as well as to identify the effect of e-cigarettes on traditional patterns of urban-rural tobacco use.

METHODS

This study analyzes repeated cross-sectional data from the National Youth Tobacco Survey for the years 2011-2014. We estimate the associations between rural residence, cigarette taxes, tobacco advertisement exposure, and ease of access to tobacco with six tobacco use outcomes: current (past 30-day) use of cigarettes, e-cigarettes, cigars, smokeless tobacco, multiple tobacco products, and any tobacco.

RESULTS

E-cigarette use among urban youths aged 11-17 years in the United States increased from .82% in 2011 to 8.62% in 2014 (p < .001). Tobacco advertisement exposure was significantly positively associated with all current tobacco use outcomes (p < .001) except for e-cigarettes. Our predictors account for approximately 40% of the difference in urban-rural cigarette use.

CONCLUSIONS

Sociodemographics, cigarette taxes, and tobacco advertisement exposure are significant predictors of adolescent tobacco use in the United States but do not entirely explain urban-rural disparities. In addition, e-cigarettes appear to be rapidly changing traditional patterns of tobacco use, particularly in urban areas.

It takes a village: Exploring the impact of social determinants on delivery system outcomes for heart failure patients

BACKGROUND

Local social determinants may act as effect modifiers for the impact of neighborhood material deprivation on patient-level healthcare outcomes. The objective of this study was to understand the mediating effect of local social determinants on neighborhood material deprivation and delivery outcomes in heart failure (HF) patients.

MATERIAL AND METHODS

A retrospective cohort study was conducted using 4737 HF patients receiving inpatient care (n=6065 encounters) from an integrated healthcare delivery system from 2010 to 2014. Outcomes included post-discharge mortality, readmission risk and length of stay. Deprivation was measured using an area deprivation index by address of residence. Effect modifications measured included urban-rural residency and faith identification using generalized linear regression models. Patient-level data was drawn from the delivery system data warehouse.

RESULTS

Faith identification had a significant protective effect on HF patients from deprived areas, lowering 30-day mortality odds by one-third over patients who did not identify with a faith (OR 0.35 95%CI:0.12-0.98;p=0.05). Significant effects persisted at the 90 and 180-day timeframes. In rural areas, lack of faith identification had a multiplicative effect on 30-day mortality for deprived patients (OR 14.0 95%CI:1.47-132.7;p=0.02). No significant effects were noted for other healthcare outcomes.

CONCLUSIONS

The lack of expected association between area deprivation and healthcare outcomes in some communities may be explained by the presence of effect modifiers.

IMPLICATIONS

Understanding existing effect modifiers for area deprivation in local communities that delivery systems serve can inform targeted quality improvement. These factors should also be considered when comparing delivery system performance for reimbursement and in population health management.

Implementation of a School-Based Educational Program to Increase Breast Cancer Awareness and Promote Intergenerational Transmission of Knowledge in a Rural Mexican Community

BACKGROUND

Rural women have limited access to breast cancer education, which partially contributes to late diagnosis and treatment. In this pilot study, we tested the feasibility of implementing a school-based breast cancer educational program for adolescents in a rural Mexican community. We hypothesized that the adolescents' knowledge on breast cancer would increase as a result of the program, and that there would be intergenerational transmission of that knowledge to their older female relatives.

MATERIALS AND METHODS

Female adolescents from a rural middle school received the educational program. The program would be considered feasible and acceptable if more than 75% reported being satisfied with its contents. Changes in knowledge in the students and their relatives were evaluated using baseline and 4 months follow-up questionnaires.

RESULTS

One hundred twenty-six students were enrolled. The program was considered acceptable by 96% of the participants. The students' knowledge regarding breast cancer increased significantly from baseline to 4 months follow-up (63% to 82%). One hundred ninety-four female relatives completed the initial knowledge questionnaires. The relatives' knowledge regarding breast cancer showed a significant increase from baseline to 4 months follow-up (55% to 61%).

