Implementing practice facilitation in research: how facilitators spend their time guiding practices to improve blood pressure control

BACKGROUND

Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure.

METHODS

The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs.

RESULTS

In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status.

CONCLUSIONS

PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691.

HealthyRHearts - reducing cholesterol in rural adults via telehealth-based medical nutrition therapy: protocol for a cluster randomised controlled trial

BACKGROUND

Few randomised controlled trials specifically focus on prevention in rural populations. Cardiovascular disease (CVD) contributes to approximately one quarter of deaths in Australia. Nutrition is a key component affecting many risk factors associated with CVD, including hypercholesterolaemia. However, access to medical nutrition therapy (MNT) is limited for people living in rural areas, potentially exacerbating inequities related to health outcomes. Telehealth services present an opportunity to improve MNT access and address healthcare disparities for rural populations. The present study aims to evaluate feasibility, acceptability, and cost-effectiveness of a telehealth MNT CVD intervention program in lowering CVD risk over 12-months in regional and rural primary health care settings.

METHODS/DESIGN

A cluster randomised controlled trial set in rural and regional general practices in NSW, Australia, and their consenting patients (n = 300 participants). Practices will be randomised to either control (usual care from their General Practitioner (GP) + low level individualised dietetic feedback) or intervention groups (usual care from their GP + low level individualised dietetic feedback + telehealth MNT intervention). Telehealth consultations will be delivered by an Accredited Practising Dietitian (APD), with each intervention participant scheduled to receive five consultations over a 6-month period. System-generated generic personalised nutrition feedback reports are provided based on completion of the Australian Eating Survey - Heart version (AES-Heart), a food frequency questionnaire. Eligible participants must be assessed by their GP as at moderate (≥ 10%) to high (> 15%) risk of a CVD event within the next five years using the CVD Check calculator and reside in a regional or rural area within the Hunter New England Central Coast Primary Health Network (HNECC PHN) to be eligible for inclusion. Outcome measures are assessed at baseline, 3, 6 and 12 months. The primary outcome is reduction in total serum cholesterol. Evaluation of the intervention feasibility, acceptability and cost-effective will incorporate quantitative, economic and qualitative methodologies.

DISCUSSION

Research outcomes will provide knowledge on effectiveness of MNT provision in reducing serum cholesterol, and feasibility, acceptability, and cost-effectiveness of delivering MNT via telehealth to address CVD risk in rural regions. Results will inform translation to health policy and practice for improving access to clinical care in rural Australia.

TRIAL REGISTRATION

This trial is registered at anzctr.org.au under the acronym HealthyRHearts (Healthy Rural Hearts), registration number ACTRN12621001495819.

Responding to Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote New South Wales

Ethical perspectives on regional, rural, and remote healthcare often, understandably and importantly, focus on inequities in access to services. In this commentary, we take the opportunity to examine the implications of normalizing metrocentric views, values, knowledge, and orientations, evidenced by the recent (2022) New South Wales inquiry into health outcomes and access to hospital and health services in regional, rural and remote New South Wales, for contemporary rural governance and justice debates. To do this, we draw on the feminist inspired approach to rural health ethics involving analysis of power relationships developed by Simpson and McDonald and related ideas from critical health sociology. In presenting this analysis, we extend contemporary thought about spatial health inequities and structural violence.

Understanding weight status and dietary intakes among Australian school children by remoteness: a cross-sectional study

OBJECTIVE

To determine whether primary school children's weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM).

DESIGN

A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake.

SETTING

Twelve regional and rural Local Government Areas in North-East Victoria, Australia.

PARTICIPANTS

Data were collected from 2456 grade 4 (approximately 9-10 years) and grade 6 (approximately 11-12 years) students.

RESULTS

The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)).

CONCLUSIONS

Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

A theory-driven, culture-tailored educational intervention for cervical cancer screening among rural Chinese females: A feasibility and pilot study

Objective

This study aimed to evaluate the feasibility and preliminarily estimate the effects of a theory-driven, culture-tailored, community-based educational intervention promoting cervical cancer screening among rural females.

