Financial barriers and inequity in medical education in India: challenges to training a diverse and representative healthcare workforce

India has been historically challenged by an insufficient and heterogeneously clustered distribution of healthcare infrastructure. While resource-limited healthcare settings, such as major parts of India, require multidisciplinary approaches for improvement, one key approach is the recruitment and training of a healthcare workforce representative of its population. This requires overcoming barriers to equity and representation in Indian medical education that are multi-faceted, historical, and rooted in inequality. However, literature is lacking regarding the financial or economic barriers, and their implications on equity and representation in the Indian allopathic physician workforce, which this review sought to describe. Keyword-based searches were carried out in PubMed, Google Scholar, and Scopus in order to identify relevant literature published till November 2023. This state-of-the-art narrative review describes the existing multi-pronged economic barriers, recent and forthcoming changes deepening these barriers, and how these may limit opportunities for having a diverse workforce. Three sets of major economic barriers exist to becoming a specialized medical practitioner in India - resources required to get selected into an Indian medical school, resources required to pursue medical school, and resources required to get a residency position. The resources in this endeavor have historically included substantial efforts, finances, and privilege, but rising barriers in the medical education system have worsened the state of inequity. Preparation costs for medical school and residency entrance tests have risen steadily, which may be further exacerbated by recent major policy changes regarding licensing and residency selection. Additionally, considerable increases in direct and indirect costs of medical education have recently occurred. Urgent action in these areas may help the Indian population get access to a diverse and representative healthcare workforce and also help alleviate the shortage of primary care physicians in the country. Discussed are the reasons for rural healthcare disparities in India and potential solutions related to medical education.

The establishment of conscientious monopolies in rural communities

In the United States, healthcare providers have the federally protected right to conscientiously refuse to provide treatments or services that they feel violate their moral or religious values. This refusal of services is colloquially known as "conscientious objection," which has become a polarizing topic in today's medical and ethical landscape. Typically, physicians exercising their right to conscientious objection do not represent a barrier in access to care for most patient populations. This dynamic shifts, however, in rural America, where there are relatively few providers. In this commentary, we discuss some of the unique ramifications that are likely to occur when rural providers invoke conscientious objection in their medical practice and how this can in turn establish conscientious monopolies for the members of their communities.

Travel distance and outcomes after surgical aortic valve among veterans

OBJECTIVE

To investigate the association between travel distance and postoperative length of stay (LOS) and discharge disposition among veterans undergoing surgical aortic valve replacement (SAVR).

DATA SOURCES/STUDY SETTING

We performed a retrospective cohort study of patients undergoing SAVR, with or without coronary artery bypass grafting (CABG) at VA Boston Healthcare (January 1, 2005-December 31, 2015).

STUDY DESIGN

Postoperative LOS and discharge disposition were compared for SAVR patients based on travel distance to the facility: <100 miles or ≥100 miles. Multivariable regression was performed to ascertain factors associated with LOS and home discharge.

DATA COLLECTION/EXTRACTION METHODS

Data were collected via chart review. All patients undergoing SAVR at our institution who primarily resided within the defined region were included.

PRINCIPAL FINDINGS

Of 597 patients studied, 327 patients underwent isolated SAVR; 270 patients underwent SAVR/CABG. Overall median (IQR) distance between the patient's residence and the hospital was 49.95 miles (27.41-129.94 miles); 190 patients (32%) resided further than 100 miles away. There were no differences in the proportion of patients with diabetes, hypertension, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, atrial fibrillation, or prior myocardial infarction between groups. Overall LOS (IQR) was 9 (7-13) days and did not differ between groups (p = 0.18). The proportion of patients discharged home was higher among patients who resided more than 100 miles from the hospital (71% vs. 58%, p = 0.01). On multivariable analysis, residing further than 100 miles from the hospital was independently associated with home discharge (OR = 1.64, 95% CI: 1.09-2.48). Travel distance was not associated with LOS.

CONCLUSIONS

Based on our institutional experience, potential concerns of longer hospital stay or discharge to other inpatient facilities for geographically distanced patients undergoing SAVR do not appear supported. Continued examination of the drivers underlying the marked shift of veterans to the private sector appears warranted.

Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study

Background

Telemedicine has proven to be a boon in the field of medical sciences, as it provides a platform for all health-care personnel to assist patients remotely through digital technology advancements. It brings hope to the lower middle-income regions of the world. Thus, the study was conducted to explore the perceptions regarding telemedicine among healthcare professionals (HCP) in rural Sindh, Pakistan.

Methodology

Overall, 19 in-depth interviews were conducted and this comprised of HCP working in the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences (PAQSJIMS) and Peoples University of Medical and Health Sciences for Women (PUMHSW) being involved in providing online consultations and practicing telemedicine. The interviews were conducted and audio recorded in Sindhi and Urdu and were later transcribed in to English, coded for themes and sub-themes, and were analyzed using content analysis.

Results

The opportunities perceived with the use of telemedicine services were reducing nosocomial infections, facilitating the healthcare in remote areas, handling telemedicine tools, application of telemedicine services on the ground and reducing stress. However, inadequate awareness regarding telemedicine, difficulty in physical examination, the need for training, lack of compliance, and concerns regarding accuracy in diagnosis and treatment were identified as the perceived barriers to the use of telemedicine services.

Conclusion

HCP had perception toward telemedicine as have numerous opportunities favoring implementation as well as various barriers are needed to overcome to promote the usage of telemedicine. Increased awareness, training programs, and technological advancements are key to overcome these challenges.

Bacterial Translocation As the Origin of Gram-Negative Rods Bloodstream Infection Among Older Patients in Rural Hospitals: A Cross-Sectional Study

Introduction Bloodstream infections caused by Gram-negative rods are a pressing concern for the aging global population, particularly in rural settings. This study investigates the prevalence and entry pathways of Gram-negative rod bloodstream infections in elderly patients at a rural Japanese hospital, aiming to clarify the frequency and associated factors of straightforward entry and bacterial translocation. Method In this cross-sectional study, we analyzed electronic medical records of patients over 18 years of age with symptomatic Gram-negative rod bloodstream infections at Unnan City Hospital, Japan, from September 2021 to August 2023. We used multivariate logistic regression to assess factors of age, sex, body mass index, care dependency, and comorbidities. Results Among the participants who met the inclusion criteria, significant differences were observed in age, sex, inpatient status, and prevalence of conditions like respiratory diseases and cancer between the straightforward entry and bacterial translocation groups. Escherichia coli was the most common pathogen identified. Conclusion The study emphasizes the need for tailored medical approaches for elderly patients with bloodstream infections, considering their unique health profiles and risks. It highlights the importance of age, inpatient status, and cancer in determining infection risks, pointing to areas for further research to enhance infection management and healthcare outcomes in older populations.

Enhancing Rural Health Dialogue: The Crucial Role of Reflective Practice in Family Physician Involvement

Health dialogue plays a pivotal role in sustaining rural communities by enhancing help-seeking behaviors (HSBs). This article delves deep into how family physicians accentuate the efficacy of rural health dialogues, prompting rural citizens to evaluate and adapt their current HSBs critically. Establishing a foundation of trust in rural family physicians significantly influences the motivation for refined HSBs. Additionally, such engagements optimize the application of limited healthcare resources. For these outcomes to be realized, family physicians must amplify their communication and leadership abilities, and confront the inherent challenges of disseminating contemporary medical evidence in rural domains.

COVID-19 epidemiology and rural healthcare: a survey in a Spanish village

We used primary care data to retrospectively describe the entry, spread, and impact of COVID-19 in a remote rural community and the associated risk factors and challenges faced by the healthcare team. Generalized linear models were fitted to assess the relationship between age, sex, period, risk group status, symptom duration, post-COVID illness, and disease severity. Social network and cluster analyses were also used. The first six cases, including travel events and a social event in town, contributed to early infection spread. About 351 positive cases were recorded and 6% of patients experienced two COVID-19 episodes in the 2.5-year study period. Five space-time case clusters were identified. One case, linked with the social event, was particularly central in its contact network. The duration of disease symptoms was driven by gender, age, and risk factors. The probability of suffering severe disease increased with symptom duration and decreased over time. About 27% and 23% of individuals presented with residual symptoms and post-COVID illness, respectively. The probability of developing a post-COVID illness increased with age and the duration of COVID-associated symptoms. Carefully registered primary care data may help optimize infection prevention and control efforts and upscale local healthcare capacities in vulnerable rural communities.

