A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

BACKGROUND

Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

METHODS

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

RESULTS

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

CONCLUSION

Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

Conceptualising relevant social context indicators for people receiving home care: A multi-method approach in Flanders, Belgium

Despite an increasing awareness of the impact of the social context of a person on personalised care planning, there is currently no generally accepted classification of social context. As a result, home care professionals have a partial understanding of what social context is and how it affects and can even benefit their work. In this study, we define the main themes and concepts of the social context in the home care setting. The goal in this study is twofold. Initially, we want to offer a multidimensional and practical model of social context, founded on the perspectives of care users and professional caregivers in home care. This model of social context, in turn, will be the foundation for the development of a Social Supplement for the interRAI assessment instruments. We conducted nine focus groups in Flanders between September and November 2017. Fifty-four people participated. The focus groups followed a semi-structured format based on themes identified from the literature and three in-depth interviews with experts. Questions focused on defining the main themes of 'social context' and their subcategories. At the end of each discussion, participants were asked to consider which concept could be suitable and essential for a Social Supplement to the current interRAI instruments. Focus groups were recorded, transcribed and analysed using NVivo. We used investigator and theoretical triangulation to ensure the quality of our analysis, and identified five overarching themes of social context; (a) care and support, (b) physical environment, (c) life and care goals, (d) psychosocial well-being and (e) civic engagement. These main themes were mentioned throughout the nine focus group discussions, even though a diverse group of stakeholders participated. This model provides the basis for the development of a Social Supplement for the interRAI assessment instruments in Flanders, Belgium.

Improving the patient discharge process: implementing actions derived from a soft systems methodology study

In the period from January 2013 to July 2014, three process change initiatives were undertaken at a major UK hospital to improve the patient discharge process. These initiatives were inspired by the findings of a study of the discharge process using Soft Systems Methodology. The first initiative simplified time-consuming paperwork and the second introduced more regular reviews of patient progress through daily multi-disciplinary "Situation Reports". These two initiatives were undertaken in parallel across the hospital, and for the average patient they jointly led to a 41% reduction between a patient being declared medically stable and their being discharged from the hospital. The third initiative implemented more proactive alerting of Social Care Practitioners to patients with probable social care needs at the front door, and simplified capture of important patient information (using a "SPRING" form). This initiative saw a 20% reduction in total length of stay for 88 patients on three wards where the SPRING form was used, whilst 248 patients on five control wards saw no significant change in total length of stay in the same period. Taken together, these initiatives have reduced total length of stay by 67% from 55.8 days to 18.6 days for the patients studied.

Community health needs assessment: a nurses' global health project in Vietnam

BACKGROUND

Global health has been directed to providing solutions to various health issues cross-nations, and nurses have received wide recognition as a key health workforce to reduce health disparities globally. Nurses involved in global health research are required to implement evidence-based global nursing practices based on the assessments of local health needs.

AIM

To assess health needs and to suggest future interventions in rural communities of Vietnam.

METHODS

A multifaceted rapid participatory appraisal with information pyramid was used applying mixed methods from six sources: existing record review, surveys of community residents, surveys of healthcare providers, focus group discussions with community leaders, informal discussions with governmental health administrators and observations of community health station (CHS) facilities.

RESULTS

The majority used the CHSs as primary health facilities with high satisfaction for services currently provided. However, there were needs for the stations to provide more comprehensive services including chronic diseases, and for healthcare providers to improve their competences. Community leaders showed high interest in health information for chronic diseases and strong commitment to involvement in the activities for health of their communities. The findings suggest future interventions in the areas of the enhancement of CHS' functions, human resources and the self-care capacity of community residents.

CONCLUSION AND POLICY IMPLICATIONS

The rapid participatory appraisal approach emphasizing community participation and partnership was a useful tool to compile accurate information about the current needs of the community on health, the preparedness of healthcare services to meet community's demands and about community capacity. This process is fundamental to nurses, who initiate global health projects in resource-limited international countries, to generate evidences regarding practice, research and policy for taking responsibilities in promoting the sustainable development goals.

The Pituri Learning Circle: central Australian Aboriginal women's knowledge and practices around the use of <I>Nicotiana</I> spp. as a chewing tobacco

INTRODUCTION

Tobacco smoking has a range of known and predictable adverse outcomes, and across the world sustained smoking reduction campaigns are targeted towards reducing individual and public risk and harm. Conversely, more than 87 million women, mostly in low- and middle-income countries, use smokeless tobacco, yet the research examining the effect of this form of tobacco exposure on women is remarkably scant. In central Australia, the chewing of wild <i>Nicotiana</i> spp., a tobacco plant, commonly known as <i>pituri</i> and <i>mingkulpa</i>, is practised by Aboriginal groups across a broad geographical area. Until recently, there had been no health research conducted on the effects of chewing <i>pituri.

METHODS

This article reports on one component of a multidimensional <i>pituri</i> research agenda. A narrative approach utilising the methodology of the Learning Circle was used to interview three key senior central Australian Aboriginal women representative of three large geographical language groupings. The participants were selected by a regional Aboriginal women's organisation. With the assistance of interpreters, a semistructured interview, and specific trigger resources, participants provided responses to enable an understanding of the women's ethnobotanical <i>pituri</i> knowledge and practices around the use of <i>pituri</i> within the context of Aboriginal women's lives. Data were transcribed, and by using a constant comparison analysis, emergent themes were categorised. The draft findings and manuscript were translated into the participants' language and validated by the participants.