Methods

An experimental study with the two-arm parallel, nonrandomized control trial design was implemented, followed by individual semi-structured interviews. Thirty rural females between 26 and 64 were recruited, with 15 in each group. Both groups were exposed to the usual care about cervical cancer screening promotion from the local clinics, while participants in the intervention group additionally received five educational sessions in 5 weeks. Data were collected at baseline and immediately postintervention.

Results

All participants completed the study, and the retention rate was 100%. Participants in the intervention group had more significant increments in cervical cancer screening-related self-efficacy (P ​< ​0.001), knowledge (P ​< ​0.001), and intention levels (P ​= ​0.003) than those in the control group. Most participants showed acceptance and satisfaction with this educational intervention.

Conclusions

This study revealed that the theory-driven, culture-tailored, community-based educational intervention was feasible among the rural populations to promote cervical cancer screening. A large-scale interventional study with a prolonged follow-up duration is warranted to explore this educational intervention's effectiveness further.

The Power in Rural Place Stigma

The phenomenon and implications of stigma have been recognized across many contexts and in relation to many discrete issues or conditions. The notion of spatial stigma has been developed within stigma literature, although the importance and relevance of spatial stigma for rural places and rural people have been largely neglected. This is the case even within fields of inquiry like public and rural health, which are expansively tasked with addressing the socio-structural drivers of health inequalities. In this paper, we argue that developing a better understanding of rural place stigma is critical for addressing contemporary patterns of spatial injustice and health inequalities affecting rural communities globally. Drawing on international literature and examples from the reported experiences of rurally living Australians and news and other media, we present an analysis highlighting the power in rural place stigma. In doing so, we build a case for the relevance and importance of interrogating rural place stigma, especially in the fields of public and rural health, for changing the conditions within-and the broader positioning of-the rural in the public and political landscapes.

A Needs Assessment for Infectious Diseases Consultation in Community Hospitals

INTRODUCTION

Infectious diseases (ID) consultations have been demonstrated to improve patient outcomes in the treatment of severe infections. However, ID consultation is often unavailable to patients that live in rural communities. Little is known regarding the treatment of infections in rural hospitals with no coverage from an ID specialist. We characterized the outcomes of patients cared for in hospitals without coverage from an ID physician.

METHODS

Patients aged 18 years or older admitted to eight community hospitals without access to ID consultation during a 6.5-month period were assessed. All patients had received at least three days of continuous antimicrobial therapy. The primary outcome was the need for transfer to a tertiary facility for ID services. The secondary outcome was the characterization of antimicrobials received. Antimicrobial courses were evaluated independently by two board-certified ID physicians.

RESULTS

3706 encounters were evaluated. Transfers for ID consultation occurred in 0.01% of patients. The ID physician would have made modifications in 68.5% of patients. Areas for improvement included treatment of chronic obstructive pulmonary disease exacerbations, broad-spectrum treatment of skin and soft tissue infection, long courses of azithromycin, and management of Staphylococcus aureus bacteremia, including choice and length of therapy, as well as obtaining echocardiography. Patients evaluated received 22,807 days of antimicrobial therapy.

CONCLUSIONS

Patients hospitalized in community hospitals are rarely transferred for ID consultation. Our work demonstrates a need for ID consultation in community hospitals, identifying opportunities to enhance patient care by modifying antimicrobial regimens to improve antimicrobial stewardship and avoid inappropriate antimicrobials. Efforts to expand the ID workforce to include coverage at rural hospitals will likely improve antibiotic utilization.

Microbiological and chemical drinking water contaminants and associated health outcomes in rural Appalachia, USA: A systematic review and meta-analysis

