Programs to encourage working as a general practitioner in rural areas: why do medical students not want to participate? A cross-sectional study

BACKGROUND

In many countries, not enough students are interested to work as general practitioners in rural areas. To solve this problem, several, sometimes partly extracurricular, programs have been developed. Most of these programs are based on continuity, which means that students stay in a rural region for an extended period of time, by completing clerkships. Although the effects of these programs are positive, it is often difficult to motivate students to participate. The purpose of the present study is to get insight into the reasons why students choose not to participate in these programs.

METHODS

We carried out a questionnaire study among medical students in the clinical phase of the Technical University of Munich in Germany. First, we asked the students whether they actively informed themselves about the program which aims to reduce the shortage of general practitioners in rural areas in Bavaria. Furthermore, the questionnaire focused on the reasons for not participating in this program.

RESULTS

Based on the answers of 442 students from study years 3-6, the most frequently chosen reason for not participating in the program is "identification with another discipline" with 61.0%, directly followed by "not willing to commit long-term" (56.1%). In third place is "personal connections to another region" with 30.5%. In the open comments, we find the same reasons: many students do not want to commit to a certain direction too early. In addition, students indicate that the number of regions where this program is offered is too limited for them.

CONCLUSIONS

Offering programs to prepare and motivate students for work as general practitioners in rural areas can contribute to increasing the pool of future general practitioners. To encourage students to participate in such a program, it is important to consider the motives of students. Many students who might be interested in general practice do not choose to take part in such a program because they do not want to commit to a particular specialty or region at an early stage. It is important to take these insights into account when designing and implementing these programs.

A model of lived experience leadership for transformative systems change: Activating Lived Experience Leadership (ALEL) project

PURPOSE

This discursive paper presents a lived experience leadership model as developed as part of the Activating Lived Experience Leadership (ALEL) project project to increase the recognition and understanding of lived experience leadership in mental health and social sectors. The model of lived experience leadership was formulated through a collaboration between the South Australian Lived Experience Leadership & Advocacy Network and the Mental Health and Suicide Prevention Research and Education Group.

DESIGN/METHODOLOGY/APPROACH

As one of the outcomes of the ALEL research project, this model incorporates findings from a two-year research project in South Australia using participatory action research methodology and cocreation methodology. Focus groups with lived experience leaders, interviews with sector leaders and a national survey of lived experience leaders provided the basis of qualitative data, which was interpreted via an iterative and shared analysis. This work identified intersecting lived experience values, actions, qualities and skills as characteristics of effective lived experience leadership and was visioned and led by lived experience leaders.

FINDINGS

The resulting model frames lived experience leadership as a social movement for recognition, inclusion and justice and is composed of six leadership actions: centres lived experience; stands up and speaks out; champions justice; nurtures connected and collective spaces; mobilises strategically; and leads change. Leadership is also guided by the values of integrity, authenticity, mutuality and intersectionality, and the key positionings of staying peer and sharing power.

ORIGINALITY/VALUE

This model is based on innovative primary research, which has been developed to encourage understanding across mental health and social sectors on the work of lived experience leaders in seeking change and the value that they offer for systems transformation. It also offers unique insights to guide reflective learning for the lived experience and consumer movement, workers, clinicians, policymakers and communities.

Peer effects on the adoption of biogas in rural households of Sichuan Province, China

Encouraging rural residents to adopt biogas is of great practical significance in tackling environmental degradation in China. Based on the survey data of 540 rural households in Sichuan Province, China, this paper studies the peer effects of biogas adoption in rural households, focusing on the influence of relatives and friends on the biogas adoption behavior of rural households. According to whether there is a Chinese New Year visit, the relatives and friends of rural households are divided into strong ties and weak ties. The peer effects are further discussed from the perspective of strong and weak ties, and the probability score matching (PSM) method is used to correct the estimation errors that may be caused by selection bias. In addition, the study further revealed the internal mechanism of peer effects through heterogeneity analysis. The results found that (1) the adoption of biogas by relatives and friends significantly promotes the adoption of biogas in rural households. (2) Compared with relatives and friends who did not visit during the Chinese New Year (weak ties), relatives and friends who visited (strong ties) had a more significant impact on the biogas adoption behavior of rural families. (3) Farmer groups with lower education levels and farther from the market are more affected by the peer effects and are more likely to adopt biogas. The driving effect of biogas behavior choice of relatives and friends on biogas behavior decision of rural households can provide a reference for decision-makers to make relevant measures.

Association between dependency on community resources and social support among elderly people living in rural areas in China: a cross-sectional study

BACKGROUND

The prevalence of dependency personality disorder (DPD) is high among elderly people living in rural areas. This study aims to explore the association between dependency on community resources and social support among elderly individuals living in rural areas.

METHODS

A cross-sectional study was conducted in 26 locations in China. A total of 1160 participants aged ≥ 60 years were selected using a complex multistage sampling design. All data were obtained using questionnaires via face-to-face interviews. DPD was measured using the Minnesota Multiphasic Personality Inventory-II in the standardized Chinese version. Self-efficacy was assessed using the Chinese version of the General Self-Efficacy Scale. Social support was measured using the Chinese version of the questionnaires of the Older American Resources and Services scale. Community services and resources comprised 44 items. The association between DPD and levels of social support and self-efficacy was evaluated using a logistic regression model. The association between social support and self-efficacy was assessed using analysis of covariance.