CONCLUSION

Implementing breast cancer educational programs for adolescents in rural communities is feasible and acceptable. The program increased the adolescents' knowledge on breast cancer, and promoted the intergenerational transmission of that knowledge to their female relatives. Intergenerational transmission of knowledge represents a potential method for providing population-based health awareness education globally.

IMPLICATIONS FOR PRACTICE

In limited-resource settings, education is a valuable tool for achieving early detection and downstaging of breast cancer. Unfortunately, rural women lack access to educational opportunities and information about breast cancer, which is a factor contributing to late diagnosis and treatment. In this study, we demonstrated that implementing a school-based breast cancer educational program for female adolescents in a rural Mexican community was feasible, acceptable, and increased their knowledge about breast cancer. Furthermore, the program encouraged the transmission of information to the students' older relatives. Intergenerational transmission of knowledge represents a novel and potentially effective tool in cancer education and promotion.

Development and testing of a community audit tool to assess rural built environments: Inventories for Community Health Assessment in Rural Towns

Rural populations face unique challenges to physical activity that are largely driven by environmental conditions. However, research on rural built environments and physical activity is limited by a paucity of rural-specific environmental assessment tools. The aim of this paper is to describe the development and testing of a rural assessment tool: Inventories for Community Health Assessment in Rural Towns (iCHART). The iCHART tool was developed in 2013 through a multistep process consisting of an extensive literature search to identify existing tools, an expert panel review, and pilot testing in five rural US communities. Tool items represent rural built environment features that influence active living and physical activity: community design, transportation infrastructure, safety, aesthetics, and recreational facilities. To assess reliability, field testing was performed in 26 rural communities across five states between July and November of 2014. Reliability between the research team and community testers was high among all testing communities (average percent agreement = 77%). Agreement was also high for intra-rater reliability (average kappa = 0.72) and inter-rater reliability (average percent agreement = 84%) among community testers. Findings suggest that the iCHART tool provides a reliable assessment of rural built environment features and can be used to inform the development of contextually-appropriate physical activity opportunities in rural communities.

•

Rural built environment research is limited by a lack of rural-specific tools.

•

We developed and tested a rural assessment tool: iCHART

•

Reliability between the research team and community testers was high.

•

Intra- and inter-rater reliabilities were also high among community testers.

•

Our tool can reliably and feasibly assess rural built environment features.

High burden of Schistosoma mansoni infection in school-aged children in Marolambo District, Madagascar

Background

A school-based survey was undertaken to assess prevalence and infection intensity of schistosomiasis in school-aged children in the Marolambo District of Madagascar.

Methods

School-aged children from six purposively selected schools were tested for Schistosoma haematobium by urine filtration and Schistosoma mansoni using circulating cathodic antigen (CCA) and Kato-Katz stool analysis. The investigators did not address soil-transmitted helminths (STH) in this study.

Results

Of 399 school-aged children screened, 93.7% were infected with S. mansoni based on CCA analysis. Kato-Katz analysis of stool revealed S. mansoni infection in 73.6% (215/ 292). Heavy infections (> 400 eggs per gram) were common (32.1%; 69/ 215), with a mean of 482 eggs per gram of stool. Moderate infection intensities were detected in 31.2% (67/ 215) and light infection intensities in 36.7% (79/ 215) of infected participants. No infection with S. haematobium was detected by urine filtration.

Conclusions

Intestinal schistosomiasis appears a considerable public health issue in this remote area of Madagascar where there is a pressing need for mass drug administration.

Assessing the active living environment in three rural towns with a high proportion of Native Hawaiians and other Pacific Islanders

Background: Existing literature on the built environment and physical activity in rural areas is very limited. Studies have shown that residents in rural areas are less likely to meet physical activity requirements than their counterparts living in urban and suburban areas. They are also less likely to have access to amenities and programs that promote physical activity. This study seeks to fill gaps in the literature by assessing the built environment in three rural towns in Hawai'i that have a high proportion of Native Hawaiians and other Pacific Islanders. Methods: The Rural Active Living Assessment (RALA) tools will be used to assess the built environment. The RALA has three components - Policy and Program Assessment (PPA), Town Wide Assessment (TWA), and Street Segment Assessment (SSA) which will be used to provide a comprehensive assessment of the active living environment. Assessments were completed in September and October 2016. Results: One assessment was completed in each town for the TWA and PPA. The SSA was completed with 60 segments (20 from each town). Conclusion: The RALA tools identified supports in these three rural towns. The assessment also identified barriers and gaps - especially with the town and school polices of each town.