RESULTS

Three themes around <i>pituri</i> emerged: (a) the plants, preparation and use; (b) individual health and wellbeing; and (c) family and community connectedness. The findings demonstrated similar participant ethnobotanical knowledge and practices across the geographical area. The participants clearly articulated the ethnopharmacological knowledge associated with mixing <i>pituri</i> with wood ash to facilitate the extraction of nicotine from <i>Nicotiana </i>spp., the results of which were biochemically verified. The participants catalogued the pleasurable and desired effects obtained from <i>pituri</i> use, the miscellaneous uses of <i>pituri</i>, as well as the adverse effects of <i>pituri</i> overdose and toxicity, the catalogue of which matched those of nicotine. The participants' overarching <i>pituri</i> theme was related to the inherent role <i>pituri</i> has in the connectiveness of people to family, friends and community.

CONCLUSIONS

Central Australian Aboriginal women have a firmly established knowledge and understanding of the pharmacological principles related to the content of <i>Nicotiana</i> spp. and the extraction of nicotine from the plant. Widespread use of <i>Nicotiana</i> spp. as a chewing tobacco by Aboriginal populations in the southern, central and western desert regions of Australia is attested to by participants who assert that <i>everyone uses it</i>, with girls in these remote areas commencing use between 5 and 7 years of age. Central Australian Aboriginal people who chew <i>Nicotiana</i> spp. do not consider it to be a tobacco plant, and will strongly refute that they are tobacco users. Central Australian Aboriginal people do not consider that the Western health information regarding tobacco (as a smoked product) is applicable or aligned to their use of <i>pituri</i>. <i>Nicotiana</i> spp. users will deny tobacco use at health assessment. There is a requirement to develop and provide health information on a broader range of tobacco and nicotine products in ways that are considered credible by the Aboriginal population. Health messages around <i>pituri</i> use need to account for the dominant role that <i>pituri</i> occupies in the context of central Australian Aboriginal women's lives.<br /> Information for readers: A consultative organisation of Aboriginal women has as a strategic intent and operational agenda the improvement of Aboriginal women's and children's health across the research region. The group seeks opportunities to enhance their knowledge based on legitimate collaborative research; accordingly, they sought to participate in a range of research activities regarding the use of <i>pituri</i> and women's health outcomes. Of particular note, the group's participants chose to be identified by name in the publication of this research activity. In this article, the term 'Aboriginal' has been chosen by the central Australian women to refer to both themselves and the Aboriginal people in their communities; 'Indigenous' has been chosen to refer to the wider Australian Aboriginal and Torres Strait Islander people. The term <i>Nicotiana</i> spp. is used when referring to the plants from a Western perspective; <i>pituri</i> is used when referring to the plants, the tobacco quid, and the practice of chewing from a general Aboriginal perspective; and <i>mingkulpa</i> is used when the participants are voicing their specific knowledge and practices.

Relevance of the Aboriginal Children's Health and Well-being Measure Beyond Wiikwemkoong

INTRODUCTION

Aboriginal children in Canada experience significant disparities in health in comparison to their mainstream peers. As Aboriginal communities and agencies strive to improve health, it is important to measure the impact of new programs and services. Since many Aboriginal children live in rural and remote communities, it is important that communities have access to measurement tools that are relevant and feasible to implement in these contexts.<b> </b>The Aboriginal Children's Health and Well-being Measure (ACHWM) was developed to meet the need for a culturally relevant measure of health and wellbeing for Aboriginal children (ages 8-18 years) in Canada. It was developed within one First Nation community: the Wiikwemkoong Unceded Territory. The intention from inception was to ensure the feasibility and relevance of the ACHWM to other Aboriginal communities. The purpose of this article is to describe the relevance of the ACHWM beyond Wiikwemkoong.

METHODS

This article presents the results of a community-based and collaborative research study that was jointly led by an academic researcher and a First Nations Health leader. The research began with the 58-question version of the ACHWM developed in Wiikwemkoong. The ACHWM was then submitted to a well-established process of community review in four new communities (in sequence): Weechi-it-te-win Family Services, M'Chigeeng First Nation, Whitefish River First Nation, and the Ottawa Inuit Children's Centre (OICC). The review process included an initial review by local experts, followed by a detailed review with children and caregivers through a detailed cognitive debriefing process. Each community/agency identified changes necessary to ensure appropriate fit in their community. The results from all communities were then aggregated and analysed to determine the similarities and differences.

RESULTS

This research was conducted in 2014 and 2015 at four sites. Interviews with 23 children and 21 caregivers were completed. Key lessons were learned in all communities that enabled the team to improve the ACHWM in subtle but important ways. A total of 12 questions were revised, and four new questions were added during the process. This produced a 62-question version of the ACHWM, which was endorsed by all communities.

CONCLUSIONS

The ACHWM has been improved through a detailed review process in four additional communities/agencies and resulted in a stable 62-question version of the survey. This process has demonstrated the relevance of the ACHWM to a variety of Aboriginal communities. This survey provides Aboriginal communities with a culturally appropriate tool to assess and track their children's health outcomes, enabling them to gather new evidence of child health needs and the effectiveness of programs in the future.