In rural areas of the United States, an estimated ~1.8 million people lack reliable access to safe drinking water. Considering the relative dearth of information on water contamination and health outcomes in Appalachia, we conducted a systematic review of studies of microbiological and chemical drinking water contamination and associated health outcomes in rural Appalachia. We pre-registered our protocols, limiting eligibility to primary data studies published from 2000 to 2019, and searched four databases (PubMed, EMBASE, Web of Science, and the Cochrane Library). We used qualitative syntheses, meta-analyses, risk of bias analysis, and meta-regression to assess reported findings, with reference to US EPA drinking water standards. Of the 3452 records identified for screening, 85 met our eligibility criteria. 93 % of eligible studies (n = 79) used cross-sectional designs. Most studies were conducted in Northern (32 %, n = 27) and North Central (24 %, n = 20) Appalachia, and only 6 % (n = 5) in Central Appalachia. Across studies, E. coli were detected in 10.6 % of samples (sample-size-weighted mean percentage from 4671 samples, 14 publications). Among chemical contaminants, sample-size-weighted mean concentrations for arsenic were 0.010 mg/L (n = 21,262 samples, 6 publications), and 0.009 mg/L for lead (n = 23,259, 5 publications). 32 % (n = 27) of studies assessed health outcomes, but only 4.7 % (n = 4) used case-control or cohort designs (all others were cross-sectional). The most commonly reported outcomes were detection of PFAS in blood serum (n = 13), gastrointestinal illness (n = 5), and cardiovascular-related outcomes (n = 4). Of the 27 studies that assessed health outcomes, 62.9 % (n = 17) appeared to be associated with water contamination events that had received national media attention. Overall, based on the number and quality of eligible studies identified, we could not reach clear conclusions about the state of water quality, or its impacts on health, in any of Appalachia's subregions. More epidemiologic research is needed to understand contaminated water sources, exposures, and potentially associated health outcomes in Appalachia.

Something to eat: experiences of food insecurity on the farm

The health of farm owners and farmworkers has significant impacts on farm businesses, farming families, and local rural communities where agriculture is an important driver of social and economic activity. Rural residents and farmworkers have higher rates of food insecurity, but little is known about food insecurity among farm owners and the collective experiences of farm owners and farmworkers. Researchers and public health practitioners have stressed the need for policies that target the health and well-being of farm owners and farmworkers while remaining sensitive to the nature of life on the farm, yet farm owner and farmworker lived experiences have been understudied, especially in relation to one another. In-depth qualitative interviews were conducted with 13 farm owners and 18 farmworkers in Oregon. Modified grounded theory was used to analyze interview data. Data were coded using a three-stage process to identify salient core characteristics of food insecurity. Farm owner and farmworker meanings and interpretations of their food insecurity were often contradicted by evaluated food security scores using validated quantitative measures. According to such measures, 17 experienced high food security, 3 had marginal food security, and 11 had low food security, but narrative experiences suggested higher rates. Narrative experiences were categorized by core characteristics of food insecurity, including seasonal food shortages, resource stretching, working extended hours most days of the week, limited use of food assistance, and the tendency to downplay hardship. These unique factors have important implications for developing responsive policies and programs to support the health and well-being of farm livelihoods whose work enables health and well-being among consumers. Future studies to test the relationships between the core characteristics of food insecurity identified in this study and farm owner and farmworker meanings and interpretations of food insecurity, hunger, and nourishment are warranted.

Postpartum Depression in Young Mothers in Urban and Rural Indonesia

OBJECTIVES

Young mothers are vulnerable to postpartum depression due to role transition-related stress. Understanding the causes underlying these stressors is essential for developing effective interventions.

METHODS

This study analyzed the 2018 Indonesian Basic Health Research data. The Mini International Neuropsychiatric Interview was used to assess postpartum depression symptoms in mothers aged 15-24 years with infants aged 0-6 months. In 1285 subjects, the risk factors for postpartum depression were evaluated using multivariate logistic regression.

RESULTS

The overall prevalence of depression in the 6 months postpartum was 4.0%, with a higher prevalence in urban areas (5.7%) than in rural areas (2.9%). Urban and rural young mothers showed distinct postpartum depression risk factors. In urban areas, living without a husband (odds ratio [OR], 3.82; 95% confidence interval [CI], 1.24 to 11.76), experiencing preterm birth (OR, 4.67; 95% CI, 1.50 to 14.50), having pregnancy complications (OR, 3.03; 95% CI, 1.20 to 7.66), and having postpartum complications (OR, 5.23; 95% CI, 1.98 to 13.80) were associated with a higher risk of postpartum depression. In rural areas, postpartum depression was significantly associated with a smaller household size (OR, 3.22; 95% CI, 1.00 to 10.38), unwanted pregnancy (OR, 4.40; 95% CI, 1.15 to 16.86), and pregnancy complications (OR, 3.41; 95% CI, 1.31 to 8.88).