Physical activity of rurally residing children with a disability: A survey of parents and carers

BACKGROUND

Children residing in rural areas face unique barriers to physical activity participation. Further, while children with a disability who reside in metropolitan areas face barriers hindering physical activity, rurally residing children with a disability may face the augmented combination of these barriers that could have negative health implications. Parents are often the key advocates for children with disabilities and are likely to have valuable insight into the opportunities and barriers to physical activity for their child.

OBJECTIVE

The aim of this study was to investigate parents' perceptions of physical activity opportunities for their child with a disability in a rural area.

METHODS

A mixed method survey examining parent's perceptions of their child's physical activity and possible barriers to participation was mailed to rurally residing parents of children with a disability. Quantitative data were analyzed descriptively using frequencies and proportions. Qualitative data were analyzed using qualitative content analysis.

RESULTS

There were 34 completed surveys, a response rate of 37%. Participants' responses indicated 74% of children were not meeting daily recommendations of physical activity. Participation barriers including emotional, physical and environmental issues. Three main themes emerged from qualitative data; segregation, access to facilities and resources and barriers specific to the child.

CONCLUSION

The children in this study were from rural areas and face similar barriers to children in metropolitan areas. However, they are also confronted with the same barriers children without a disability in rural areas face, participating in physical activity. This may have detrimental effects on their health and development.

Evaluation of an extracurricular program for students interested in rural and public health

PURPOSE

The problem regarding the geographic imbalance of the physician workforce has been a long-standing problem in South Korea. Additionally, rural medicine and public health have been marginalized across whole undergraduate curriculums. The aim of this study was to evaluate the effectiveness of an extracurricular program targeting medical students interested in rural and public health.

METHODS

A 2-day extracurricular program was held twice in 2015 and 2016. A total of 53 students were selected among eighty students who voluntarily applied to participate in the program. The effectiveness of the program was evaluated by pre- and post-program surveys.

RESULTS

The overall satisfaction for the program was 5.35 out of 6. The participants showed a significant improvement in perception of the clerkship experience in a rural and public health care setting as well as the importance of rural medicine and public health in South Korea.

CONCLUSION

In conclusion, this study showed the acceptability of a short-term extracurricular program for medical students interested in rural and public health.

Correlates of alcohol consumption in rural western Kenya: A cross-sectional study

BACKGROUND

Studies on alcohol consumption in rural areas in sub-Saharan Africa are scarce. This study aimed to determine the prevalence and determinants of alcohol consumption in rural western Kenya. The study was conducted as a preliminary stage of a community-based intervention to reduce hazardous alcohol consumption.

METHODS

A cross-sectional survey of 478 participants aged 18-65 years residing in Ikolomani Sub-county, Kakamega County was conducted in April 2015. Data were collected using an interviewer-administered questionnaire. We defined current drinkers as participants who consumed any alcoholic product in the preceding one month, and hazardous/high-risk drinkers as participants with an Alcohol Use Disorders Identification Test (AUDIT) score of 8 and above. We summarised data using descriptive statistics and used logistic regression to explore for the correlates of each of current alcohol consumption and hazardous/high-risk alcohol consumption.