Use of cell phones and computers for health promotion and tobacco cessation by American Indian college students in Montana

INTRODUCTION

Cell phones and personal computers have become popular mechanisms for delivering and monitoring health information and education, including the delivery of tobacco cessation education and support. Tobacco smoking is prevalent among American Indians (AIs) and Alaska Natives (ANs), with 26% AI/AN adult men smoking compared to 19% of Caucasian adult males and 22% of African American adult males. Smoking is even more prevalent in Northern Plains AI populations, with 42% of men <i>and</i> women reporting current smoking. The literature on the availability and use of cell phones and computers, or the acceptability of use in health promotion among AIs and ANs, is scant. The authors report findings from a survey of AI students regarding their cell phone and computer access and use. The survey was conducted to inform the development and implementation of a text messaging smoking cessation intervention modeled on a program developed and used in Australia.

METHODS

A 22-item paper and pencil survey was administered to students at tribal colleges in rural Montana. The survey questions included cell phone ownership and access to service, use of cell phones and computers for health information, demographics, tobacco use habits, and interest in an intervention study. The study was reviewed and determined exempt by the institutional review boards at the tribal colleges and the lead research university. The study was conducted by researchers at the tribal colleges. Survey respondents received $10 when the survey was completed and returned. Data analysis was performed with the Statistical Package for the Social Sciences.

RESULTS

Among 153 AI respondents, the mean age was 29 years, range was 18-64 years. Overall, 40% reported smoking cigarettes with a mean age of 16 years at initiation. A total of 131 participants (86%) had cell phones and, of those, 122 (93%) had unlimited text messaging. A total of 104 (68%) had smart phones (with internet access), although 40% of those with smart phones reported that internet access on their phone was very slow or location limited. A total of 146 (95%) participants reported having access to a computer, although 32% of those did not have daily access. Students aged less than 23 years were more likely to have cell phones with internet access. Cell phone ownership differed by site (93% vs 77%,<i> p</i>=0.007). About 60% of the respondents who smoked indicated interest in participating in the intervention study.

CONCLUSIONS

This study revealed that<b> </b>AI<b> </b>tribal college students in the rural communities surveyed had less<b> </b>cell phone, smart phone, and computer and internet access than that reported for undergraduate college students elsewhere in the USA.<b> </b>Research efforts and public health interventions must be culturally appropriate and technologically viable, therefore access to and acceptability of mobile technology must be evaluated when planning and implementing interventions for rural and other marginalized populations. The findings from this study contribute to the literature regarding the access to and acceptability of mobile technology for health promotion among AI/AN college students in rural and remote areas, and helped introduce the proposed study to the community and solicited useful data regarding tobacco prevalence and interest in tobacco research in the target population.

Mental health nurses in South Africa's public rural primary care settings: a human resource crisis

INTRODUCTION

South Africa is a middle-income country with serious socioeconomic risk factors for mental illness. Of its population of 52 million, 53% live below the poverty line, 24% are unemployed and 11% live with HIV/AIDS, all of which are factors associated with an increased burden of neuropsychiatric disease. The negative social implications due to the mortality caused by AIDS are immense: thousands of children are being orphaned, increasing the risk of intergenerational mental illness. Ensuring sufficient mental health human resources has been a challenge, with South Africa displaying lower workforce numbers than many low- and middle-income countries. It is in South Africa's public rural primary healthcare (PRPHC) areas where access to mental healthcare services, especially medical prescribers, is most dire. In 1994, primary healthcare (PHC) was mainstreamed into South Africa's public healthcare system as an inclusive, people-orientated healthcare system. Nurses provide for the majority of the human resources at PHC level and are therefore seen as the backbone of this sector. Efforts to decentralize mental healthcare and integrate it into the PHC system rely on the availability of mental health nurses (MHNs), to whom the task of diagnosing mental illness and prescribing psychotropic medications can be shifted. The goal of this situation analysis was to fill knowledge gaps with regard to MHN human resources in South Africa's PRPHC settings, where an estimated 40% of South Africa's population reside.

METHODS

Both primary and secondary data were analysed. Primary data was collected by inviting 160 (98%) of South African rural hospitals' clinical heads to participate in an interview schedule regarding mental health human resources at their institutions. Primary data were collated and then analysed using descriptive quantitative analysis to produce lists of MHNs per institution and per province. Secondary data was obtained from an extensive literature review of MHNs in South Africa, but also of mental healthcare services in other low- and middle-income countries. The literature review included reports by the National Department of Health and the South African Nursing Council, academic publications and dissertations as well as census data from Statistics South Africa, including findings from the 2011 general household survey. International secondary data was obtained from the WHO's most recent reports on global mental health.

RESULTS

The findings suggest a distressing shortage of MHNs in South Africa's rural public areas. Only 62 (38.7%) of the 160 facilities employ MHNs, a total of 116 MHNs. These MHNs serve an estimated population of more than 17 million people, suggesting that MHNs are employed at a rate of 0.68 per 100 000 population in South Africa's PRPHC areas.

CONCLUSIONS

Secondary data analysis indicates that MHNs are practicing in South Africa at a national rate of 9.7 per 100 000 population. This unequal distribution calls for a redistribution of MHNs to PRPHC areas. Further recommendations are made to address the mental healthcare workforce crisis by upscaling human resources in PRPHC areas. Revisiting policy surrounding training programs and the current evidence-based approach of task shifting is advised. Innovative approaches such as extending mental healthcare professions' roles and scopes of practice at PHC level are necessary to ensure adequate mental health care for all South Africans.