Utilizing Learn-to-Rank Systems for More Effective Diagnosis in Rural Family Medicine

This editorial investigates the development and efficacy of Japanese learn-to-rank approach systems in family medicine, emphasizing their establishment by Dr. Keijiro Torigoe and their significance in rural community hospitals. Initiated in 1977, Dr. Torigoe's innovative system integrated international medical knowledge with technology, yielding a comprehensive database of 7,000 registered diseases. These learn-to-rank approaches, notably the listwise method, address technological gaps in extracting data on differential diseases and enhance the predictive performance of clinical decision support systems, offering a holistic, culturally resonant healthcare approach. They are especially vital in rural medicine, aiding in managing the volatility, uncertainty, complexity, and ambiguity prevalent among older patients, streamlining diagnoses, and improving healthcare delivery in resource-constrained settings. In conclusion, integrating Japanese learn-to-rank approach systems is pivotal in revolutionizing disease diagnosis, catering to diverse rural health needs, and fostering sustainability in rural healthcare systems. By harmonizing medical insights with innovation, they demonstrate the potential for a comprehensive and contextually relevant approach to healthcare in Japan.

Antibiotic Utilization and Prophylaxis in Paediatric Cardiac Surgery: A Retrospective Observational Study at a Rural Tertiary Care Hospital in India

Introduction Antimicrobial prophylaxis, involving short antibiotic courses preceding surgical procedures, is recommended to minimize postoperative infections. Paediatric cardiac surgeries are classified as clean procedures, though infection challenges persist due to illness severity and extended ICU stays. Antimicrobial prophylaxis varies, ranging from single doses to extended administration until catheters are removed. Typically lasting 24 to 48 hours, it has proven infection-reduction benefits. Despite these practices, uncertainties surround the optimal nature, timing, and duration of administration. This concern is amplified by escalating antimicrobial resistance driven by antibiotic overuse. Vulnerable paediatric populations bear heightened consequences of irrational antimicrobial use, contributing to global resistance trends. Yet, a defined optimal prophylaxis schedule for paediatric cardiac surgery is lacking. Importing adult guidelines may be inadequate due to paediatric research complexities and population diversity. Developing effective prophylaxis protocols is crucial for children undergoing cardiac surgery, given global antibiotic overuse and evolving drug resistance. Establishing an optimal prophylactic strategy remains a challenge, necessitating further research for evidence-based protocols to mitigate infections in this vulnerable patient cohort. Methods This study investigates antibiotic use in paediatric cardiac surgery. A retrospective analysis of 100 patients from a rural Indian hospital (2017-2018) assesses antibiotic patterns, including type, dose, duration, and adherence to prophylaxis protocols. Results In the studied cohort of paediatric cardiac surgery patients, complete compliance (100%) with antibiotic prophylaxis was observed. However, deviations were identified: 30% received antibiotics prematurely, and 30% did not align with institutional protocol criteria. Concerning antibiotic selection, 87% followed hospital policy with the recommended cefoperazone and sulbactam combination plus amikacin, while 9% received piperacillin/tazobactam + amikacin due to sepsis. Irregular use (22%) based on clinical records occurred. Furthermore, 4% received piperacillin/tazobactam + teicoplanin, with one instance of inappropriate higher antibiotic use. Regarding prophylaxis duration, only 27% adhered to the appropriate timeline, with 40% exceeding 48 hours, indicating extended use. Upon discharge, a notable proportion (45 patients) received antibiotic prescriptions. Among them, 73% were prescribed rationally, while 27% exhibited irrational antibiotic use. Conclusion The findings of this study shed a significant light on the issue of antibiotic misuse within the context of paediatric cardiac surgery. It underscores the pressing need for more stringent measures to regulate and address this concerning trend. The study underscores the pivotal importance of adhering rigorously to established protocols and guidelines for antibiotic prophylaxis. This adherence not only holds the potential to elevate the overall quality of patient care but also plays a critical role in combating the escalating challenge of antibiotic resistance. Through a concerted effort to optimize antibiotic usage, we can simultaneously enhance patient outcomes and contribute to the ongoing fight against the emergence of antibiotic-resistant strains, thus preserving the efficacy of these vital medications for future generations.

Aortic Dissection and Hypotension Without Cardiac Tamponade: A Case Report

Ascending aortic dissection is typically characterized by severe chest or back pain. However, its presentation can be atypical, leading to diagnostic challenges, especially in settings where classic symptomatology may not be evident. In this report, we described the case of a 74-year-old woman who presented to the emergency room of a rural community hospital with chief complaints of vertigo, nausea, and vomiting, without the classic symptoms of chest or back pain associated with aortic dissection. Despite initial treatment for autonomic dysregulation, the patient's symptoms persisted. Subsequent comprehensive assessments, including computed tomography angiography, revealed an ascending aortic dissection extending to the bilateral common carotid arteries. This atypical presentation, characterized by cerebral hypoperfusion and systemic hypotension without tachycardia, emphasizes the need to maintain a high suspicion index, even in the absence of hallmark symptoms. This case underscores the importance of considering the possibility of ascending aortic dissection in patients with nontraditional symptoms. Recognizing these atypical presentations is crucial for timely intervention, especially in rural settings with limited advanced diagnostic tools. This case also highlights potential sex disparities in symptom presentation, emphasizing the need for clinicians to recognize nontraditional symptoms in women. Rapid identification, evaluation, and management are imperative to prevent severe outcomes, and a multidisciplinary approach has proven to be the most effective in such cases.

Staff Successes and Challenges with Telecommunications-Facilitated Patient Care in Hybrid Hospital-at-Home during the COVID-19 Pandemic

Technology-enhanced hospital-at-home (H@H), commonly referred to as hybrid H@H, became more widely adopted during the COVID-19 pandemic. We conducted focus group interviews with Mayo Clinic staff members (n = 14) delivering hybrid H@H in three separate locations-a rural community health system (Northwest Wisconsin), the nation's largest city by area (Jacksonville, FL), and a desert metropolitan area (Scottsdale, AZ)-to understand staff experiences with implementing a new care delivery model and using new technology to monitor patients at home during the pandemic. Using a grounded theory lens, transcripts were analyzed to identify themes. Staff reported that hybrid H@H is a complex care coordination and communication initiative, that hybrid H@H faces site-specific challenges modulated by population density and state policies, and that many patients are receiving uniquely high-quality care through hybrid H@H, partly enabled by advances in technology. Participant responses amplify the need for additional qualitative research with hybrid H@H staff to identify areas for improvement in the deployment of new models of care enabled by modern technology.

Agricultural Safety and Health Curriculum: Preparing the Next Generation of Rural Nurses

The purpose of this study is to examine the impact of including/expanding agricultural health and safety curriculum in a prelicensure baccalaureate of nursing program on the nursing students' knowledge of agricultural health and safety. A convenience sample of baccalaureate nursing students in their first year of nursing school on two different campuses of a Midwestern college of nursing. Agricultural health and safety content was introduced with pre- and post-surveys completed after delivery of the agricultural health and safety education unit. Independent T-test (p < .05) performed on pre (n = 135) and post surveys (n = 109). There were no significant differences between baseline data on the two campus sites or between genders. There were statistically significant differences between baseline and post levels of knowledge, with an increase in perceived knowledge. Students "raised on a farm" or "that worked on a farm" and students "not raised on a farm" or "didn't work on a farm" had significantly different knowledge levels at baseline, and all groups had a statistically significant change in knowledge, but no significant posttest difference between groups. Incorporation of agricultural health and safety into a Bachelor of Science Nursing program can lead to significant knowledge increase and better prepare student nurses to provide care to patients with agricultural-related injuries and health concerns.

Multidisciplinary Perspectives on the Implementation of a Comprehensive Sexual Assault Telehealth Program in Rural Communities: A Qualitative Study

Access to quality sexual assault (SA) care in rural communities is limited by challenges surrounding building and sustaining a skilled SA nurse examiner workforce. Telehealth can facilitate access to expert care while cultivating a local sexual assault response. The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center aims to decrease disparities in SA care by providing expert, live, interactive mentoring, quality assurance, and evidence-based training via telehealth. This study examines multidisciplinary perceptions of pre-implementation barriers and SAFE-T program impact using qualitative methods. Implications for the implementation of telehealth programs to support access to quality SA care are considered.