RESULTS

Univariate analysis results showed that elderly people living in rural areas had higher DPD scores and lower levels of self-efficacy compared with those living in urban areas (P < 0.001). Logistic regression analysis showed that DPD was positively associated with the received frequencies of community health service, contracted family doctor services, and regular lectures on health knowledge among the elderly people with odd ratios of 1.58 (P < 0.001), 2.03 (P = 0.013), and 2.67 (P = 0.005), respectively. Logistic regression analysis showed significant interaction between social support and self-efficacy effect on DPD was found in the additive model (P < 0.001).

CONCLUSION

DPD was associated mainly with the community resources among elderly people living in rural areas. Social support and self-efficacy were commonly associated with DPD through a synergistic effect. These results suggest that DPD among elderly people may be reduced through effective social support to directly and indirectly promote the elderly's use of community resources and improve their self-efficacy.

Psychological distress, multimorbidity and health services among older adults in rural South Australia

OBJECTIVE

Psychological distress may relate to higher health services use. However, data on psychological distress and health services use among rural older adults are limited. This study investigates psychological distress in older adults (aged ≥60) and evaluates the relationship between psychological distress, multimorbidity and health services utilization.

DESIGN

A cross-sectional design was adopted using data on older adults (≥60) (n = 5920) from the South Australia's 2013-2017 population health survey. The Modified Monash Model MM2-7 was used to designate rural areas. The dataset provides information on reported physical health conditions, psychological distress, and patterns of health services use. The Kessler Psychological Distress Scale (K10) was used to compute scores for reported mental health disorders in this population.

RESULTS

The mean (SD) age of the study participants was 72.1 (8.1) years. Women constituted 58.8% of the sample. The mean (SD) score for psychological distress was 12.5 (3.6). One-fourth (33.7%) report one-chronic condition, 20.4% reported 2 chronic conditions and 13% had more than 3 chronic conditions. High psychological distress was associated with female gender (χ² = 14.4, p < 0.001), <80 years (χ² = 11.7, p = 0.019), lower education (χ² = 10.9, p = 0.027). Similarly, multimorbidity was associated with female gender (χ² = 51.1, p < 001), increasing age (χ² = 173.6, p < 0.001) and lower education (χ² = 28.8 p < 0.001). Psychological distress and multimorbidity were independently associated with health service use. High psychological distress was associated with general practitioner (GP) visit (odds ratio 3.6 (95% CI 2.6-5.1), p < 0.001), emergency department (ED) visit (odds ratio 2.5 (95% CI 1.2-5.0), p < 0.001) and hospital admission (odds ratio 2.3 (95% CI 1.3-4.3), p < 0.001). Multimorbidity was associated with general practitioner (GP) visit (odds ratio 6.8 (95% CI 5.6-8.3), p < 0.001), emergency department (ED) visit (odds ratio 2.5 (95% CI 1.4-4.3), p < 0.001) and hospital admission (odds ratio 3.1 (95% CI 1.9-5.1), p < 0.001). Model included age, gender, education, number of chronic condition and psychological distress.

CONCLUSION/IMPLICATION

Psychological distress and multimorbidity were independently associated with health services use. Thus, psychological distress, particularly in the presence of multimorbidity, presents an opportunity for intervention by clinicians that may reduce the demand on rural health services.

Assessment of multiple mycotoxin exposure and its association with food consumption: a human biomonitoring study in a pregnant cohort in rural Bangladesh

Aflatoxins (AFs), ochratoxin A (OTA), citrinin (CIT), fumonisin B1 (FB1), zearalenone (ZEN), and deoxynivalenol (DON) are mycotoxins that may contaminate diets, especially in low-income settings, with potentially severe health consequences. This study investigates the exposure of 439 pregnant women in rural Bangladesh to 35 mycotoxins and their corresponding health risks and links their exposure to certain foods and local stimulants. Overall, 447 first-morning urine samples were collected from pregnant women between July 2018 and November 2019. Mycotoxin biomarkers were quantified by DaS-HPLC-MS/MS. Urinary concentration of frequently occurring mycotoxins was used to estimate dietary mycotoxin exposure. Median regression analyses were performed to investigate the association between the consumption of certain foods and local stimulants, and urinary concentration of frequently occurring mycotoxins. Only in 17 of 447 urine samples (4%) were none of the investigated mycotoxins detected. Biomarkers for six major mycotoxins (AFs, CIT, DON, FB1, OTA, and ZEN) were detected in the urine samples. OTA (95%), CIT (61%), and DON (6%) were most frequently detected, with multiple mycotoxins co-occurring in 281/447 (63%) of urine samples. Under the lowest exposure scenario, dietary exposure to OTA, CIT, and DON was of public health concern in 95%, 16%, and 1% of the pregnant women, respectively. Consumption of specific foods and local stimulants-betel nut, betel leaf, and chewing tobacco-were associated with OTA, CIT, and DON urine levels. In conclusion, exposure to multiple mycotoxins during early pregnancy is widespread in this rural community and represents a potential health risk for mothers and their offspring.