RESULTS

The sex-standardized prevalence of current alcohol drinkers was 31.7% (95% confidence interval (CI): 26.8%-37.2%). The prevalence was higher in men (54.6%) than in women (8.9%). The mean AUDIT score among current drinkers was 16.9 (SD 8.2) and the sex-standardized prevalence of hazardous/high-risk alcohol drinking was 28.7% (95% CI: 24.1%-34.0%). Traditional brews were the most commonly consumed types of alcohol and most drinkers took alcohol in the homes of alcohol sellers/brewers. In multivariate analyses, the number of drinkers in the family, the number of friends who are drinkers and the attitude towards alcohol intake were positively associated with current alcohol drinking status, and with hazardous/high-risk alcohol consumption. Women were less likely to be current drinkers and hazardous/high-risk drinkers than were men. Other socio-demographic factors were not significantly associated with alcohol consumption.

CONCLUSIONS

The prevalence of alcohol consumption in the study area was higher than the national level estimate of 13.3%. The results suggest that the social environment is the main determinant of alcohol consumption in this setting. These findings imply that interventions to mitigate alcohol consumption in this area will have to target the social networks of the alcohol consumers, change the drinkers' attitude towards alcohol, and tackle the issue of availability of unlicensed homemade brews.

Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia

An undersupply of generalists doctors in rural communities globally led to widening participation (WP) initiatives to increase the proportion of rural origin medical students. In 2002 the Australian Government mandated that 25% of commencing Australian medical students be of rural origin. Meeting this target has largely been achieved through reduced standards of entry for rural relative to urban applicants. This initiative is based on the assumption that rural origin students will succeed during training, and return to practice in rural locations. One aim of this study was to determine the relationships between student geographical origin (rural or urban), selection scores, and future practice intentions of medical students at course entry and course exit. Two multicentre databases containing selection and future practice preferences (location and specialisation) were combined (5862), representing 54% of undergraduate medical students commencing from 2006 to 2013 across nine Australian medical schools. A second aim was to determine course performance of rural origin students selected on lower scores than their urban peers. Selection and course performance data for rural (461) and urban (1431) origin students commencing 2006-2014 from one medical school was used. For Aim 1, a third (33.7%) of rural origin students indicated a preference for future rural practice at course exit, and even fewer (6.7%) urban origin students made this preference. Results from logistic regression analyses showed significant independent predictors were rural origin (OR 4.0), lower Australian Tertiary Admissions Rank (ATAR) (OR 2.1), or lower Undergraduate Medical and Health Sciences Admissions Test Section 3 (non-verbal reasoning) (OR 1.3). Less than a fifth (17.6%) of rural origin students indicated a preference for future generalist practice at course exit. Significant predictors were female gender (OR 1.7) or lower ATAR (OR 1.2), but not rural origin. Fewer (10.5%) urban origin students indicated a preference for generalist practice at course exit. For Aim 2, results of Mann-Whitney U tests confirmed that slightly reducing selection scores does not result in increased failure, or meaningfully impaired performance during training relative to urban origin students. Our multicentre analysis supports success of the rural origin WP pathway to increase rural student participation in medical training. However, our findings confirm that current selection initiatives are insufficient to address the continuing problem of doctor maldistribution in Australia. We argue for further reform to current medical student selection, which remains largely determined by academic meritocracy. Our findings have relevance to the selection of students into health professions globally.

The effects of rurality on substance use disorder diagnosis: A multiple-groups latent class analysis

BACKGROUND

Rates of accidental overdose mortality from substance use disorder (SUD) have risen dramatically in the United States since 1990. Between 1999 and 2004 alone rates increased 62% nationwide, with rural overdose mortality increasing at a rate 3 times that seen in urban populations. Cultural differences between rural and urban populations (e.g., educational attainment, unemployment rates, social characteristics, etc.) affect the nature of SUD, leading to disparate risk of overdose across these communities.

METHODS

Multiple-groups latent class analysis with covariates was applied to data from the 2011 and 2012 National Survey on Drug Use and Health (n=12.140) to examine potential differences in latent classifications of SUD between rural and urban adult (aged 18years and older) populations. Nine drug categories were used to identify latent classes of SUD defined by probability of diagnosis within these categories. Once the class structures were established for rural and urban samples, posterior membership probabilities were entered into a multinomial regression analysis of socio-demographic predictors' association with the likelihood of SUD latent class membership.