CONCLUSIONS

In both urban and rural contexts, postpartum depression relates to the availability of others to accompany young mothers throughout the postpartum period and offer support with reproductive issues. Support from the family and the healthcare system is essential to young mothers' mental health. The healthcare system needs to involve families to support young mothers' mental health from pregnancy until the postpartum period.

American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Totally devoted to you: A qualitative study examining the experiences of sacrifice among pharmacists in rural and regional areas

BACKGROUND

The health of rural and regional communities is routinely identified as poor and access to healthcare services is often limited. Rural and regional pharmacists are well placed to deliver a variety of high-quality services to their community, however there is a limited examination of the complexities of their role in rural contexts. This study seeks to examine the types of personal sacrifices and what impact these may have among pharmacists working in rural and regional communities of Australia.

METHOD

A qualitative approach was adopted to examine the experiences of pharmacists working in public health service and private community pharmacies across 13 rural communities in Australia. Purposive sampling was used to recruit pharmacists as part of a larger study examining the efficacy of a workforce recruitment tool (PharmCAQ). As part of the development of the tool, a one-on-one interview were conducted.

RESULTS

A total of 20 participants were recruited. Two major themes emerged: Above all the community and More than just a script monkey that embodies the experiences of pharmacists. Centred around self-sacrifice, the first theme captures the tension that is experienced by these professionals as they tread an unsustainable path for the benefit of the community. The second theme provides some insights into the complex nature of the rural and regional context that is juxtaposed with that of their urban counterparts.

CONCLUSION

Pharmacist in rural and regional areas offer a highly skilled and accessible resource to better address the growing needs of those living in rural and regional areas. Despite the opportunities that exist to expand the role of pharmacists in these areas and to capitalise on their expertise, there is a growing need to find ever better ways to support those who support others.

Rural-urban disparities in mortality and geriatric assessment among older adults with cancer: The cancer & aging resilience evaluation (CARE) registry

INTRODUCTION

Rural-urban disparities persist in cancer mortality, despite improvement in cancer screening and treatment. Although older adults represent the majority of cancer cases and are over-represented in rural areas, few studies have explored rural-urban disparities in mortality and age-related impairments among older adults with cancer.

MATERIALS AND METHODS

We included 962 newly-diagnosed older adults (≥60 years) with cancer who underwent geriatric assessment (GA) at their first pre-chemotherapy visit to an academic medical center in the Southeastern United States. We used Rural-Urban Commuting Area (RUCA) codes to classify residence at time of diagnosis into urban and rural areas. We used one-year survival and pre-treatment frailty as outcomes. We used Cox proportional hazards regression to evaluate the association between residence and one-year mortality, and logistic regression to evaluate the association between residence and pre-treatment frailty. All tests were two-sided.

RESULTS

Median age at GA was 68.0 (interquartile rage [IQR]: 64.0, 74.0) years; most had colorectal cancer (24.3%) with advanced stage (III/IV 73.2%) disease. Overall, 11.4% resided in rural and 88.6% in urban areas. Rural areas had a higher proportion of White and less educated participants. After adjustment for age, sex, race, education, employment status, and cancer type/stage, rural residence was associated with higher hazard of one-year mortality (hazard ratio [HR] = 1.78, 95% confidence interval [CI] = 1.23, 2.57) compared to urban residence. Frailty was an effect modifier of this association (HROverall = 1.83, 95% CI = 1.27, 2.57; HRFrail = 2.05, 95% CI = 1.23, 3.41; HRNot Frail = 1.55, 95% CI = 0.90, 2.68).

DISCUSSION

Among older adults with newly diagnosed cancer, rural residence was associated with reduced one-year survival, particularly among frail older adults. The rural-urban disparities observed in the current study may be due to frailty in conjunction with disparities in social determinants of health across rural and urban areas. Future studies should focus on understanding and intervening on underlying causes of these disparities.

Rural Research Network to engage rural and minority community members in translational research

Background

To address the high prevalence of health disparities and lack of research opportunities among rural and minority communities, the University of Arkansas for Medical Sciences (UAMS) developed the Rural Research Network in January 2020.

Aim

The aim of this report is to describe our process and progress in developing a rural research network. The Rural Research Network provides a platform to expand research participation opportunities to rural Arkansans, many of whom are older adults, low-income individuals, and underrepresented minority populations.