Factors related to help-seeking for cancer medical care among people living in rural areas: a scoping review

Despite the importance of timely diagnosis and access to treatment, previous studies have not adequately explored help-seeking behavior in cancer treatment among rural and remote residents. The barriers preventing help-seeking behavior also remain unclear. To address this research gap, this study conducted a scoping review to suggest a framework for eliminating barriers and facilitating help-seeking for cancer treatment among rural and remote residents. To conduct the scoping review, three English medical databases (PubMed, MEDLINE, and CINAHL) were examined for the keywords "rural," "remote," "cancer," and "help-seeking." The research objectives and study designs, participants, and excerpts describing help-seeking of the selected papers were recorded in a data charting form. Descriptions of help-seeking behavior were organized and summarized according to their meaning and integrated into factors using thematic analysis. All extracted factors related to help-seeking were sorted into four main themes according to the Ecological Model of Health Behavior, the theoretical lens for this scoping review: (1) Intrapersonal; (2) Interpersonal; (3) Groups, culture, and organizations; and (4) Policy/environment. Factors were categorized as barriers and facilitators of help-seeking. A total of 13 papers were analyzed. Intrapersonal factors such as self-reliance, symptom appraisal, and fatalism, were identified as barriers to help-seeking, whereas presentation of abnormal and serious symptoms facilitated help-seeking. Interpersonal factors such as lack of understanding of family members, influence of surrounding people, role obligations, and lack of trust in experts hindered help-seeking, whereas understanding from surrounding people such as family and friends, promoted help-seeking. Groups, cultural, and organizational factors such as prejudice, social stigma, shame, lack of anonymity, and social norms acted as barriers to help-seeking. Policy-related barriers to help-seeking included lack of medical services and physical distance from medical institutions, leading to a time burden. The study discussed the identified factors from a rural context. Future studies should consider the identified barriers and facilitators according to the four main themes in rural areas when formulating interventions to promote help-seeking. Our findings can offer a theoretical foundation to develop actionable policies, preventive strategies, and relevant interventional tools that may facilitate oncological service utilization in rural areas.

Implementing a health labour market analysis to address health workforce gaps in a rural region of India

BACKGROUND

Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health-Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India.

METHODS

The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state's health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce.

RESULTS

The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%.

CONCLUSION

The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

The effects of air pollution on the lung cancer mortality in rural areas of eastern China: a multi-region study

Recently, the burden of lung cancer (LC) has attracted global attention. Meanwhile, LC has become the leading cause of death in China. Many studies found a strong link between air pollutants and the risk of LC mortality in some large cities, but the results have been inconsistent, and most studies have only focused on the daily effects of six pollutants in large cities, ignoring their potential cumulative effects. This study was to investigate the weekly effects of six air pollutants (CO, NO₂, O₃, PM_2.5, PM₁₀, and SO₂) on LC mortality in rural areas of eastern China and to further clarify which population groups were susceptible to air pollution and seasonal trends. First, a generalized additive model was combined with a distributed lag nonlinear model to evaluate the individual impact of air pollution on LC deaths in each area. The random-effect model was then used to pool the associations between air pollutants and LC mortality risk in ten counties or districts. The results showed that six air pollutants had a statistically significant effect on the risk of LC mortality at different lag weeks. The effects of NO₂, PM₁₀, and CO on weekly LC mortality were strongest at a cumulative lag of 1, 0, and 1 week, respectively, the maximum cumulative risk ratio (RR) of 1.37 (95%CI: 1.23 to 1.52), 1.30 (95%CI: 1.15 to 1.46), and 1.30 (95%CI: 1.17 to 1.43), with interquartile concentrations increasing. In summary, air pollution was an important factor in LC mortality, and the effect was stronger on males, the elderly, and during cold season. It was suggested that relevant departments should formulate air pollution management measures for the elderly, males, and in different seasons in rural areas and reduce the burden of lung cancer caused by air pollution.

Treatment of decentralized low-strength livestock wastewater using microcurrent-assisted multi-soil-layering systems: performance assessment and microbial analysis

Discharge of decentralized livestock wastewater without effective treatment has become a common problem in rural areas, threatening the regional water environment. A new microcurrent-assisted multi-soil-layering (MSL) system was developed for treating rural decentralized livestock wastewater. The results showed the highest removal rates of chemical oxygen demand (COD) and total phosphorus (TP) in MSL systems reached 95.45% and 92.0%, respectively. The removal rate of total nitrogen (TN) in MSL systems ranged from 60 to 75%. The bacterial diversity changes among MSL systems showed that high-level height of bottom submergence had a positive effect on the abundance of denitrifying bacteria, while low-level height of bottom submergence had a positive impact on the abundance of nitrifying bacteria. The effect of low-level external voltage on bacterial abundance was better than that of high-level external voltage. Both high- and low-level influent C/N ratios had no significant effect on bacterial abundance. The metabolism and activity of microorganisms were promoted with microcurrent stimulation from the perspective of increased bacterial abundance in MSL systems with improved treatment performance.