Disparities in melanoma incidence and mortality in rural versus urban Michigan

INTRODUCTION

We sought to identifying the possible existence of disparities between rural and urban residents of Michigan for the incidence by stage of disease and disease-specific mortality for cutaneous melanoma (CM).

METHODS

Incidence rates for stage of disease and disease-specific mortality of cutaneous melanoma were calculated and controlled for gender, age, and area of residence from January 1, 2014, to December 31, 2018, from data collected form the Michigan Department of Health and Human Services and the Centers for Disease Control and Prevention.

RESULTS

The incidence rates for CM were significantly higher in rural Michigan counties, from 2014-2018, for all patients, both age groups, both genders and all stages. Melanoma-specific mortality rates were also significantly higher for all patients, both age groups and both genders in rural Michigan counties. Using logistic regression analysis, while controlling for age and gender, rural Michigan counties continued to have a higher melanoma-specific morality rate during our study period (OR = 1.491; 95% CI, 1.27-1.74; p = <.001).

CONCLUSION

We found significant disparities in the incidence rates and disease specific mortality for cutaneous melanoma in rural compared to urban Michigan from 2014-2018.

Comparing outcomes of an innovative interprofessional student placement model to standard placement models in rural healthcare settings

This unique study investigated the educational and service delivery impacts of a team-based, innovative model of interprofessional education (IPE) namely the Rural Interprofessional Education and Supervision (RIPES) model on participating students, clinical educators, and their workplaces, in rural Australian healthcare settings. Participating professions included dietetics, occupational therapy, physiotherapy, and speech pathology. Outcomes from the RIPES model were compared with regular uni-professional placement models. A multi-site, pre-post, comparative design was used. The main data collection measures included were the Students Perceptions of Interprofessional Clinical Education - Revised scale, the Interprofessional Socialization and Valuing Scale, and time-usage data. The RIPES model resulted in significant improvement in students' beliefs, behaviors, and attitudes that underpin interprofessional socialization and collaborative practice in healthcare settings. Importantly, students were able to benefit from the RIPES learning activities without compromising their contact time with patients. Clinical educators spent significantly more time in non-patient contact activities than the uni-professional group. This important work was undertaken in response to previous calls to address a gap in IPE models in rural areas. It involved students from multiple professions and universities, measured impacts on multiple stakeholders, and followed international best practice interprofessional education research recommendations.

Distance and Transportation Barriers to Colorectal Cancer Screening in a Rural Community

Rural residents in underserved areas face many barriers to health services, including colonoscopies for colorectal cancer (CRC) screening, but rural healthcare providers may assist patients navigating these challenges due to familiarity with local contexts. In 2017 to 2018, we interviewed clinical practitioners and staff (n = 40) at 13 primary care and gastroenterology locations across rural Southern Illinois. We used a semi-structured interview guide that addressed system, provider, and patient levels including domains related to barriers, facilitators, and needs for intervention. This article focuses on 3 main elements related to distance and transportation that emerged from inductive coding. First, providers described long distance travel for care as normalized but not necessarily preferable. Second, they identified and described distance-related challenges specific to CRC screening, and third, providers discussed strategies, mostly related to transportation, they use to navigate those challenges. Finally, they suggested a variety of broader solutions to reduce distance and transportation barriers to screening. Overall, distance to care remains a challenge to increasing CRC screening and contributes to disparities in rural communities. To increase early detection and reduce rural cancer disparities, efforts to increase screening and follow-up must address ways to help patients and providers navigate this distance within their local communities and contexts.

Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe

INTRODUCTION

Mental healthcare systems are primarily designed to urban populations. However, the specific characteristics of rural areas require specific strategies, resource allocation, and indicators which fit their local conditions. This planning process requires comparison with other rural areas. This demonstration study aimed to describe and compare specialized rural adult mental health services in Australia, Norway, and Spain; and to demonstrate the readiness of the healthcare ecosystem approach and the DESDE-LTC mapping tool (Description and Evaluation of Services and Directories of Long Term Care) for comparing rural care between countries and across areas.

METHODS

The study described and classified the services using the DESDE-LTC. The analyses included context analysis, care availability, placement capacity, balance of care, and diversity of care. Additionally, readiness (Technology Readiness Levels - TRL) and impact analyses (Adoption Impact Ladder - AIL) were also assessed by two independent raters.

RESULTS

The findings demonstrated the usability of the healthcare ecosystem approach and the DESDE-LTC to map and identify differences and similarities in the pattern of care of highly divergent rural areas. Day care had a greater weight in the European pattern of care, while it was replaced by social outpatient care in Australian areas. In contrast, care coordination was more common in Australia, pointing to a more fragmented system that requires navigation services. The share between hospital and community residential care showed no differences between the two regions, but there were differences between catchment areas. The healthcare ecosystem approach showed a TRL 8 (the tool has been demonstrated in a real-world environment and it is ready for release and general use) and an AIL of 5 (the target public agencies provided resources for its completion). Two experts evaluated the readiness of the use of DESDE-LTC in their respective regional studies. All of them were classified using the TRL.

DISCUSSION

In conclusion, this study strongly supports gathering data on the provision of care in rural areas using standardized methods to inform rural service planning. It provides information on context and service availability, capacity and balance of care that may improve, directly or through subsequent analyses, the management and planning of services in rural areas.

Understanding Clinician's Experiences with Implementation of a Younger Onset Dementia Telehealth Service

The successful implementation of telehealth services depends largely on clinician acceptance of telehealth as a viable healthcare option and their adoption of telehealth methods into their clinical practice. While growing research supports the feasibility of telehealth services, no research has evaluated clinicians' experiences during the implementation of a younger onset dementia telehealth service. Semi-structured group interviews were conducted with 7 metropolitan (hub) clinicians and 16 rural (spoke) clinicians during the pre-and post-implementation phases of a novel Younger onset dementia (YOD) telehealth service. Reflexive thematic analysis identified five themes at pre-implementation: clinical need, previous experiences and views, potential telehealth barriers, solutions to potential telehealth barriers, and potential clinical outcomes. At post-implementation, nine themes were identified: clinical need, clinical relationships, concerns about the future of rural healthcare, clinical practice and resourcing factors, patient suitability, difficulties with technology, service quality, the way forward, and the impact of COVID-19. Most clinicians held positive views regarding the service, particularly the ability to provide more options to rural-dwelling patients. However, some concerns about threats to rural healthcare and the validity of telehealth assessments remained. Overall, this study has identified service implementation barriers and facilitators and contributes to the long-term sustainability of current and future telehealth YOD services.

Understanding medical students' transformative experiences of early preclinical international rural placement over a 20-year period

INTRODUCTION

Rural placements are an important component of rural medical education programs seeking to develop rural practice pathways for medical students. These placements are usually domestic, but James Cook University in Australia developed an international rural placement program in the first half of the medical course that was funded through bursaries. This study explores how the international rural placement helped to shape the lives (personal development and learning) of the participants, using Transformational Learning Theory as a framework for identifying and describing the transformational elements, process and impact of the program.

METHODS

Sixty-five students received a bursary for an international rural placement between 2001-2019. All were contacted by email and invited to participate in a short survey and a follow-up interview. Fifteen participants agreed and twelve were able to participate in individual semi-structured interviews which were recorded, transcribed and analysed using inductive thematic analysis.

RESULTS

Participants reported that the bursary provided a "once in a lifetime opportunity" to "experience eye-opening and culturally rich difference". Nonetheless, some elements of the placement experience presented disorientating dilemmas that triggered deep reflections and shifts in perceptions. The bursary recipients realised that "being open-minded" allowed them "enjoy good company". They were also able to assume "outsider view which allowed reassessment of their own country" and the "isolation experiences gingered desire to right health wrongs". The triggers and mental shifts had significant impact on the bursary recipients and fostered the development of "inspirational new horizons" based on an appreciation of the "value of rural practice" and "role-modelling for life-long learning." These findings are consistent with Transformational Learning Theory.