Methods

The Rural Research Network leverages existing UAMS Regional Programs family medicine residency clinics within an academic medical center.

Results

Since the inception of the Rural Research Network, research infrastructure and processes have been built within the regional sites. Twelve diverse studies have been implemented with recruitment and data collection from 9248 participants, and 32 manuscripts have been published with residents and faculty from the regional sites. Most studies were able to recruit Black/African American participants at or above a representative sample.

Conclusions

As the Rural Research Network matures, the types of research will expand in parallel with the health priorities of Arkansas.

Relevance to Patients

The Rural Research Network demonstrates how Cancer Institutes and sites funded by a Clinical and Translational Science Award can collaborate to expand research capacity and increase opportunities for research among rural and minority communities.

Location, age, and race matter: a path model of emotional distress in the U.S. during COVID-19

BACKGROUND

We aim to identify factors that explain emotional distress among underserved populations during the COVID-19 pandemic.

METHODS

Starting in August 2020, we conducted an online epidemiological survey among 947 U.S. adults. The survey asked a wide array of constructs, including demographics, past-month substance use, and psychological distress. We developed a path model to understand how financial strain, age, and substance use are associated with emotional distress among People of Color (POC) and those living in rural areas.

RESULTS

22.6% (n = 214) of participants were POC; 114 (12%) resided in rural areas; 17.2% (n = 163) made between $50,000 and $74,999 annually; and the emotional distress average was 1.41 (SD = 0.78). POC, especially those younger, experienced higher rates of emotional distress (p < .05). People living in rural contexts reported lower rates of emotional distress through low alcohol intoxication and less financial strain (p < .05).

CONCLUSIONS

We found mediating factors related to emotional distress among vulnerable populations during the COVID-19 pandemic. Younger POC experienced higher rates of emotional distress. People in rural communities had less emotional distress when they had fewer days spent intoxicated by alcohol, which was associated with lower financial strain. We conclude with a discussion of important unmet needs and future research directions.

Geographic proximity to immunization providers and vaccine series completion among children ages 0-24 months

OBJECTIVES

In the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.

METHODS

We analyzed records from Montana's immunization information system for children born 2015-2017. Using geolocated address data, we calculated distance in road miles from children's residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.

RESULTS

Among 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96-0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85-0.92).

CONCLUSIONS

Long travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.

Newly qualified registered nurses' and midwives' experiences from rural health district placement in Namibia

BACKGROUND

The transition period for newly qualified registered nurses/midwives (NQRN/Ms) is a fundamental phase in their career. Yet, transition experiences have been studied mostly within urban and/or specialised healthcare settings in high-resource countries. This study aimed to explore and describe the experiences of NQRN/Ms in a rural health district in Namibia.

METHODS

A qualitative, descriptive, explorative, and contextual design was followed. The sample consisted of eight participants who were purposively selected. Data were collected via in-depth individual interviews and analysed following a reflexive thematic analysis. The researchers were guided by Lincoln and Guba's strategies for establishing trustworthiness.

FINDINGS

Themes conceptualised from the analysis include encounters with rural community members; encounters with colleagues; staffing, management, and supervision; shortage of resources; poor infrastructure; unreliable communication networks; and the lack of social life.

CONCLUSION

The NQRN/Ms had mixed experiences related to a variety of aspects such as social life, resources, colleagues and community members. These findings can be used to improve undergraduate nursing curricula, as well as to create graduate job preparation workshops and support networks.

Undergraduate rural medical training experiences and uptake of rural practice: a retrospective cohort study in South Australia

BACKGROUND

Rural medical training experiences provided by Rural Clinical Schools (RCS) can encourage future practice in rural locations. However, the factors influencing students' career choices are not well understood. This study explores the influence of undergraduate rural training experiences on graduates' subsequent practice location.

METHODS

This retrospective cohort study included all medical students who completed a full academic year at the University of Adelaide RCS training program between 2013-2018. Details of student characteristics, experiences, and preferences were extracted from the Federation of Rural Australian Medical Educators (FRAME, 2013-2018) survey and linked to graduates' recorded practice location obtained from the Australian Health Practitioner Regulation Agency (AHPRA, January 2021). The rurality of the practice location was defined based on the Modified Monash Model (MMM 3-7) or Australian Statistical Geography Standard (ASGS 2-5). Logistic regression was used to examine associations between student rural training experiences and rural practice location.