Prevalence of and factors associated with acute diarrhea among children under five in rural areas in Ethiopia with and without implementation of community-led total sanitation and hygiene

Background

Since Ethiopia has been implemented the Community-Led Total Sanitation and Hygiene (CLTSH) approach to control incidence of diarrhea, few studies have compared the prevalence of diarrhea and associated factors in rural areas that have implemented this approach with those that have not implemented it, and none have examined it in the district of Menz Gera Midir in the Amhara Region of Ethiopia. This study addressed this gap.

Method

A community-based comparative cross-sectional study was conducted among 224 children under five in three randomly selected rural kebeles (the smallest administrative units in Ethiopia) where CLTSH had been implemented and 448 similar children in three other randomly selected rural kebeles where CLTSH had not been implemented during February and March, 2020. Data were collected using a structured questionnaire and an on-the-spot observational checklist. Data were analyzed using three different binary logistic regression models with 95% confidence interval (CI): the first model (Model I) was used for CLTSH-implementing kebeles, the second model (Model II) for non-CLTSH-implementing kebeles, and the third model (Model III) for pooled analysis of CLTSH-implementing and non-implementing kebeles. To control confounders, each multivariable logistic regression model was built by retained variables with p < 0.25 from the bi-variable logistic regression analysis. From the adjusted multivariable analysis of each model, variables with p-values < 0.05 were declared factors significantly associated with acute diarrhea.

Results

The prevalence of acute diarrhea among children under five from households in kebeles that had implemented CLTSH was 10.6% (95% CI:6.6–14.7%) and among those that had not implemented CLTSH 18.3% (95%CI:14.8–22.2%). In CLTSH-implementing areas, use of only water to wash hands (AOR: 3.28; 95% CI:1.13–9.58) and having a mother/caregiver who did not wash their hands at critical times (AOR: 3.02; 95% CI:1.12–8.12) were factors significantly associated with acute diarrhea. In non-CLTSH-implementing areas, unimproved water source (adjusted odds ratio [AOR]: 2.81; 95% CI:1.65–4.78), unsafe disposal of child feces (AOR: 2.10; 95% CI:1.13–3.89), improper solid waste disposal (AOR: 1.95; 95% CI:1.12–3.38), and untreated drinking water (AOR: 2.33; 95% CI:1.21–4.49) were factors significantly associated with acute diarrhea. From the pooled analysis, not washing hands at critical times (AOR: 2.54; 95% CI:1.59–4.06), unsafe disposal of child feces (AOR: 2.20; 95% CI:1.34–3.60) and unimproved water source (AOR: 2.56; 95% CI:1.62–4.05) were factors significantly associated with the occurrence of acute diarrhea while implementation of CLTSH was a preventive factor (AOR: 0.24; 95%: 0.20–0.60) for the occurrence of acute diarrhea.

Conclusion

The prevalence of acute diarrhea among under-five children in Menz Gera Midir District was lower in kebeles where CLTSH had been implemented than in kebeles where CLTSH had not been implemented. Therefore, we recommend that governmental and non-governmental sectors increase implementation of CLTSH programs, including improving handwashing at critical times, promoting safe disposal of child feces and enhancing the availability of improved water sources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03202-8.

Seeking medical services among rural empty-nest elderly in China: a qualitative study

Background

The number of empty-nest elderly in China is rapidly increasing. Empty-nest elderly could not receive adequate daily care, economic support and spiritual consolation from their children. Rural empty-nest elderly are facing more serious health challenges than those in urban areas.

Objective

This study aimed to understand the experiences of rural empty-nest elderly in seeking medical services in China.

Methods

The method of inductive content analysis was used to collect and analyze data. Data were collected by in-depth interviews. A total number of 16 participants were involved in this study. A semi-structured interview guideline, which was discussed in depth and agreed upon by all researchers, was used to encourage participants to talk about their experiences in seeking medical services.

Results

Rural empty-nest elderly is facing a great challenge in seeking medical services in China. There are some barriers for rural nest elderly to get access to healthcare services, such as low-income status, high expenditure of medical treatment and inadequate health insurance coverage. Due to the absence of the companionship of their adult children, empty-nest elderly have to rely on their neighbors and relatives to seek medical services.

Conclusions

Rural empty-nest elderly have great difficulty in seeking medical services in China. More efforts should be made to get medical services more accessible to rural empty-nest elderly.

Trends of and factors associated with access to residential toilets among the middle-aged and elderly in rural China from 2011 to 2018

BACKGROUND

At the global and country levels, several important sanitation improvement initiatives were launched in the last decade. This study aimed to explore the temporal trend of and factors associated with access to residential toilets among the middle-aged and elderly in rural China from 2011 to 2018.

METHODS

This study used the 2011, 2013, 2015, and 2018 data of China Health and Retirement Longitudinal Study (CHARLS). CHARLS was conducted among adults aged ≥ 45 years in 28 provinces of China. We used descriptive statistics and logistic regressions for data analysis.