Supports for medical students during rural clinical placements: factors associated with intention to practise in rural locations

INTRODUCTION

Through rural clinical schools (RCSs), medical students may undertake an extended block of clinical training in rural Australia. The premise of these placements is that meaningful rural exposure will facilitate rural career uptake. RCSs offer a range of supports to facilitate student engagement in the program. This study aims to analyse RCS students' perceptions of these supports and impact on intentions to work rurally.

METHODS

Between September 2012 and January 2013 RCS students were invited to complete questions regarding perceptions of student support, as a part of the annual Federation of Australian Medical Educators survey. Multivariable logistic regression was used to identify associations between supports and intentions for rural internship or career.

RESULTS

There were 454 participants. A majority of students (n=349, 79.1%) felt well supported by their RCS. Students from a rural background (odds ratio (OR)=1.64 (95% confidence interval (CI):1.13-2.38)), or who indicated that their placement had a positive impact on their wellbeing (OR=1.38 (95%CI:1.07-1.80)), were more likely to intend to complete a rural internship. Those who felt socially isolated were less likely to elect this (OR=0.82 (0.70-0.97)). Outcomes were similar for those indicating a preference for rural or remote practice after completing training.

CONCLUSIONS

Student perceptions of supports offered by RCSs were generally very positive. Perceptions of financial support were not predictive of rural career intent. Although this does not negate the importance of providing appropriate financial supports, it does demonstrate that student wellbeing is a more important recruitment factor for rural practice.

Diabetes knowledge and self-efficacy among rural women in Gujarat, India

INTRODUCTION

Type II diabetes has risen dramatically among rural women in India, specifically in the states of Gujarat, Karnataka, Tamil Nadu and Uttar Pradesh. Recent studies suggest that rural Indian women's low level of self-efficacy, or confidence in their ability to carry out tasks, such as managing diabetes, is a key reason for this increase. Therefore, this study utilizes the Health Belief Model to analyze whether increased awareness of diabetes leads to a positive increase in levels of self-efficacy among diabetic women in two rural villages of Gujarat.

METHODS

A cross-sectional study of 126 known cases of women with diabetes was carried out in the villages of Rajpur and Valam in the Mehsana District in the state of Gujarat, India, to assess the relationship between diabetes knowledge and self-efficacy. The instrument was adapted from the Michigan Diabetes Research and Training Center's Diabetes Empowerment Scale-Short Form and Knowledge, Attitudes and Practices Assessment of the Indian Institute of Public Health Gandhinagar.

RESULTS

Participants' mean knowledge score was 10.77±2.86 out of a possible 24 points, for a mean percentage of 45%. The median self-efficacy score for the women was 7 with an interquartile range of 3. The age-adjusted multiple regression analysis demonstrated a significant positive correlation between knowledge and self-efficacy (p<0.001).

CONCLUSIONS

The observations of this study suggest a positive correlation between diabetes knowledge and self-efficacy. Future diabetes educational interventions in India should place a greater emphasis on increasing knowledge among rural women. Specifically, these interventions should emphasize the major gaps in knowledge regarding causes of diabetes, complications and treatment procedures. Educational interventions that are catered more towards rural women will be critical for improving their self-efficacy.

Geographical access to radiation therapy in North Queensland: a retrospective analysis of patient travel to radiation therapy before and after the opening of an additional radiotherapy facility

INTRODUCTION

Access to radiation therapy (RT) underlies optimal care for prostate and breast cancer patients. This study investigates the impact of opening a new RT clinic on distance and road travel time to RT, and overall utilisation for prostate and breast cancer patients over a 3-year period in North Queensland (NQ), Australia.

METHODS

The study used retrospective audit of two radiotherapy databases and a geographic information system to illustrate patient origins and distance to the RT clinic used over 3 years. Prostate and female breast cancer patients were selected from the radiation oncology databases of The Townsville Hospital (TTH) and Radiation Oncology Queensland (ROQ) Cairns between 1 July 2010 and 30 June 2013. Distance from a patient's home origin to the RT facility was mapped using a geographic information system (ArcGIS software), and travel time (minutes) and road distance (km) determined by Google Maps road directions.

RESULTS

Overall number of prostate and breast cancer patients treated by RT in Cairns and Townsville clinics increased by 16% in 2011-2012 and by 29% in 2012-2013 from year 1 values. In 2010, 44% of the patients travelled 200-400 km to RT, which reduced to 21% in 2013. By 2013, with a second treatment facility, more than 70% of patients lived within 200 km of an RT facility (p<0.0001). Total median road travel time reduced annually from 201 minutes in 2010-2011 to 66 minutes in 2011-2012 and 56 minutes in 2012-2013 (p<0.0001), corresponding to a decrease in the median distance travelled to an RT facility.

CONCLUSIONS

An additional RT facility in NQ has led to an increase in patients treated with RT for prostate and breast cancer and, on average, less travel distance and time to treatment, suggesting improvement in access to RT in NQ.