CONCLUSION

Participants in this study reported meaningful and strongly positive impacts from the experiences gained during an international rural clinical placement early in their course. They described transformative experiences which appear to contribute strongly to personal development. This finding supports maintaining opportunities for international experiences during rurally-oriented medical programs as these may impact longer term career choice.

The lived experience of frontline nurses: COVID-19 in rural America

Aim

This multisite study describes the lived experience of registered nurses (RNs) caring for coronavirus (COVID‐19) patients during the pandemic in rural America.

Design

A qualitative phenomenological design was used.

Methods

From January to June 2021, using the purposeful sampling method, 19 frontline nurses were interviewed regarding their experience caring for seriously ill COVID‐19 patients in three Upper Midwest tertiary care hospitals. Three doctoral prepared nurses transcribed and analyzed verbatim interviews with data interpreted separately and conjointly. Approved qualitative methods specific to transcendental phenomenology were used.

Results

This phenomenological study identified four themes describing the lived experience: (1) feeling of being overwhelmed, (2) feeling of role frustration related to chaos in the care environment, (3) feeling of abandonment by leaders, families, and communities, and (4) progressing from perseverance to resilience.

Implications for Practice

Significant implications include ensuring frontline RNs are in communication with leaders, and are involved in tactical planning. Leaders can provide a stabilizing presence, build resilience, confidence, and security. Recommendations for additional research are provided.

Conclusion

Nurses in intensive care and COVID‐19 designated medical units had experiences similar to high population United States and international cities. Their shared experience included high volumes of critically ill patients in hospitals frenzied by rapid change, uncertainty, and capacity strain. Differences in the experience of rural nurses included close social connection to patients, families, and community members. This rural connectedness had both positive and negative effects.

Living in Rural Areas and Receiving Cancer Treatment Away From Home: A Qualitative Study Foregrounding Temporality

We used explorative interviews to gauge (inter)personal, physiological, and emotional challenges of seven rural cancer patients who traveled long distances to cancer treatment centers. After a thematic analysis, we foregrounded experiences of temporality by using a phenomenologically inspired approach. The analysis resulted in three themes: (a) An epiphany of “what really matters in life”—time gains new meaning, (b) Feeling out of sync with others and own body—striving for coherence and simultaneity, and (c) Being torn between benefits of home and treatments site—time and distance as a tangible aspect of traveling and being away. Under these themes, 13 meaning units were generated, which reflected changes in temporality. During treatment, life primarily revolved around repeating circles of travel arrangements, staying on top of treatment schedule, and synchronizing a home life with a life away from home. Nurses should provide comprehensive care to enhance stability in cancer patients’ temporal experiences.

What do Health Workers say About Rural Practice?

Adequately staffed rural health services improve healthcare delivery and health outcomes, yet this is lacking in rural Ghana. We used a descriptive qualitative design to understand the contextual issues that affect rural practice, in the Upper East Region, Ghana. Sixty-eight in-depth interviews were conducted with healthcare workers and analysed thematically. Four themes were identified: types of postings to rural settings, healthcare workers’ perceptions of their rural postings, perceived enablers and motivators for rural practice, and perceived challenges and barriers to rural practice. While adequate supervision and family proximity are needed to improve the feelings of loneliness, isolation and neglect in rural areas, challenges and barriers such as inadequate security, unstable electricity supply, language barrier, lack of equipment and transport/ambulance have been identified to have negative influence on healthcare workers. The findings highlight the need for healthcare managers to improve fairness and transparency in the posting and reshuffling processes of healthcare workers.

Does Fecal Microbiota Transplant Have a Role in Treating Recurrent Clostridioides difficile Infection in Rural Hospitals?

Clostridioides difficile infection possesses a significant economical burden, specifically in the inpatient and rural settings. Fecal Microbiota Transplant has been used for treatment of recurrent Clostridioides difficile but its utility is limited by current guidelines and resources. We conducted a retrospective chart review to evaluate the financial benefit of using Fecal Microbiota Transplant after first recurrence of Clostridioides difficile infection. We found that while its use was restricted, on average Fecal Microbiota Transplant can save $11,603.49 per patient. In conclusion, our study shows that using Fecal Microbiota Transplant could prove to be economically beneficial in treating recurrent CDI in rural hospitals.

Copan eNAT Transport System To Address Challenges in COVID-19 Diagnostics in Regions with Limited Testing Access

Community-based health care clinics and hospital outreach services have the potential to expand coronavirus disease 2019 (COVID-19) diagnostics to rural areas. However, reduced specimen stability during extended transport, the absence of a cold chain to centralized laboratories, and biosafety concerns surrounding specimen handling have limited this expansion.

Community-based health care clinics and hospital outreach services have the potential to expand coronavirus disease 2019 (COVID-19) diagnostics to rural areas. However, reduced specimen stability during extended transport, the absence of a cold chain to centralized laboratories, and biosafety concerns surrounding specimen handling have limited this expansion. In the following study, we evaluated eNAT (Copan Italia, Brescia, Italy) as an alternative transport system to address the biosafety and stability challenges associated with expanding COVID-19 diagnostics to rural and remote regions. In this study, we demonstrated that high-titer severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV-2) lysate placed into eNAT medium cannot be propagated in cell culture, supporting viral inactivation. To account for off-site testing in these settings, we assessed the stability of contrived nasopharyngeal (NP) specimens stored for up to 14 days in various transport media (eNAT, eSwab, viral transport medium [VTM], saline, and phosphate-buffered saline [PBS]) at 4°C, 22 to 25°C, and 35°C. The molecular detection of SARS-CoV-2 was unaffected by sample storage temperature over the 2 weeks when stored in eNAT or PBS (change in cycle threshold, ≤1). In contrast, variable stability was observed across test conditions for other transport media. As eNAT can inactivate SARS-CoV-2, it may support COVID-19 diagnostics at the point of care. Evaluation of compatibility of eNAT with Cepheid Xpert Xpress SARS-CoV-2 assay demonstrated diagnostic accuracy and sensitivity equivalent to those of VTM. Taken together, these findings suggest that the implementation of eNAT as a collection device can expand COVID-19 testing to areas with limited health care access.

Improving Pneumococcal Vaccination Rates among Rural Older Adults through Academic Detailing: Medicine, Nursing and Pharmacy Partnership

Academic detailing is an educational approach involving provision of evidence-based information by healthcare providers for healthcare providers with the goal of improving clinical decision-making. An interprofessional academic detailing initiative was developed to encourage rural providers to utilize guidelines when deciding which patients to vaccinate against pneumonia. This study utilized a quasi-experimental, single-group, pre-post observational design with physicians, nurses, and staff at two rural medical clinics. The 12-month academic detailing intervention included a needs assessment, workflow assessment of practice-based health information technology, vaccination training for providers and staff, and creation of exam-room posters encouraging patients to discuss vaccination with their provider. Six visits were made to deliver education, discuss needs, select priorities, and develop action plans from recommendations. Data were collected from each site for three years prior to the intervention year and for one year following the intervention. The annual rate of patients vaccinated increased during the five-year study. The cumulative proportion of the sample population that received vaccination also increased over time. Interprofessional academic detailing was well received and increased pneumococcal vaccination rates among rural-dwelling older adults. Given the alarming disparities in health outcomes for rural patients, educational outreach is needed to improve healthcare access and outcomes.

Cardiology clinic visit increases likelihood of evidence-based cholesterol prescribing in severe hypercholesterolemia

Background

Patients with phenotypic severe hypercholesterolemia (SH), low‐density lipoprotein‐cholesterol (LDL‐c) ≥ 190 mg/dl, atherosclerotic cardiovascular disease (ASCVD) or adults 40–75 years with diabetes with risk factors or 10‐year ASCVD risk ≥20% benefit from maximally tolerated statin therapy. Rural patients have decreased access to specialty care, potentially limiting appropriate treatment.

Hypothesis

Prior visit with cardiology will improve treatment of severe hypercholesterolemia.

Methods

We used an electronic medical record‐based SH registry defined as ever having an LDL‐c ≥ 190 mg/dl since January 1, 2000 (n = 18 072). We excluded 3205 (17.7%) patients not alive or age 20–75 years. Patients defined as not seen by cardiology if they had no visit within the past 3 years (2017–2019).