RESULTS

We found that residential toilet coverage increased by about 6% among population aged ≥ 45 years in rural China from 2011 to 2018. The coverage of flushable toilets and toilets with seats among this sector of the population increased by more than 10% during this period. We also found that being female, higher levels of education, higher annual per capita household consumption, having running water in the residence, larger household size, and better health status were significantly associated with an increased likelihood of residential toilet ownership among population aged ≥ 45 years in rural China.

CONCLUSIONS

China made progress in sanitation improvement in rural areas from 2011 to 2018. However, considering the current coverage levels of residential toilets and the vulnerable subgroups who are more prone to toilet deprivation in rural areas, we suggest to the government to implement further targeted toilet improvement interventions to ensure universal coverage of sanitation facilities for the whole of the Chinese population.

The prevalence of elder abuse and neglect in rural areas: a systematic review and meta-analysis

PURPOSE

Many epidemiological studies have reported that elder abuse and neglect were prevalent in rural areas. However, none of them has synthesized the literature in this field. Therefore, we aimed to estimate the overall prevalence of elder abuse and neglect in rural areas through a systematic review and meta-analysis.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Library were systematically searched to identify eligible articles, with no language restrictions. Statistical analyses were conducted using Review Manager software (version 5.3). Meta-analyses and sensitivity analysis were performed using a random-effects model. All results were reported as the pooled prevalence of elder and neglect with their 95% confidence intervals (CIs). The quality of the included studies was evaluated by strengthening the reporting of observational studies in epidemiology (STROBE) checklist. Potential publication bias was assessed by the funnel plot.

RESULTS

13 cross-sectional studies involving 10,313 participants were eligible. The prevalence of elder abuse and neglect ranged from 4.5 to 61.7% across the rural areas, and pooled prevalence estimate was 33% (95% CI 23-43). The prevalence of physical abuse was estimated at 7% (95% CI 5-9), financial abuse at 5% (95% CI 4-7), psychological/emotional abuse at 17% (95% CI 11-23), and neglect at 26% (95% CI 17-35). There was significant heterogeneity among the included studies. Stratified analyses revealed that sampling design was part of the heterogeneity source. WHO regions, gender, countries' income classification, and study quality could not explain the potential reasons for heterogeneity.

CONCLUSIONS

The pooled prevalence of elder abuse and neglect was relatively high in rural areas. Early and targeted screening and prevention are needed. There is an urgent need for high quality studies using agreed definition of elder abuse and neglect to protect the potential high risk populations.

Effects of exposure to fine particulate matter on the decline of lung function in rural areas in northwestern China

Our aim was to clarify the main factors associated with lung function and to analyze the correlation between fine particulate matter (PM_2.5) and lung function in a rural Chinese population. We analyzed data of 5195 participants in the China Northwest Natural Population Cohort: Ningxia Project who were ≥ 30 years old. They were recruited from 2018 to 2019, underwent spirometry during the physical examination, and completed a self-report questionnaire. A satellite-based spatiotemporal model was used to estimate the 2-year average PM_2.5 exposure based on participants' home addresses. A generalized linear mixed model was used to test the relationship between PM_2.5 concentration and lung function. Sex, age, exposure to cooking oil fumes, and occupational exposure were negatively correlated (P < 0.05) with forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV₁). Educational status, economic level, tea consumption, and alcohol consumption were positively correlated (P < 0.05) with FVC and FEV₁. The adjusted results of each model revealed that FVC and FEV₁ decreased with increased exposure to PM_2.5. There was a strong negative correlation between a PM_2.5 concentration of 35.66 μg/m³ and FVC, FEV1, and FEV1/FVC, with unadjusted hazard ratios of - 0.06 (95% confidence interval, - 0.10 to - 0.01), - 0.13 (- 0.17 to - 0.10), and - 22.10 (- 24.62 to - 19.26), respectively. In conclusion, long-term exposure to high concentrations of ambient PM_2.5 is related to reduce lung function among people in rural areas in northwestern China.

Mobility enhancement among older adults 75 + in rural areas: Study protocol of the MOBILE randomized controlled trial

BACKGROUND

Maintaining mobility in old age is crucial for healthy ageing including delaying the onset and progress of frailty. However, the extent of an individuals´ mobility relies largely on their personal, social, and environmental resources as outlined in the Life-Space Constriction Model. Recent studies mainly focus on facilitating habitual out-of-home mobility by fostering one type of resources only. The MOBILE trial aims at testing whether tablet-assisted motivational counselling enhances the mobility of community-dwelling older adults by addressing personal, social, and environmental resources.

METHODS

In the MOBILE randomized controlled trial, we plan to enrol 254 community-dwelling older adults aged 75 and older from Havelland, a rural area in Germany. The intervention group will receive a tablet-assisted motivational counselling at the participant´s home and two follow-up telephone sessions. Main focus of the counselling sessions lays on setting and adapting individual mobility goals and applying action planning and habit formation strategies by incorporating the personal social network and regional opportunities for engaging in mobility related activities. The control group will receive postal general health information. The primary mobility outcome is time out-of-home assessed by GPS (GPS.Rec2.0-App) at three points in time (baseline, after one month, and after three months for seven consecutive days each). Secondary outcomes are the size of the GPS-derived life-space convex hull, self-reported life-space mobility (LSA-D), physical activity (IPAQ), depressive symptoms (GDS), frailty phenotype, and health status (SF-12).