Mais Médicos program: provision of medical doctors in rural, remote and socially vulnerable areas of Brazil, 2013-2014

INTRODUCTION

The Mais Médicos program was introduced in 2013 with the aim of reducing the shortage of doctors in priority regions and diminishing regional inequalities in health. One of the strategies has been to offer 3-year contracts for doctors to work in primary healthcare services in small towns, inland, rural, remote, and socially vulnerable areas. This report describes the program's implementation and the allocation of doctors to these target areas in 2014.

METHODS

To describe the provision of doctors in the first year of implementation, we compared the doctor-to-population ratio in the 5570 municipalities of Brazil before and after the program, based on the Federal Board of Medicine database (2013), and the official dataset provided by the Ministry of Health (2014).

RESULTS

In its first public call (July 2013) 3511 municipalities joined the Mais Médicos program, requesting a total of 15 460 doctors; although the program prioritizes the recruitment of Brazilians, only 1096 nationals enrolled and were hired, together with 522 foreign doctors. As a consequence, an international cooperation agreement was set in place to recruit Cuban doctors. In 12 months the program recruited 14 462 doctors: 79.0% Cubans, 15.9% Brazilians and 5.1% of other nationalities, covering 93.5% of the doctors demanded; they were assigned to all the 3785 municipalities enrolled. The study reveals a major decrease in the number of municipalities with fewer than 0.1 doctors per thousand inhabitants, which dropped from 374 in 2013 to 95 in 2014 (75% reduction). Of the total, 294 doctors were sent to work in the country's 34 Indigenous Health Districts (100% coverage) and 3390 doctors were deployed in municipalities containing certified rural maroon communities (formed centuries ago by runaway slaves). After 1 year of implementation, the municipalities with maroon communities with less than 0.1 doctors per thousand inhabitants were reduced by 87% in the poorest north region. More than 30% of municipalities with maroon communities in the richest regions had more than 1.0 doctors per thousand inhabitants, whereas in the poorest regions fewer than 7% of municipalities reached that level.

CONCLUSIONS

The Mais Médicos program has granted medical assistance to these historically overlooked populations. However, it is important to evaluate the mid- and long-term sustainability of this initiative.

Factors affecting willingness to practice medicine in underserved areas: a survey of Argentine medical students

INTRODUCTION

Previous research has explored the effect of motivations, incentives and working conditions on willingness to accept jobs in rural and remote areas. These studies demonstrated that difficult working conditions, low job satisfaction and remuneration, and poor security, predisposed new medical graduates to select cities instead of rural districts. Since Argentina has a critical shortage of health staff in rural and low-income marginal suburban settings, and limited qualitative and quantitative local research has been done to address this issue, the present study was developed to assess the factors associated with the willingness of medical students to work in low-resource underprivileged areas of the country after graduation.

METHODS

A cross-sectional descriptive design was used with data collected from a self-administered questionnaire and using quantitative analysis methods. A total of 400 eligible second-year medical students were invited to participate in a survey focused on sociodemographic characteristics, incentives and working conditions expected in deprived areas, extrinsic and intrinsic motivations, university medical education and government promotion policies.

RESULTS

Twenty-one per cent of medical students showed a strong willingness to work in a deprived area, 57.3% manifested weak willingness and 21.5% unwillingness to work in a low-resource setting. Being female, of older age, not having a university-trained professional parent, previous exposure or service in a poor area, choice of pediatrics as a specialty and strong altruistic motivations were highly associated with the willingness to practice medicine in rural or underprivileged areas. Only 21.5% of respondents considered that medical schools encourage the practice of medicine in poor deprived regions. Likewise, only 6.2% of students considered that national public health authorities suitably stimulate physician distribution in poorer districts.

CONCLUSIONS

One-third of students expressed high altruistic motivations and should therefore be encouraged during their careers. Better remuneration and the assurance of a position at an urban hospital in the future may tip the choice in favor of underprivileged regions. Since most respondents said that neither government nor medical schools sufficiently encourage the practice of medicine in poor deprived regions, government policy-makers should recommend changes in resource allocation to better promote official proposals and opportunities to work.

Monitoring interhospital transfers in Western Greece during 2003-2011: its role in health policy

INTRODUCTION

Interhospital transfers (ITs) could provide insight into regional healthcare efficiency and evidence for policy-making. The aim of this study was to analyse ITs carried out in the Western Greece region over a nine-year period.

METHODS

Archives of the National Center of Emergency Medical Services of Patras and official healthcare resources were used to analyze patient transfers from rural to 'reception' hospitals in the area, during the period 2003-2011, by hospital, medical, seasonal and population variations.

RESULTS

A total of 2500 ITs from the eight rural hospitals to the central ones in the metropolitan area of Patras were monitored yearly. Transfer rates per population ranged between less than 0.3% and more than 1.0%. Only a few patients transferred outside the area (0.9%). Almost 10% of total transfers regarded diagnostic evaluation (mostly CT scan). Transfer rates were inversely related to hospital admission rates (Pearson -0.973, p=0.027), while time (in minutes) (Pearson -0.903, =0.036) and distance (in kilometers) between the rural and central hospitals (Pearson -0.907, p=0.034) also exhibited significant relationships. The level of understaffing does not have a clear effect on ITs.

CONCLUSIONS

By monitoring ITs, it becomes evident where efforts should be prioritized and which of the interconnections should be optimized in a specific network of health care. In this case, interventions should be focused towards the (a) very high transfer rates from the general hospital (GH) of Aigio, (b) lack of orthopedists at GH Kalavryta, which could provide a 24 hour emergency service in a tourist ski area, (c) understaffing in the microbiological laboratory and lack of a CT scanner at GH Mesologi, and (d) lack of radiologists in several hospitals, rendering the installed equipment worthless. By monitoring the ITs, real needs and win-win actions may emerge in the complex interplay of infrastructural factors.