Results

We included 14 867 patients (82.3%; mean age 59.7 ± 10.3 years; 58.7% female). Most patients were not seen by cardiology (n = 13 072; 72.3%). After adjusting for age, sex, CVD, hypertension, diabetes and obesity, patients seen by cardiology were more likely to have any lipid‐lowering medication (OR = 1.46, 95% CI: 1.29–1.65), high‐intensity statin (OR = 1.81, 95% CI: 1.61–2.03), or proprotein convertase subtilisin‐kexin type 9 (PCSK9) inhibitor (OR = 5.96, 95% CI: 3.34–10.65) compared to those not seen by cardiology. Mean recent LDL‐c was lower in patients seen by cardiology (126.8 ± 51.6 mg/dl vs. 152.4 ± 50.2 mg/dl, respectively; p < .001).

Conclusion

In our predominantly rural population, a visit with cardiology improved the likelihood to be prescribed any statin, a high‐intensity statin, or PCSK9 inhibitor. This more appropriately addressed their high life‐time risk of ASCVD. Access to specialty care could improve SH patient's outcomes.

An Age-Friendly Health System

BACKGROUND/OBJECTIVES

To describe a screening and intervention program for geriatric syndromes instituted at a rural healthcare system that utilizes the 4Ms of an age-friendly health system, and to provide exercise and cognitive stimulation therapy (CST) as part of an age-friendly health program.

DESIGN

Retrospective evaluation of clinical data.

SETTING

Rural primary healthcare system.

PARTICIPANTS

Older adults aged 65 years and older in Perry County, Missouri.

MEASUREMENTS

Screening for geriatric syndromes was done using the Rapid Geriatric Assessment (RGA), which includes the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS). Outcomes for exercise and CST included the Five Times Sit to Stand (FTSS) and Timed Up and Go (TUG) tests, Cornell Scale for Depression in Dementia (CSDD), Saint Louis University Mental Status Examination (SLUMS), and Quality of Life in Alzheimer's Disease (QoL-AD) measures.

RESULTS

The RGA was administered to 1,326 individuals of which 36.5% were frail, 42.1% were sarcopenic, 26.1% were at risk for anorexia, and 20.8% had dementia. Of these receiving exercise therapy, both the FTSS and the TUG were improved at 3 months and 12 to 24 months. In the CST group, SLUMS, QoL-AD, and CSDD were improved at 7 weeks and 6 to 12 months.

CONCLUSION

It is feasible to introduce a screening program for geriatric syndromes and respond to the results with successful exercise and cognitive stimulation therapy programs.

Determinants of Depressive Symptoms Among Rural Health Workers: An Application of Socio-Ecological Framework

OBJECTIVE

The objective of this study was to assess depressive symptoms among rural health workers (RHWs) through a multi-factorial socio-ecological framework (SEF) encompassing personal, interpersonal, organizational and community components.

PATIENTS AND METHODS

A random sample of 394 RHWs in all rural areas of East Azerbaijan and fulfilling our other inclusion criteria were recruited. The participants underwent the Short-Form Beck's Depression Inventory and a validated researcher-constructed SEF questionnaire, including subscales on personal, interpersonal, organizational and community factors associated with depressive symptoms. Internal consistency and factor structure parameters of the SEF were also calculated.

RESULTS

A total of 394 RHWs were screened, of whom 170 (43.2%) had mild to major depressive symptoms. Only 6.8% were identified with major depressive symptoms. The SEF-based scale was found to have acceptable content validity (content validity index and ratio were 0.80 and 0.77, respectively) and reliability (Cronbach's alpha=0.7). In the structural equation modeling, the fit indices showed our model to fit the data well (χ 2=14.06, df=14, χ 2/df=1.00, CFI=0.967, RMSEA=0.032). The highest direct contribution to depressive symptoms was found from the personal factors component (β=-2.32). Also, "work load and roles interference" (from organizational level, β=-0.76) and "family/colleague support" (from community level, β=-1.28) made significant direct contributions towards depressive symptoms. Besides the SEF components, female gender (β=1.69), family history of mental illness (β=-1.48), having chronic illnesses (β=-1.64) and being religious (β=3.43) were the strongest direct contributors to depressive symptoms.

CONCLUSION

Depressive symptoms were common among RHWs, arising from all personal-, interpersonal-, organizational- and community-level factors. Our SEF had adequate internal consistency and factor structure parameters to be applied in the Middle East and North Africa (MENA) region countries, such as Iran, as a theoretical framework to plan for interventional efforts aiming at preventing depressive symptoms among RHWs. The burden of depressive symptoms should be reduced through multi-factorial interventions and rational perspectives.

Systematic Review of Clinical Insights into Novel Coronavirus (CoVID-19) Pandemic: Persisting Challenges in U.S. Rural Population

(1) Introduction. A recent viral outbreak of novel coronavirus (CoVID-19) was declared as a pandemic by the World Health Organization (WHO) due to its global public health concern. There has been an aggressive growth in the number of emerging cases suggesting rapid spread of the virus. Since the first reported case of CoVID-19, there has been vast progress in understanding the dynamics of CoVID-19. However, there is an increasing evidence of epidemiological disparity in disease burden between urban and rural areas, with rural areas having minimal pandemic preparedness and their own healthcare challenges. Therefore, this review aims to provide insight on the pathogenesis and the transmission dynamics of CoVID-19 along with pharmacological and non-pharmacological intervention strategies to mitigate the clinical manifestation of this virus. This review also aims to assess existing challenges of the CoVID-19 pandemic in rural areas based on past pandemic experiences and the effect on rural population. (2) Methods. A literature review was conducted using databases such as PubMed, Science Direct, Academic Search Premier, ProQuest, and Google Scholar, along with information from governmental organizations such as Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). (3) Results. The causative virus, with its likely zoonotic origin, has demonstrated high pathogenicity in humans through increasing human-to-human transmission leading to extensive mitigation strategies, including patient quarantine and mass “social distancing” measures. Although the clinical manifestation of symptoms is mild in majority of the virus-inflicted population, critical patients may present with pneumonia and acute respiratory distress syndrome, exacerbated by pre-existing comorbidities, eventually leading to death. While effective coronavirus disease (CoVID-19)-specific vaccines and drugs are under clinical trials, several pharmacological and non-pharmacological interventions have been adapted to manage symptoms and curtail the effect of the virus to prevent increasing morbidity and mortality. Several persisting challenges have been noted for mitigating CoVID-19 in rural areas, including the poor healthcare infrastructure, health literacy, pandemic preparedness along with the fact that majority of rural population are frail subjects with pre-existing comorbidities. (4) Discussion. The increasing rate of incidence of CoVID-19 presents its own challenges, burdening healthcare institutions and the global economy, and impacting the physical and mental health of people worldwide. Given the clinical insights into CoVID-19 and the challenges presented in this review for the U.S. rural population, mitigation strategies should be designed accordingly to minimize the morbidity and mortality of this contagion.

Diabetes in Appalachia: providers' perspectives

BACKGROUND

Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers' experiences treating people with diabetes in this region. This study explored providers' perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.

METHODS

We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).

RESULTS

Qualitative analysis revealed four themes: (1) patients' diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers' cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.

CONCLUSIONS

Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.

Development of the Pediatric Advanced Life Support Skills Self-Efficacy Inventory to Assess Rural Healthcare Providers

BACKGROUND AND PURPOSE

Rural healthcare provider's willingness to implement pediatric resuscitation may be impeded by comfort level. The purpose of this study was to evaluate the psychometric properties of the Pediatric Advanced Life Support Skill Self-Efficacy Inventory (PALS-SSEI).

METHODS

A 19-item inventory was created based on PALS skills. The PALS-SSEI was completed by 94 participants in a study to test the effects of simulation training on PALS knowledge and skill.

RESULTS

Six clinical content experts rated the content validity of the PALS-SSEI as high. Item and factor analysis supported the tool's construct validity. A Cronbach's alpha coefficient of 0.88 supported the internal consistency of the tool.

CONCLUSIONS

The PALS-SSEI demonstrated good initial psychometric properties. The tool can be used to assess self-efficacy for PALS skills among healthcare providers.