DISCUSSION

The MOBILE trial will test the effect of a motivational counselling intervention on out-of-home mobility in community-dwelling older adults. Novel aspects of the MOBILE trial include the preventive multi-level intervention approach in combination with easy-to-use technology. The ecological approach ensures low-threshold implementation, which increases the benefit for the people in the region.

TRIAL REGISTRATION

The MOBILE trial is prospectively registered at DRKS (Deutsches Register Klinischer Studien, German Registry of Clinical Trials) DRKS00025230 . Registered 5 May 2021.

What do urban and rural hotel managers say about the future of hotels after COVID-19? The new meaning of safety experiences

The pandemic crisis has caused a change in tourism trends that affect the way hotels are managed. In accordance with the United Nations (2020), hotels must guarantee safe experiences for customers by incorporating sustainability measures. Collaboration between health and tourism authorities and the tourism industry is key. To test this proposal among hotels in Spain, 3 online focus groups and 25 personal interviews with 36 urban and 28 rural hotels were held in order to define the indicators. The questionnaire was applied to a sample of 475 urban hotels out of 443 rural hotels. The conclusions were: 1.) While in urban areas the testing protocols, especially for workers, are followed by most hotels, in rural areas hotel managers do not consider it as a priority in daily activity due to the reduced contact they have. 2.) A change in trends in the sustainable management of both rural and urban hotels is justified. 3.) Urban and rural hotels are more likely to incorporate collaborative strategies with tourism and health authorities to reduce the negative impact of COVID-19. According to the estimates of the hotels, the implementation of these measures would help to start the recovery process of the hotel industry.

Six air pollutants and cause-specific mortality: a multi-area study in nine counties or districts of Anhui Province, China

Air pollution and its negative effects on health of people have been a global concern. Many studies had found a strong association between air pollutants and risk of death, but few had focused on the effects of six pollutants and rural areas. Our study aimed to investigate the effects of six air pollutants (CO, NO₂, O₃, PM_2.5, PM₁₀, and SO₂) on non-accidental and respiratory deaths in rural areas of Anhui Province by adjusting for confounding factors, and to further clarify which populations were susceptible to death associated with air pollution. In the first phase of the analysis, the generalized additive models were combined with the distributed lag non-linear models to evaluate the individual effects of air pollution on death in each area. In the second stage, random-effects models were used to aggregate the associations between air pollutants and mortality risk in nine areas. Overall, six pollutants had the strongest effects on the risk of death on the lag 07 days. The associations between PM_2.5 and NO₂ and daily non-accidental deaths were strongest, with maximum RR (lag 07): 1.63 (1.37-1.88) and 1.67 (1.37-1.96). The maximum pooled effects of association between six air pollutants and RD were PM_2.5, with RR (lag 07): 1.89 (1.45-2.34). PM_2.5 and PM₁₀ had significant differences between the elderly and the non-elderly with respectively, RRR: 1.22 (1.04-1.41) and 1.26 (1.11-1.42). In general, we found that six air pollutants were the important risk factors for deaths (deaths from respiratory disease and non-accidental) in rural areas of Anhui Province. PM₁₀ and PM_2.5 had a considerable impact on the elderly.

Association of selenium levels with the prevention and control of Keshan disease: A cross-sectional study

PURPOSE

The prevalence of Keshan disease (KD) is low and has reached controlled or eliminated levels even in counties that had a high KD prevalence in the past. Few nationwide surveys on selenium levels in KD areas have been conducted in the past 2 decades. We conducted a cross-sectional study to investigate the selenium levels and their association with KD control and prevention in areas where KD is prevalent.

METHODS

We collected 2143 human-hair, 698 soil, 701 rice, 607 flour, 521 corn, and 330 other-food samples from 49 counties with KD and 19 non-KD counties of nine KD provinces of China. The selenium content of samples was examined with hydride generation atomic fluorescence spectrometry. The difference in selenium levels between the KD and non-KD areas was analyzed. Cochran-Armitage trend tests were used to evaluate the association between selenium levels and KD control.

RESULTS

The selenium levels in human hair, soil, staple foods, and other foods in the KD areas (0.2996 mg/kg, 0.1380 mg/kg, 0.0190 mg/kg and 0.0076 mg/kg, respectively) were lower than those in the non-KD areas (0.3700 mg/kg, 0.1930 mg/kg, 0.0240 mg/kg and 0.0165 mg/kg, respectively). The Cochran-Armitage tests showed that there was a trend for the selenium standard ratio in the counties to increase in the order of KD uncontrolled, to controlled, to eliminated (Z = 2.229, P < 0.05).

CONCLUSION

The residents in the KD areas were found to be selenium-deficient. Improving the supply of staple foods containing selenium levels exceeding 0.025 mg/kg and abundant foodstuffs might contribute to KD control and prevention.