RESULTS

Latent class structures differed across the sub-groups, with the rural sample fitting a 3-class structure (Bootstrap Likelihood Ratio Test P value=0.03) and the urban fitting a 6-class model (Bootstrap Likelihood Ratio Test P value<0.0001). Overall the rural class structure exhibited less diversity in class structure and lower prevalence of SUD in multiple drug categories (e.g. cocaine, hallucinogens, and stimulants).

CONCLUSIONS

This result supports the hypothesis that different underlying elements exist in the two populations that affect SUD patterns, and thus can inform the development of surveillance instruments, clinical services, and prevention programming tailored to specific communities.

Comparative cost-benefit analysis of tele-homecare for community-dwelling elderly in Japan: Non-Government versus Government Supported Funding Models

OBJECTIVE

Tele-homecare is gaining prominence as a viable care alternative, as evidenced by the increase in financial support from international governments to fund initiatives in their respective countries. The primary reason for the funding is to support efforts to reduce lags and increase capacity in access to care as well as to promote preventive measures that can avert costly emergent issues from arising. These efforts are especially important to super-aged and aging societies such as in Japan, many European countries, and the United States (US). However, to date and to our knowledge, a direct comparison of non-government vs. government-supported funding models for tele-homecare is particularly lacking in Japan. The aim of this study is to compare these operational models (i.e., non-government vs. government-supported funding) from a cost-benefit perspective. This simulation study applies to a Japanese hypothetical cohort with implications for other super-aged and aging societies abroad.

METHODS

We performed a cost-benefit analysis (CBA) on two operational models for enabling tele-homecare for elderly community-dwelling cohorts based on a decision tree model, which we created with parameters from published literature. The two models examined are (a) Model 1-non-government-supported funding that includes monthly fixed charges paid by users for a portion of the operating costs, and (b) Model 2-government-supported funding that includes startup and installation costs only (i.e., no operating costs) and no monthly user charges. We performed base case cost-benefit analysis and probabilistic cost-benefit analysis with a Monte Carlo simulation. We calculated net benefit and benefit-to-cost ratios (BCRs) from the societal perspective with a five-year time horizon applying a 3% discount rate for both cost and benefit values. The cost of tele-homecare included (a) the startup system expense, averaged over a five-year depreciation period, and (b) operation expenses (i.e., labor and non-labor) per user per year. The benefit of tele-homecare was measured by annual willingness to pay (WTP) for tele-homecare by a user and medical expenditures avoided. Both costs and benefits were inflated using the relevant Japanese consumer price index (CPI) and converted into 2015 US dollars with purchasing power parity (PPP) adjusted.

RESULTS

Base case net benefits of Model 1 and Model 2 were $417.00 and $97.30, respectively. Base case BCR of Model 1 tele-homecare was 1.63, while Model 2 was 1.03. The probabilistic analysis estimated mean (95%CI) for BCRs of Model 1 and Model 2 was 1.84 (1.89, 1.88) and 1.46 (1.43, 1.49), respectively. Sensitivity analysis showed robustness of Model 1 in 7 parameters but Model 2 was sensitive in all key parameters such as initial system cost, device cost, number of users, and medical expenditure saved. Break-even analysis showed that the system cost of Model 2 had to be under $187,500.

CONCLUSIONS

Our results for each model collectively showed that tele-homecare in Japan is cost-saving to some extent. However, the government-funded model (i.e., Model 2), which typically requires use of all startup funding to be spent within the first year on system costs, was inferior to the monthly fee model (i.e., Model 1) that did not use the government funding for installation or continued operations, but rather incorporated a monthly fee from users to support the receipt of services via tele-homecare. While the benefits of Model 1 outweighed the benefits of Model 2, the government-subsidized method employed in Model 2 could be more beneficial in general if some explicit prequalifying estimated metrics are instituted prior to funding. Thus, governments need to require applicants requesting funding to note, at a minimum, (a) estimated costs, (b) the expected number of tele-homecare users, and expected benefits such as (c) WTP by the user, or (d) medical expenditure saved by tele-homecare as a means of financing some of the operational costs.