Experiences of women receiving mhealth-supported antenatal care in the village from community health workers in rural Burkina Faso, Africa

Objective

This qualitative study explored the experiences of women receiving mhealth-supported antenatal care in a village, from community health workers (CHWs) in rural Burkina Faso, Africa.

Intervention

CHWs entered patient clinical data manually in their smartphone during their home visits. All wireless transferred data was monitored by the midwives in the community clinic for arising medical complications.

Methods

Semi-structured interviews were conducted with 19 pregnant women, who were housewives, married and their age ranged from 18 to 39 years. None had completed their formal education. Depending on the weeks of gestation during their first antenatal care visit, length of enrollment in the project varied between three and eight months. Transcripts were content-analyzed.

Results

Despite the fact that mhealth was a novel service for all participants, they expressed appreciation for these interventions, which they found beneficial on three levels: 1) it allowed for early detection of pregnancy-related complications, 2) it was perceived as promoting collaboration between CHWs and midwives, and 3) it was a source of reassurance during a time when they are concerned about their health. Although not unanimous, certain participants said their husbands were more interested in their antenatal care as a result of these services.

Conclusion

Findings suggested that mhealth-supported visits of the CHWs have the potential to increase mothers’ knowledge about their pregnancy and, as such, motivate them to attend more ANC visits. In response to this increased patient engagement, midwives approached women differently, which led to the mothers’ perception of improvement in the patient–provider relationship. Results also indicated that mhealth may increase spousal involvement, as services are offered at home, which is an environment where spouses feel more comfortable.

The Underlying Stroke Etiology: A Comparison of Two Classifications in a Rural Setup

Introduction This study compares the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and the atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) classification performed in a rural hospital setup. Stroke is the second leading cause of death after ischemic heart disease with over 9.5 million new cases of ischemic stroke in 2016. Stroke is a complex disease with numerous contributing factors. India needs a standardized stroke classification system, as without one it becomes difficult to collect data on stroke patients, perform follow-ups, and provide appropriate secondary prevention. A standardized stroke classification system would also help in building a nationwide database in order to note epidemiological trends of ischemic stroke. This would also create greater awareness regarding stroke in rural parts of India where healthcare is difficult to access.  Aims and objectives Our aim was to review all admitted stroke patients' data and classify their etiology and mechanism based on the TOAST and ASCOD classification systems. The ASCOD classification has yet to be utilized in the Indian population. The two classifications are then compared in order to gain a better insight into which classification is a better fit for the Indian population. Both are based on the etiology of ischemic stroke but the ASCOD classification differs because it gives suitable secondary prevention measures based on the diseases linked to stroke. ASCOD also gives a proper indication of the patient's present causative factor (similar to TOAST) and other factors that can possibly lead to further recurrences. This is different from TOAST, which denotes only a single cause for stroke and eliminates the possibility of other involved contributing factors. Materials and methods All patients involved in the study were admitted to a rural Indian hospital from January 2014 to July 2016. All the relevant clinical details of each patient were then retrieved from the hospital's electronic medical record system for the study. We then classified all the patients based on the TOAST and ASCOD classification criteria. Results Using the ASCOD classification, we found that 179 (86%) patients out of 209 had either atherothrombosis or small vessel disease. The ASCOD classification also showed substantial evidence that the determined stroke mechanism/etiology is interconnected to multiple causal factors in over 50% of patients. In contrast, the TOAST classification had identified a larger number of ischemic stroke patients as having an etiology of other and undetermined causes as compared to the ASCOD classification. Conclusion The ASCOD classification is better to use in patients and helps decide the secondary prevention appropriately.

Integrating professionals in French multi-professional health homes: Fostering collaboration beyond the walls

Current evidence of the effectiveness of multi-disciplinary co-location for healthcare integration is mixed. This case study investigates a territorial healthcare project that is implemented across four French rural healthcare practices that co-locate multi-disciplinary healthcare practitioners. Two levels of collaboration were identified: (i) local, intra-team collaboration (i.e., care and prevention) and (ii) territorial, inter-team collaboration (i.e., patient therapeutic education and knowledge sharing). An analysis of 50 interviews with healthcare professionals uncovers important aspects of successful multi-disciplinary collaboration, which is an intermediary between co-location and care integration. By highlighting the social dimension of care integration, with a specific focus on the professional component of interpersonal integration, this study expands the theory of care integration by identifying three antecedents of multi-disciplinary collaboration: (i) prior general practitioner joint-practice experience, (ii) professional impetus (i.e., initiated by practitioners) and (iii) general practitioner peer group membership. Successful multi-disciplinary co-location and, in turn, collaboration offer a range of benefits to both patients and practitioners and advance progress towards promising perspectives, such as local competence transfer and territorial contagion.

Rural Public Health Workforce Training and Development: The Performance of an Undergraduate Internship Programme in a Rural Hospital and Healthcare Centre

Workforce shortages in the field of public health and healthcare are significant. Due to the limitations of career opportunities and compensation, rural hospitals and healthcare centres usually have on-going career openings for all departments. As a result, university departments of public health and healthcare management, and rural hospitals and health centres may need to establish internship and training programmes for undergraduate senior-year students in order to provide opportunities and human resource opportunities for both students and public health professions. The research examined the performance, feedback, and opinions of a university-based one-year-long on-site internship training programme between a university public health and healthcare undergraduate department and a regional hospital and healthcare centre in a rural region in the United States. Individual interview data were collected from management trainees and focus group activities data were collected from hospital departmental supervisors who have completed this one-year-long on-site internship training programme. The results offered an assessment of performance and evaluation of how a one-year-long internship programme could be beneficial to hospitals and health centres in the areas of human resources, manpower management, and skill training to prospective professionals in rural and regional communities. Also, the study provided a blueprint and alternative for universities and partnered sites to redesign and improve their current internship programmes which may better fit their needs for their actual situations.

Development of a Three-dimensional Printed Emergent Burr Hole and Craniotomy Simulator

Patients with a traumatic head injury (THI) require immediate surgical intervention, as rapidly expanding intracranial hematomas can be imminently life-threatening, not permitting transfer time to neurosurgical care in a tertiary care center. In rural and remote areas, where neurosurgeons may not be readily available, surgical intervention by Community General Surgeons (CGS) may be required. Currently, the CGS in Newfoundland and Labrador (NL) do not have access to, or have experience training with, an emergent burr hole/craniotomy (EBHC) simulator. One of the barriers is the availability of inexpensive and reliable simulators to practice these skills. Therefore, a low-cost, three-dimensional (3D) printed EBHC simulator was designed and 3D-printed by MUN Med 3D (St John's, NL).

The aim of this technical report is to assess the need for such simulator in rural and remote healthcare centers and report on the iterative development of the EBHC simulator. The 3D-printed EBHC simulator developed by MUN Med 3D was utilized during a general surgery workshop at the 26^th Annual Rural and Remote Medicine Conference in St. John’s, NL. A total of six 3D-printed EBHC simulators were provided for the hour and a half workshop. At the end of the workshop, 16 participants were asked to provide feedback on the need for this simulator in their rural or remote environment as well as feedback on the physical attributes. The feedback received from the participants was overall positive, informative, and supported the need for the 3D-printed EBHC simulator.