Online Health Information-Seeking Behavior Among Korean American Immigrants in Rural Alabama: Dose Discrimination Matter?

Little attention has been paid to online health information seeking (OHIS) among immigrants residing in rural areas. This study examines the intensity of OHIS among Korean American (KA) immigrants living in rural Alabama. A total number of 261 KA immigrants aged 23 to 75 participated in the study. Multiple linear regression analyses were conducted. Age (B = - 0.044, p < 0.05), marital status (B = 1.132, p < 0.05), race/ethnic discrimination (B = 0.821, p < 0.05), having computer or tablet (B = 1.286, p < 0.05), and access to internet (B = 1.778, p < 0.01) were associated with the intensity of OHIS. Substantial efforts should be devoted to narrowing the access gap by providing offline health information services for those without internet access and with limited health literacy. Moreover, culturally competent healthcare services and information should be provided to serve racial/ethnic minority populations better.

Factors influencing the retention of secondary midwives at health centres in rural areas in Cambodia: the role of gender-a qualitative study

BACKGROUND

Retention of skilled midwives is crucial to reducing maternal mortality in rural areas; hence, Cambodia has been trying to retain at least one secondary midwife who can provide basic emergency obstetric care at every health centre even in rural areas. The factors influencing the retention of midwives, but not solely secondary midwives, have been identified; however, the security issues that affected female health workers during the conflict and the post-conflict years and gender issues have been unexplored. This study explores these and other potential factors influencing secondary midwife retention and their significance.

METHODS

Sequential two-stage qualitative interviews explored influential factors and their significance. The first stage comprised semi-structured interviews with 19 key informants concerned with secondary midwife retention and in-depth interviews with eight women who had deliveries at rural health centres. Based on these interview results, in-depth interviews with six secondary midwives who were deployed to a rural health centre were conducted in the second stage. These midwives ranked the factors using a participatory rural appraisal tool. These interviews were coded with the framework approach.

RESULTS

Living with one's parents or husband, accommodation and security issues were identified as more significant influential factors for secondary midwife retention than current salary and the physical condition of the health centre. Gender norms were entrenched in these highly influential factors. The deployed secondary midwives who were living apart from one's parents or spouse requested transfer (end of retention) to health centres closer to home, as other midwives had done. They feared gender-based violence, although violence against them and the women around them was not reported. The health workers surrounding the midwives endorsed the gender norms and the midwives' responses. The ranking of factors showed similarities to the interview results.

CONCLUSIONS

This study suggests that gender norms increased the significance of issues with deployments to rural areas and security issues as negative factors on female health workforce retention in rural areas in Cambodia. This finding implies that further incorporating gendered perspectives into research and developing and implementing gender-responsive policies are necessary to retain the female health workforce, thereby achieving SDGs 3 and 5.

Life cycle assessment of greywater treatment systems for water-reuse management in rural areas

Water scarcity is a major concern worldwide. Population growth, as well as the intensive use of water resources for industrial and agricultural activities, among others, have caused water stress in various regions of the world. Rural areas are usually more affected due to water scarcity and a lack of sanitary infrastructure. The current practices associated with urban water management have been considered inefficient to respond to these problems. In recent years, the reuse of greywater has emerged as a promising and sustainable alternative. Several pilot greywater treatment systems have been implemented in rural areas of different countries, however, studies about the environmental impacts of these decentralized systems under different scenarios are lacking. In this work, the life cycle assessment of greywater treatment systems considering several scenarios was studied. Our results showed that the decrease in environmental impacts due to the saving of drinking water is more evident when the water supply is carried out through cistern trucks. This occurs because the environmental impact of land transport of water is extremely high and represents over 89% of the global warming indicator [kg CO₂ eq] and 96% ozone depletion [kg CFC-11 eq] contributions of the system. Greywater treatment systems with backwashing and solar panels as a source of energy have lower environmental impacts, reducing CO₂ and CFC emissions by 50% for the maintenance phase and by 85% (CO₂) and 47% (CFC) for the operation phase. Furthermore, the acquisition of solar panels was economically feasible, with a payback of 19.7 years. This analysis showed the environmental feasibility of small-scale greywater treatment systems in rural areas affected by water scarcity. Furthermore, the proposed approach has contributed to understand the impact of greywater treatment systems in rural areas, which could become a support tool to integrate greywater reuse practices in different communities.

Unhealthy lifestyles, environment, well-being and health capability in rural neighbourhoods: a community-based cross-sectional study

BACKGROUND

Non-communicable diseases are a leading cause of health loss worldwide, in part due to unhealthy lifestyles. Metabolic-based diseases are rising with an unhealthy body-mass index (BMI) in rural areas as the main risk factor in adults, which may be amplified by wider determinants of health. Changes in rural environments reflect the need of better understanding the factors affecting the self-ability for making balanced decisions. We assessed whether unhealthy lifestyles and environment in rural neighbourhoods are reflected into metabolic risks and health capability.