The Fly-in Fly-out and Drive-in Drive-out model of health care service provision for rural and remote Australia: benefits and disadvantages

CONTEXT

Rural Australians experience poorer health and poorer access to health care services than their urban counterparts, and there is a chronic shortage of health professionals in rural and remote Australia. Strategies designed to reduce this rural-urban divide include fly-in fly-out (FIFO) and drive-in drive-out (DIDO) services. The aim of this article is to examine the opportunities and challenges involved in these forms of service delivery. This article reviews recent literature relating to FIFO and DIDO healthcare services and discusses their benefits and potential disadvantages for rural Australia, and for health practitioners.

ISSUES

FIFO and DIDO have short-term benefits for rural Australians seeking healthcare services in terms of increasing equity and accessibility to services and reducing the need to travel long distances for health care. However, significant disadvantages need to be considered in the longer term. There is a potential for burnout among health professionals who travel long distances and work long hours, often without adequate peer support or supervision, in order to deliver these services. A further disadvantage, particularly in the use of visiting medical practitioners to provide generalist services, is the lack of development of a sufficiently well-resourced local primary healthcare system in small rural communities.

LESSONS LEARNED

Given the potential negative consequences for both health professionals and rural Australians, the authors caution against the increasing use of FIFO and DIDO services, without the concurrent development of well-resourced, funded and staffed primary healthcare services in rural and remote communities.

Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum

INTRODUCTION

The establishment of the rural clinical schools funded through the Commonwealth Department of Health and Ageing (now Department of Health) Rural Clinical Training and Support program over a decade ago has been a significant policy initiative in Australian rural health. This article explores the impacts of this policy initiative and presents the wide range of educational innovations contextualised to each rural community they serve.

METHODS

This article reviews the achievements of the Australian rural clinical and regional medical schools (RCS/RMS) through semi-structured interviews with the program directors or other key informants. The questions and responses were analysed according to the funding parameters to ascertain the numbers of students, types of student placements and range of activities undertaken by each university program.

RESULTS

Sixteen university medical schools have established 18 rural programs, creating an extensive national network of RCS and RMS in every state and territory. The findings reveal extensive positive impacts on rural and regional communities, curriculum innovation in medical education programs and community engagement activities. Teaching facilities, information technology, video-conferencing and student accommodation have brought new infrastructure to small rural towns. Rural clinicians are thriving on new opportunities for education and research. Clinicians continue to deliver clinical services and some have taken on formal academic positions, reducing professional isolation, improving the quality of care and their job satisfaction. This strategy has created many new clinical academics in rural areas, which has retained and expanded the clinical workforce. A total of 1224 students are provided with high-quality learning experiences for long-term clinical placements. These placements consist of a year or more in primary care, community and hospital settings across hundreds of rural and remote areas. Many programs offer longitudinal integrated clerkships; others offer block rotations in general practice and specialist clinics. Nine universities established programs prior to 2004, and these well-established programs are finding graduates who are returning to rural practice. Universities are required to have 25% of the students from a rural background. University admission policies have changed to encourage more applications from rural students. This aspect of the policy implements the extensive research evidence that rural-origin students are more likely to become rural practitioners. Additional capacity for research in RCS has influenced the rural health agenda in fields including epidemiology, population health, Aboriginal health, aged care, mental health and suicide prevention, farming families and climate change. There are strong research partnerships with rural workforce agencies, research centres for early career researchers and PhD students.

CONCLUSIONS

The RCS policy initiative has vastly increased opportunities for medical students to have long-term clinical placements in rural health services. Over a decade since the policy has been implemented, graduates are being attracted to rural practice because they have positive learning experiences, good infrastructure and support within rural areas. The study shows the RCS initiative sets the stage for a sustainable future Australian rural medical workforce now requiring the development of a seamless rural clinical training pipeline linking undergraduate and postgraduate medical education.

Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi

INTRODUCTION

Persons with disabilities and their families still live with stigma and a high degree of social exclusion especially in rural areas, which are often poorly resourced and serviced. Community-based workers in health and social development are in an ideal position to assist in providing critical support for some of those most at risk of neglect in these areas. This article analyses the work of community disability workers (CDWs) in three southern African countries to demonstrate the competencies that these workers acquired to make a contribution to social justice for persons with disabilities and their families. It points to some gaps and then argues that these competencies should be consolidated and strengthened in curricula, training and policy. The article explores local experiences and practices of CDWs so as to understand and demonstrate their professional competencies and capacity to deliver disability-inclusive services in rural areas, ways that make all information, activities and programs offered accessible and available to persons with disabilities.

METHODS

A qualitative interpretive approach was adopted, informed by a life history approach. Purposive sampling was used to select 16 CDWs who had at least 5 years experience of disability-related work in a rural area. In-depth interviews with CDWs were conducted by postgraduate students in Disability Studies. An inductive and interpretative phenomenological approach was used to analyse data.