RESULTS

A total of 241 medical students (60.1% females; mean age 23.2 ± 1.8 years) completed the FRAME survey (response rate 93.2%). Of these, 91.7% felt well supported, 76.3% had a rural-based clinician mentor, 90.4% reported increased interest in a rural career, and 43.6% preferred a rural practice location after graduation. Practice locations were identified for 234 alumni, and 11.5% were working rurally in 2020 (MMM 3-7; 16.7% according to ASGS 2-5). In adjusted analysis, the odds of working rurally were 3-4 times more likely among those with a rural background or lived the longest in a rural location, 4-12 times more likely among those preferring a rural practice location after graduation, and increased with the student's rural practice self-efficacy score (p-value < 0.05 in all cases). Neither the perceived support, having a rural-based mentor, or the increased interest in a rural career were associated with the practice location.

CONCLUSIONS

These RCS students consistently reported positive experiences and increased interest in rural practice after their rural training. Student reported preference for a rural career and rural practice self-efficacy score were significant predictors of subsequent rural medical practice. Other RCS could use these variables as indirect indicators of the impact of RCS training on the rural health workforce.

"I am not a junkie": Social categorization and differentiation among people who use drugs

BACKGROUND

Substance use stigma is a form of group-based exclusion, and delineating pathways from stigma to poor health requires a deeper understanding of the social dynamics of people who use drugs (PWUD). Outside of recovery, scant research has examined the role of social identity in addiction. Framed by Social Identity Theory/Self-Categorization Theory, this qualitative study investigated strategies of within-group categorization and differentiation among PWUD and the roles these social categories may play in shaping intragroup attitudes, perceptions, and behaviors.

METHODS

Data come from the Rural Opioid Initiative, a multi-site study of the overdose epidemic in rural United States. We conducted in-depth interviews with people who reported using opioids or injecting any drug (n=355) living in 65 counties across 10 states. Interviews focused on participants' biographical histories, past and current drug use, risk behaviors, and experiences with healthcare providers and law enforcement. Social categories and dimensions along which categories were evaluated were inductively identified using reflexive thematic analysis.

RESULTS

We identified seven social categories that were commonly appraised by participants along eight evaluative dimensions. Categories included drug of choice, route of administration, method of attainment, gender, age, genesis of use, and recovery approach. Categories were evaluated by participants based on ascribed characteristics of morality, destructiveness, aversiveness, control, functionality, victimhood, recklessness, and determination. Participants performed nuanced identity work during interviews, including reifying social categories, defining 'addict' prototypicality, reflexively comparing self to other, and disidentifying from the PWUD supra-category.

CONCLUSION

We identify several facets of identity, both behavioral and demographic, along which people who use drugs perceive salient social boundaries. Beyond an addiction-recovery binary, identity is shaped by multiple aspects of the social self in substance use. Patterns of categorization and differentiation revealed negative intragroup attitudes, including stigma, that may hinder solidary-building and collective action in this marginalized group.

Qualitative Analysis of Colorectal Cancer Screening in Rural Nebraska

Compared to urban residents, rural populations are less likely to engage in colorectal cancer (CRC) screening. As part of a statewide cancer needs assessment, we aimed to elicit rural perspectives about CRC screening and resources. We conducted three focus groups with rural Nebraska cancer survivors and caregivers (N = 20) in Spring 2021 using a collective case study design. Participant awareness of and knowledge about CRC screening methods varied across focus groups; overall, 95% of participants had heard of colonoscopy. Participants were less familiar with fecal tests and had confusion about them. Colonoscopy was associated with negative perceptions regarding the time, cost, and discomfort of the preparation and procedure, but some providers did not discuss alternative methods unless the patient resisted colonoscopy. Healthcare providers played a key role educating rural communities about CRC screening recommendations (age, risk) and testing options and being persistent in those recommendations. CRC awareness campaigns should include a variety of communication channels (TV, radio, billboards, health fairs, churches, healthcare settings). Promotion of CRC screening should include education about screening age guidelines, alternative test types, and informed decision-making between provider and patient regarding preferred screening methods based on the pros and cons of each test type. Individuals with a family history of colon issues (Crohn's disease, CRC) are considered high risk and need to be aware that screening should be discussed at earlier ages.