A Farmer Becoming a Quasi-doctor: The Daegok Diary and Rural Healthcare from the 1960s to the 1980s

This article attempts to review the reality of rural health care in Korea from the 1960s to the 1980s by analyzing the Daegok Diary. There has been two myths about rural healthcare. One is that the absence of institutional medicine was replaced by folk medicine, which could be identified with folk remedies or shamanic healing distinguished from Western medicine. This is a frame that understands institutional and Western medicine as a pair and folk medicine and traditional medicine as another. Another popular belief is that rural healthcare had remained almost nonexistent, and only dramatically improved after the Regional Health Insurance was implemented. Of course, some claim that the Regional Health Insurance was disadvantageous to farmers, but it is generally understood that there was an absence of government policy regarding medical care. The Daegok Diary, telling many aspects of rural life, is a good source to reflect on these common notions. Unlike other farmers' diaries, the diary of Shin Kwonsik contains a wealth of medical culture records because he chose unique ways to cure his and neighbors' illnesses by himself. It can be summarized as the life of "quasi-doctor". Shin was distinguished from quacks in that he practiced as an intellectual in the village rather than as a profession, and that he learned official medical knowledge and recognized the difference between a licensed physician and himself. Also, he was different from doctors because of the lack of a medical license and the limited range of diseases that he could treat. The life of quasi-doctor shows the social structure of rural areas in Korea from the 1960s to the 1980s. The reality of rural healthcare can be summarized in two ways. First, the medical vacuum was filled by civilian efforts. There was virtually no institutional healthcare in rural areas, but the government did little to improve the situation . The policy of sending doctors to the countryside proved to be ineffective, and the community doctor system did not work properly. Health Insurance was also a system for city workers rather than farmers. In the late 1970s, the situation only slightly improved due to reasons unrelated to the government policy regarding rural healthcare. These were improvements in traffic conditions and the increasing popularity of private insurance, which improved the physical and economic accessibility to medical institutions. Second, Western medicine had become a part of folk medicine. Those who could not go to a hospital utilized Western medicine, which had penetrated the folk medical culture. When people were sick, they bought Western drugs from pharmacies, drug dealers, and sometimes quacks. The knowledge of Western medicine also spread widely, with family medical books such as Million People's Medicine as the medium. These two characteristics show that the existing myths that regard the absence of government policy as that of medical care and interpret the medical vacuum as the prevalence of folk remedies and shamanic healing are far from the truth. From the 1960s to the 1980s, gaps in institutional medicine was filled by Western medicine which had become part of the folk medicine already, and the accessibility of institutional medicine was improved through civilian efforts. Of course, the Daegok Diary shows more than the social structure of rural areas. It also reveals a lot about the man who wrote it, Shin Kwonsik. Unlike the others, Shin chose to become a quasi-doctor because of his separation from the tradition and his desire to learn. He grew up alone without parental care and later moved to Seoul by himself. This meant a break with the tradition. He joined the army in the wake of the Korean War and learned how to give injections there. After he was discharged, he devoured many books and newspapers including Million People's Medicine. In short, the existence of a quasi-doctor like Shin was the result of the combination of the absence of institutional medicine, the predominance of Western medicine, and the characteristic of Shin as a 'learning modern.'

'The disease isn't listening to the drug': The socio-cultural context of antibiotic use for viral respiratory infections in rural Uganda

To identify factors precipitating antibiotic misuse and discuss how to promote safe antibiotics use and curb antibiotic resistance. Antibiotic misuse is a significant problem globally, leading to increased antibiotic resistance. Many socio-cultural factors facilitate antibiotic misuse: patient and provider beliefs about antibiotics, inadequate regulation, poor health literacy, inadequate healthcare provider training, and sub-optimal diagnostic capability. This study investigates the influence of such factors on antibiotic use and community health in rural Uganda. Attention was paid to patient-provider dynamics, providers' concerns, and the role of drug shops in the communities and how these situations exacerbate antibiotic misuse. Using a grounded ethnographic approach, interviews, focus groups, and observations were conducted over six weeks. Five salient themes emerged from data analysis. Based on the study results and a review of past literature on antibiotic resistance, there is need for improved health literacy and education, continued focus on efficiency and affordability in healthcare, and recognition of the role of stewardship and government in providing better healthcare. The problem of antibiotic misuse is multifactorial. Proposed solutions must target multiple contributing factors and must ultimately modify the culture and beliefs surrounding antibiotic use and encourage proper use. Such a multi-pronged approach would be most effective and would decrease rates of antibiotic resistance.

Perspectives of rural health and human service practitioners following suicide prevention training programme in Australia: A thematic analysis

There are well-established training programmes available to support health and human services professionals working with people vulnerable to suicide. However, little is known about involving people with lived experience in the delivery of suicide prevention training with communities with increased rates of suicide. The aim of this paper was to report on a formative dialogical evaluation that explored the views of health and human services workers with regard to a suicide prevention training programme in regional (including rural and remote areas) South Australia which included meaningful involvement of a person with lived experience in the development and delivery of the training. In 2015, eight suicide prevention training workshops were conducted with health and human services workers. All 248 participants lived and worked in South Australian regional communities. We interviewed a subsample of 24 participants across eight sites. A thematic analysis of the interviews identified five themes: Coproduction is key, It is okay to ask the question, Caring for my community, I can make a difference and Learning for future training. The overall meta-theme was "Involvement of a person with lived experience in suicide prevention training supports regional communities to look out for people at risk of suicide." This paper highlights the need for suicide prevention training and other workforce development programmes to include lived experience participation as a core component in development and delivery.

Cost-effectiveness of Access to Critical Cerebral Emergency Support Services (ACCESS): a neuro-emergent telemedicine consultation program

AIMS

Access to Critical Cerebral Emergency Support Services (ACCESS) was developed as a low-cost solution to providing neuro-emergent consultations to rural hospitals in New Mexico that do not offer comprehensive stroke care. ACCESS is a two-way audio-visual program linking remote emergency department physicians and their patients to stroke specialists. ACCESS also has an education component in which hospitals receive training from stroke specialists on the triage and treatment of patients. This study assessed the clinical and economic outcomes of the ACCESS program in providing services to rural New Mexico from a healthcare payer perspective.

METHODS

A decision tree model was constructed using findings from the ACCESS program and existing literature, the likelihood that a patient will receive a tissue plasminogen activator (tPA), cost of care, and resulting quality adjusted life years (QALYs). Data from the ACCESS program includes emergency room patients in rural New Mexico from May 2015 to August 2016. Outcomes and costs have been estimated for patients who were taken to a hospital providing neurological telecare and patients who were not.

RESULTS

The use of ACCESS decreased neuro-emergent stroke patient transfers from rural hospitals to urban settings from 85% to 5% (no tPA) and 90% to 23% (tPA), while stroke specialist reading of patient CT/MRI imaging within 3 h of onset of stroke symptoms increased from 2% to 22%. Results indicate that use of ACCESS has the potential to save $4,241 ($3,952-$4,438) per patient and increase QALYs by 0.20 (0.14-0.22). This increase in QALYs equates to ∼73 more days of life at full health. The cost savings and QALYs are expected to increase when moving from a 90-day model to a lifetime model.

CONCLUSION

The analysis demonstrates potential savings and improved quality-of-life associated with the use of ACCESS for patients presenting to rural hospitals with acute ischemic stroke (AIS).

Rural Palliative Care in North India: Rapid Evaluation of a Program Using a Realist Mixed Method Approach

CONTEXT

Palliative care has not developed widely in rural North India. Since 2010, the Emmanuel Hospitals Association (EHA) has been developing a model of palliative care appropriate for this setting, based on teams undertaking home visits with the backup of outpatient and inpatient services. A project to further develop the model operated from 2012 to 2015 supported by funding from the UK.

AIMS

This study aims to evaluate the EHA palliative care project.

SETTINGS AND DESIGN

Rapid evaluation method using a mixed method realist approach at the five project hospital sites.

METHODS

An overview of the project was obtained by analyzing project documents and key informant interviews. Questionnaire data from each hospital were collected, followed by interviews with staff, patients, and relatives and observations of home visits and other activities at each site.

ANALYSIS

Descriptive analysis of quantitative and thematic analysis of qualitative data was undertaken. Each site was measured against the Indian Minimum Standards Tool for Palliative Care (IMSTPC).

RESULTS

Each team followed the EHA model, with local modifications. Services were nurse led with medical support. Eighty percent of patients had cancer. Staff demonstrated good palliative care skills and patients and families appreciated the care. Most essential IMSTPC markers were achieved but morphine licenses were available to only two teams. Remarkable synergy was emerging between palliative care and community health. Hospitals planned to fund palliative care through income from surgical services.

CONCLUSIONS

Excellent palliative care appropriate for rural north India is delivered through the EHA model. It could be extended to other similar sites.