METHODS

We conducted a community-based cross-sectional study in 15 Portuguese rural neighbourhoods to describe individuals' health functioning condition and to characterize the community environment. We followed a qualitatively driven mixed-method design to gather information about evidence-based data, lifestyles and neighbourhood satisfaction (incorporated in eVida technology), within a random sample of 270 individuals, and in-depth interviews to 107 individuals, to uncover whether environment influence the ability for improving or pursuing heath and well-being.

RESULTS

Men showed to have a 75% higher probability of being overweight than women (p-value = 0.0954); and the reporting of health loss risks was higher in women (RR: 1.48; p-value = 0.122), individuals with larger waist circumference (RR: 2.21; IC: 1.19; 4.27), overweight and obesity (RR: 1.38; p-value = 0.293) and aged over 75 years (RR: 1.78; p-value = 0.235; when compared with participants under 40 years old). Metabolic risks were more associated to BMI and physical activity than diet (or sleeping habits). Overall, metabolic risk linked to BMI was higher in small villages than in municipalities. Seven dimensions, economic development, built (and natural) environment, social network, health care, demography, active lifestyles, and mobility, reflected the self-perceptions in place affecting the individual ability to make healthy choices. Qualitative data exposed asymmetries in surrounding environments among neighbourhoods and uncovered the natural environment and natural resources specifies as the main value of rural well-being.

CONCLUSIONS

Metabolic risk factors reflect unhealthy lifestyles and can be associated with environment contextual-dependent circumstances. People-centred approaches highlight wider socioeconomic and (natural) environmental determinants reflecting health needs, health expectations and health capability. Our community-based program and cross-disciplinary research provides insights that may improve health-promoting changes in rural neighbourhoods.

Challenges in current nursing home care in rural Germany and how they can be reduced by telehealth - an exploratory qualitative pre-post study

Background

Telemedical care of nursing home residents in Germany, especially in rural areas, is limited to a few pilot projects and is rarely implemented as part of standard care. The possible merits of implementing video consultations in longer-term nursing care currently lack supporting evidence. In particular, there is little documentation of experiences and knowledge about the effects and potential benefits of the implementation in presently existing structures. The goal was to assess the effect of implementing medical video consultations into nursing home care addressing the following research questions:

How is medical care currently provided to nursing home residents, and where do problems in its implementation arise?

How can video consultations be used to reduce difficulties arising in everyday care?

How does implementation of video consultations impact day-to-day nursing home care delivery?

Methods

Twenty-one guided interviews (pre-implementation n = 13; post-implementation n = 8) were conducted with a total of 13 participants (physicians, nurses and medical technical assistants). Narratives were analysed using qualitative content analysis. The results were contrasted in a pre-post analysis.

Results

Challenges described by the participants before implementation included a requirement for additional organisational and administrative efforts, interruptions in the daily care routine or delayed treatments, and risk for loss of patient-relevant information due to process diversity. After implementation, communication was facilitated upon introduction of assigned time slots for video consultations. Clinical information was less likely to be lost, additional work was spared, and medication and therapeutic and assistive devices were provided more quickly.

Conclusions

Telehealth cannot replace physical, in-person visits, but does offer an alternative form of service delivery when properly integrated into existing structures. Our results suggest that the use of video consultations in nursing homes can reduce the burden and additional workload, and increase the efficiency of care provision for nursing home residents. Video consultations can complement in-person visits to nursing homes, especially to address the shortage of medical specialists in rural areas in Germany. To promote implementation and acceptance of video consultation in nursing homes, we need to increase awareness of its benefits and undertake further evaluation of video consultations in nursing home care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06950-y.

Influence of COVID-19 lockdown overlapping Chinese Spring Festival on household PM2.5 in rural Chinese homes

During the 2019 novel coronavirus (COVID-19) pandemic, many countries took strong lockdown policy to reduce disease spreading, resulting in mitigating the ambient air pollution due to less traffic and industrial emissions. However, limited studies focused on the household air pollution especially in rural area, the potential risk induced by indoor air pollution exposure was unknown during this period. This field study continuously measured real-time PM_2.5 levels in kitchen, living room, and outdoor in the normal days (Period-1) and the days of COVID-19 lockdown overlapping the Chinese Spring Festival (Period-2) in rural homes in China. The average daily PM_2.5 concentrations increased by 17.4 and 5.1 μg/m³ in kitchen and living room during Period-2, respectively, which may be due to more fuel consumption for cooking and heating caused by larger family sizes than those during the normal days. The ambient PM_2.5 concentration in rural areas in Period-2 decreased by 6.7 μg/m³ compared to the Period-1, less than the drop in urban areas (26.8 μg/m³). An increase of mass fraction of very fine particles in ambient air was observed during lockdown overlapping annual festival days, which could be explained by the residential solid fuel burning. Due to higher indoor air pollution level and longer time spent in indoor environments, daily personal exposure to PM_2.5 was 134 ± 40 μg/m³ in Period-2, which was significantly higher than that during in Period-1 (126 ± 27 μg/m³, p < 0.05). The increase of personal PM_2.5 exposure during Period-2 could potentially have negative impact on human health, indicating further investigations should be performed to estimate the health impact of global COVID-19 lockdown on community, especially in rural homes using solid fuels as the routine fuels.