RESULTS

Three main themes with sub-categories emerged demonstrating the competencies of CDWs. First, integrated management of health conditions and impairments within a family focus comprised 'focus on the functional abilities' and 'communication, information gathering and sharing'. Second, negotiating for disability-inclusive community development included four sub-categories, namely 'mobilising families and community leaders', 'finding local solutions with local resources', 'negotiating retention and transitions through the education system' and 'promoting participation in economic activities'. Third, coordinated and efficient intersectoral management systems involved 'gaining community and professional recognition' and the ability to coordinate efforts ('it's not a one-man show'). The CDWs spoke of their commitment to fighting the inequities and social injustices that persons with disabilities experienced. They facilitate change and manage the multiple transitions experienced by the families at different stages of the disabled person's development.

CONCLUSIONS

Disability-inclusive development embraces a philosophy of social inclusion and a set of values that seeks to protect the human dignity and rights of persons with disabilities. It requires a workforce equipped with skills to work intersectorally and in a cross-disciplinary manner in order to operationalise the community-based rehabilitation guidelines that are designed to promote delivery of services in remote and rural areas. CDWs potentially have a unique set of competencies that enables them to facilitate disability-inclusive community development in rural areas. The themes reveal how the CDWs contribute to building relationships that restore the humanity and dignity of persons with disabilities in their family and community. These competencies draw from different disciplines which necessitates recognition of the CDWs as a cross-disciplinary profession.

Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians

INTRODUCTION

Opioid abuse has reached epidemic levels. Evidence-based treatments such as buprenorphine maintenance therapy (BMT) remain underutilized. Offering BMT in primary care settings has the potential to reduce overall costs of care, decrease medical morbidity associated with opioid dependence, and improve treatment outcomes. However, access to BMT, especially in rural areas, remains limited. This article will present a review of barriers to adoption of BMT among family physicians in a primarily rural area in the USA.

METHODS

An anonymous survey of family physicians practicing in Vermont or New Hampshire, two largely rural states, was conducted. The survey included both quantitative and qualitative questions, focused on BMT adoption and physician opinions of opioids. Specific factors assessed included physician factors, physicians' understanding of patient factors, and logistical issues.

RESULTS

One-hundred and eight family physicians completed the survey. Approximately 10% were buprenorphine prescribers. More than 80% of family physicians felt they regularly saw patients addicted to opiates. The majority (70%) felt that they, as family physicians, bore responsibility for treating opiate addiction. Potential logistical barriers to buprenorphine adoption included inadequately trained staff (88%), insufficient time (80%), inadequate office space (49%), and cumbersome regulations (37%). Common themes addressed in open-ended questions included lack of knowledge, time, or interest; mistrust of people with addiction or buprenorphine; and difficult patient population.

CONCLUSIONS

This study aims to quantify perceived barriers to treatment and provide insight expanding the community of family physicians offering BMT. The results suggest family physicians are excellent candidates to provide BMT, as most report regularly seeing opioid-addicted patients and believe that treating opioid addiction is their responsibility. Significant barriers remain, including inadequate staff training, lack of access to addiction experts, and perceived efficacy of BMT. Addressing these barriers may lower resistance to buprenorphine adoption and increase access to BMT in rural areas.

Non-physician communities in Japan: are they still disadvantaged?

INTRODUCTION

Non-physician community' (NPC) is a policy term that indicates a medically underserved area in Japan. Designated NPCs are politically targeted as the foci of medical resource allocation. NPC is defined as a specified district where 50 or more persons dwell within a geographic diameter of 4 km and medical care is not easily accessible. The definition of NPC was first introduced in 1960 and has been unchanged for more than half a century despite radical social changes in rural Japan. This study examines whether designated NPCs are still more disadvantaged in terms of geographical access to healthcare in comparison to other communities.

METHODS

Hiroshima prefecture, which has the largest number of NPCs in terms of tertiary healthcare areas of Japan, was used as the study area. Targeted communities were all the NPCs in the prefecture, and, as controls, two community groups were selected: non-NPC adjacent to NPC, and municipal center. We measured driving time from NPCs and control communities to the nearest healthcare facilities, which were classified into the following two types: primary or secondary care facilities (n=2636) and tertiary care facilities (equal to tertiary emergency care centers; n=6). We further calculated the driving time to the nearest facilities for secondary emergency care (n=246) extracted from the 2636 primary or secondary care facilities.

RESULTS

The median driving times to the nearest primary or secondary healthcare facility for NPC, non-NPC, and municipal center were 11 minutes, 11 minutes, and 1 minute, respectively; the times to a tertiary healthcare facility (equal to an accident and emergency care center) were 80 minutes, 84 minutes, and 68 minutes, respectively; and the times to a secondary emergency care facility were 24 minutes, 18 minutes, and 15 minutes, respectively. Although a municipal center was significantly more advantageous in driving time compared to a primary or secondary care facility, the disadvantage of a NPC in access was no more obvious than an adjacent non-NPC for any type of healthcare facility.

CONCLUSIONS

NPCs had a disadvantage in access time to primary, secondary and tertiary medical care compared with a municipal center. NPCs, however, did not have a greater access disadvantage in comparison to adjacent rural communities for any type of medical facility. As such, future resource allocation policies in Japan need to redefine medically underserved communities.

Knowledge and perceptions of Chagas disease in a rural Honduran community

INTRODUCTION

Honduras has a high prevalence of Trypanosomacruzi infection. The purpose of this study was to assess the knowledge and attitudes of Chagas disease in 17 geographically proximal rural Honduran communities. These communities are under the same local health ministry and are served by yearly medical relief efforts. La Hicaca (LH), although impoverished, is wealthier than the surrounding villages (SV).