Usability and perceptions of a one-on-one telementoring program for young physicians in rural settings of Peru: a mixed method study

BACKGROUND

Telementoring seems to be a promising strategy to deliver training and counselling to physicians in remote areas. In Peru, early graduated physicians must work for the Rural and Urban-Edge Health Service Program where they face important training needs. The aim of this study was to describe the usage of a one-on-one telementoring program for rural physicians and evaluate the aspects related to the perceptions of acceptability and usability.

METHODS

Mixed methods study on recently graduated physicians who work in rural areas and participate in the telementoring program. The program used a mobile application to connect these young doctors with specialized mentors to answer queries about real-life problems raised by working in a rural area. We summarize administrative data to assess participant characteristics and their participation in the program. Additionally, we conducted in-depth interviews to explore the perceived usability, ease of use, and reason for non-use of the telementoring program.

RESULTS

Of 74 physicians (mean age 25, 51.4% women) enrolled, 12 (16.2%) actively used the program and performed a total of 27 queries, which received response in an average time of 5.4 ± 6.3 h. In the interviews, the main reasons for non-use were connectivity issues, feelings of shame, and self-efficacy. For those who used the telementoring program they referred it was easy to use and solve their inquiries timely.

CONCLUSIONS

The implementation of a telementoring program sought to provide guidance to recently graduated physicians working in rural areas. Low use rates show that administrative and process-related deficiencies in the program implementation need to be improved.

Factors predicting parent engagement in a family-based childhood obesity prevention and control program

BACKGROUND

Family-based interventions are efficacious at preventing and controlling childhood overweight and obesity; however, implementation is often hindered by low parent engagement. The purpose of this study was to evaluate predictors of parent engagement in a family-based childhood obesity prevention and control intervention.

METHODS

Predictors were assessed in a clinic-based community health worker (CHW)-led Family Wellness Program consisting of in-person educational workshops attended by parents and children. This program was part of a larger effort known as the Childhood Obesity Research Demonstration projects. Participants included 128 adult caretakers of children ages 2-11 (98% female). Predictors of parent engagement (e.g., anthropometric, sociodemographic, psychosocial variables) were assessed prior to the intervention. Attendance at intervention activities was recorded by the CHW. Zero-inflated Poisson regression was used to determine predictors of non-attendance and degree of attendance.

RESULTS

Parents' lower readiness to make behavioral and parenting changes related to their child's health was the sole predictor of non-attendance at planned intervention activities in adjusted models (OR = 0.41, p < .05). Higher levels of family functioning predicted degree of attendance (RR = 1.25, p < .01).

CONCLUSIONS

To improve engagement in family-based childhood obesity prevention interventions, researchers should consider assessing and tailoring intervention strategies to align with the family's readiness to change and promote family functioning.

TRIAL REGISTRATION

NCT02197390, 22/07/2014.

Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study

BACKGROUND

Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs.

METHODS

Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically.

RESULTS

TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk.

CONCLUSIONS

This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Analysis of the demand of care from Primary Care to Traumatology: Proposals for the improvement of the continuous care

OBJECTIVE

To analyze referrals from Primary Care consultation to Orthopaedic Surgery reference department. As a secondary objective, to establish 2referral scenarios in order to determine the impact of variability on referral.

MATERIAL AND METHODS

Cross-sectional observational study, analyzing referrals from Primary Care to Orthopaedic Surgery during the first half of the years 2018, 2019, and 2021. The number of referrals issued by each doctor and each Primary Care Healthcare Center was examined, according to the classification of the different Basic Healthcare Zones.

RESULTS

There is great variability in the number of referrals, both according to the type of Basic Healthcare Zone and by each Primary Care facultative. The referral ratios behaved uniformly over time (P<0.001). Due to a large number of referrals, 2scenarios have been constructed: In the first scenario, the referral ratio would be in the middle of the referral rate spectrum. In the second scenario, the lowest referral ratios recorded have been taken as a reference. The reduction of variability in the 2scenarios assumed provides a significant reduction in the demand for care.

CONCLUSION

Reducing variability would have a beneficial effect on the capacity of the Orthopaedic Surgery service to provide care.