METHODS

A 15-item, interviewer-administered, convenience sample questionnaire was employed on adult patients attending a brigade clinic in LH and SV. Pearson χ² and Fisher's exact tests were used to compare knowledge and attitudes of Chagas disease, environmental risks, and access to treatment between LH and SV.

RESULTS

One hundred and seventy-seven questionnaires were completed. The majority of respondents were aware of Chagas disease (90%, n=159). Only a minority of respondents understood disease transmission (2%, n=3). There was no significant difference in self-reported presence of the reduviid bug in homes in SV or LH (76% (n=85) vs 65% (n=42), p=0.11). In SV, 77% (n=74) of people had never been tested for Chagas, compared to 67% (n=42) in LH, p=0.90. Likewise, no significant difference was observed in perceived access to treatment between SV and LH (54% (n=50) vs 44% (n=24), p=0.23). Participants from SV perceived a higher risk of contracting Chagas disease than did people from LH (38% (n=40) vs 23% (n=23), p=0.05). Nearly all participants were interested in being tested for Chagas disease (90%, n=159) and in implementing preventative measures (98%, n=170).

CONCLUSIONS

Prior studies reported differences in healthcare access across these communities. In contrast, these findings suggest that knowledge of Chagas disease and environmental risk factors are similar between communities, although SV respondents perceived a higher risk of disease transmission. These findings have implications for future education and prevention campaigns in the area.

E-Health readiness in outback communities: an exploratory study

INTRODUCTION

E-health has been a recurrent topic in health reform, yet its implementation, ultimate role and feasibility are yet to be clearly defined. Organisations such as the Royal Flying Doctor Service South East Section (RFDS SE) are in a position to utilise technology to enhance the effectiveness of existing clinical services for remote communities. The study aim was to explore the readiness of the remote population of far-west New South Wales, Australia, and RFDS SE as a monopoly service provider to take up e-health innovations.

METHODS

A convenience sample of patients sequentially attending 15 remote fly-in clinics conducted by RFDS SE medical officers were invited to participate in a semi-structured telephone survey using an established survey tool to gather quantitative and qualitative data. RFDS SE health staff and managers were also surveyed.

RESULTS

The overall core-readiness to embrace new e-health technologies was at a moderate level; barriers were mainly technical competence and technology availability. Enablers were willingness to learn and engage. The majority of patients did not feel isolated and had their health needs met; albeit there was interest in change if this improved outcomes. Video consultations for mental health and access to specialists were particularly welcome, although responses also indicated concern that video links might replace existing face-to-face services. Health staff saw the need for new technology to assist in healthcare provision but technology availability and support were flagged as key points. Organisational views as elicited from managers identified internal needs for workplace readiness to assist with adoption of new technology.

CONCLUSIONS

Patients, healthcare providers and RFDS SE as an organisation are interested in engaging in e-health to improve the level of healthcare delivery. There are challenges around the technical capacity and the structural and organisational support for an e-health venture in an outback setting. Specific patient, healthcare provider and organisational needs have been identified and allow for the development of a tailor-made implementation strategy particularly to overcome technical challenges.

Impact of an interprofessional education program on developing skilled graduates well-equipped to practise in rural and underserved areas

INTRODUCTION

Poverty, limited access to resources and a lack of infrastructure characterise the division of rural areas from urban South Africa. Low numbers of social welfare professionals compound the problem. With education linked inextricably in social responsibility, higher education institutions (HEIs) are called upon increasingly to create conditions that encourage students and graduates to practise in more socially responsible ways, involving more than mere disciplinary expertise or technical knowledge, and that consider the problems of rural areas. Use of interprofessional education (IPE) programs, based on teamwork, could enable HEIs to train and guide health sciences students in how best to cooperate with each other and combine their skills to mutual benefit. This would enable them to develop professional skills facilitated by interactive engagement within community settings.

METHODS

Referencing experience gained in Australia and elsewhere, the Faculty of Community and Health Sciences (FCHS) at the University of Western Cape (UWC) has developed and applied an IPE program for South Africa. Students were placed in interdisciplinary groups in a rural and underserved municipality of the Western Cape - 17 students participated in a study on the effectiveness of this program. A quantitative self-administered questionnaire, followed by qualitative focus group discussions, established student perceptions of their IPE experience, how the experience influenced their intentions for or against future practice in rural and underserved areas, and their interest in future interprofessional collaboration and practice.

RESULTS

More than 75% of the participating students agreed that they had learnt to develop knowledge base, procedural and healthcare practice presentation skills, along with preparing written community health histories. Student willingness to practise in rural areas was evidenced, citing community- and resource-based factors as determinants; however, concerns that some community members had 'own agendas' were expressed. Nearly all students highly appreciated their learning and service delivery development, but 47% felt that their educational experience did not go as far as expected. Student concerns were a lack of structured student placement for IPE to occur in the program, as well as limited staff supervision of students.

CONCLUSIONS

The UWC FCHS IPE program is evidenced as a valid approach to encouraging health sciences students and graduates to choose to practise in more socially responsible ways. However, improvement of placement and supervision methodology and practice should be explored at faculty level and implemented in future IPE programs.