Management of Cold Water-induced Hypothermia: A Simulation Scenario for Layperson Training Delivered via a Mobile Tele-simulation Unit

Newfoundland and Labrador (NL) has one of the highest provincial drowning rates in Canada, largely due to the many rural communities located near bodies of water. Factor in the province's cold climate (average NL's freshwater temperature is below 5.4°C)and the prevalence of winter recreational activities among the population, there exists an inherent risk of ice-related injuries and subsequent hypothermia. Oftentimes, these injuries occur in remote/rural settings where immediate support from Emergency Medical Services (EMS) may not be available. During this critical period, it frequently falls on individuals without formal healthcare training to provide lifesaving measures until help arrives. Training individuals in rural communities plays an important role in ensuring public safety. In recent years, simulation-based education has become an essential tool in medical, marine and first aid training. It provides learners with a safe environment to hone their skills and has been shown to be superior to traditional clinical teaching methods. The following case aims to train laypeople from rural settings in the immediate management of an individual who becomes hypothermic following immersion into cold water. However, reaching these individuals to provide training can be a challenge in a province with such a vast geography. To assist with overcoming this, the development of a simulation center that is portable between communities (or Mobile Tele-Simulation Unit) has occurred. By utilizing modern technology, this paper also proposes an innovative method of connecting with learners in more difficult to reach regions.

Complete Blood Count Reference Ranges from a Rural Haitian Ambulatory Care Clinic

Background

At rural healthcare centers in developing countries, it is difficult to recruit healthy individuals for reference range studies. So, in this study, I evaluated complete blood count (CBC) data to determine reference ranges for a rural Haitian population.

Methods

A convenience sample of laboratory records was reviewed to obtain CBC results for 157 adult patients with normal screening examination results. Central 95% reference ranges were determined for male and female subjects.

Results

Relative to reference ranges obtained with United States (US)-based subjects, the hemoglobin (Hgb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and absolute neutrophil count (ANC) ranges were lower in subjects who resided in rural Haiti. The upper reference limit of the red blood cell distribution width-coefficient of variation (RDW-CV) was higher than the reference range for the US-based group.

Conclusion

Locally derived CBC reference ranges were established using data from subjects who resided in rural Haiti. Ranges for Hgb, Hct, MCV, MCH, RDW-CV, and ANC differed from those established using data from US-based subjects.

Leading-Following in the Context of Rural Nursing

Leading-following, as defined by Parse, is "deliberately innovating with potent engaging in persistently pursuing excellence. It is an indivisible, unpredictable, ever changing cocreation." Parse noted that processes forming the essence of leading-following require commitment, risk-taking, acknowledging ambiguity, respecting others, and vigilance. There is a bond between members of society and nurses-an expectation that nurses will provide care to individuals, families, and communities. Nursing is a profession where the potential to create meaning in healthcare has not yet been fully realized.

Deep learning for cardiac computer-aided diagnosis: benefits, issues & solutions

Cardiovascular diseases are one of the top causes of deaths worldwide. In developing nations and rural areas, difficulties with diagnosis and treatment are made worse due to the deficiency of healthcare facilities. A viable solution to this issue is telemedicine, which involves delivering health care and sharing medical knowledge at a distance. Additionally, mHealth, the utilization of mobile devices for medical care, has also proven to be a feasible choice. The integration of telemedicine, mHealth and computer-aided diagnosis systems with the fields of machine and deep learning has enabled the creation of effective services that are adaptable to a multitude of scenarios. The objective of this review is to provide an overview of heart disease diagnosis and management, especially within the context of rural healthcare, as well as discuss the benefits, issues and solutions of implementing deep learning algorithms to improve the efficacy of relevant medical applications.

First experiences with patient safety initiatives in Greek rural primary care. Action research by the LINNEAUS collaboration on patient safety in primary care

BACKGROUND

Accreditation of primary care organizations within Greece is still in its infancy. Our task in Greece was to attempt to introduce a patient safety initiative in a local area, focusing on developing minimum standards for accreditation, assess whether a pragmatic approach would engage physicians, and provide evidence of improvement.

OBJECTIVE

To use monitoring of clinical performance as the basis for the launch of an accreditation system for primary care in Greece and to report on the process and lessons learnt.

METHODS

An established set of clinical indicators for patient safety was introduced in five Greek primary health centres. A web-based platform, for reporting practitioners' scores on the selected indicators, was used to record the activity of the practitioners.

RESULTS

There was considerable variation in the use of clinical indicators by individual GPs. Following the intervention, the reporting on the indicators had increased while the scores on indicators only increased slightly. However, GPs engaged with the process and recognized its relevance to improving patient safety.

CONCLUSION

We successfully piloted a means of engaging with GPs to improve patient safety using established indicators even where there was limited infrastructure to support such initiatives.

Short-term differences in drug prices after implementation of the national essential medicines system: A case study in rural Jiangxi Province, China

Objectives:

China's 2009 national essential medicine system (NEMS) was designed to reduce prices through a zero-markup policy and a centralized bidding system. To analyze NEMS's short-term impact on drug prices, we estimated the retail and wholesale prices before and after the reform at health institutions in rural Jiangxi Province.

Materials and Methods:

We undertook two cross-sectional surveys of prices of 39 medicines in November 2008 and May 2010, calculated inflation adjusted prices, and used the Wilcoxon signed-rank and rank-sum tests to examine price changes at different health institutions.

Results:

Retail prices at pilot (P < 0.01) and nonpilot (P < 0.01) township health centers decreased significantly, whereas the declines at retail pharmacies (P = 0.57) and village clinics (P = 0.29) were insignificant. The decline at pilot township health centers was the largest, compared with other kinds of health institutions (P < 0.01). Retail prices of essential and non-essential medicines declined significantly at pilot facilities (P < 0.05); price drops for non-essential medicines occurred only at pilot facilities (P < 0.05). No significant decline of wholesale prices were found at pilot (P = 0.86) and nonpilot units (P = 0.18), retail pharmacies (P = 0.18), and village clinics (P = 0.20). The wholesale prices changes at pilot units before and after the reform were higher than at nonpilot public units (P < 0.05), retail pharmacies (P < 0.05), and village clinics (P < 0.05).

Conclusion:

While the NEMS zero-markup policy significantly reduced retail prices at pilot health institutions, the centralized bidding system was insufficient to lower wholesale prices. A drug price management system should be constructed to control medicine prices and a long-term price information system is needed to monitor price changes.

Identifying barriers to move to better health coverage: preferences for health insurance benefits among the rural poor population in La Guajira, Colombia

Even though access to health insurance in Colombia has improved since the implementation of the 1993 health reforms (Law 100), universal coverage has not yet been accomplished. There is still a segment of the population under the low-income (subsidized) health insurance policy or without health insurance altogether. The purpose of this research was to identify preferences and behavior regarding health insurance among the subsidized rural population in La Guajira, Colombia, and to understand why that population remains under the subsidized health insurance policy. The field experiment gathered information from 400 households regarding their socioeconomic situation, health conditions, and preferences for health insurance characteristics. Results suggest that the surveyed population gives priority to expanded family coverage, physician and hospital choice, and access to specialists, rather than to attributes associated with co-payments or premiums. That indicates that people value healthcare benefits and family coverage more than health insurance expenses, and policy makers could use these preferences to enroll subsidized population into the contributory regime.

What elements of the work environment are most responsible for health worker dissatisfaction in rural primary care clinics in Tanzania?

BACKGROUND

In countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers' satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania.

METHODS

Overall, 70 health workers in rural Tanzania participated in a self-administered job satisfaction survey. We calculated mean ratings for 17 aspects of the work environment. We used principal components analysis (PCA) to identify groupings of these variables. We then examined the bivariate associations between health workers demographics and clinic characteristics and each of the satisfaction scales.

RESULTS

Results showed that 73.9% of health workers strongly agreed that they were satisfied with their job; however, only 11.6% strongly agreed that they were satisfied with their level of pay and 2.9% with the availability of equipment and supplies. Two categories of factors emerged from the PCA: the tools and infrastructure to provide care, and supportive interpersonal environment. Nurses and medical attendants (compared to clinical officers) and older health workers had higher satisfaction scale ratings.

CONCLUSIONS

Two dimensions of health workers' work environment, namely infrastructure and supportive interpersonal work environment, explained much of the variation in satisfaction among rural Tanzanian health workers in primary health clinics. Health workers were generally more satisfied with supportive interpersonal relationships than with the infrastructure. Human resource policies should consider how to improve these two aspects of work as a means for improving health worker morale and potentially rural attrition.

TRIAL REGISTRATION

(ISRCTN 17107760).

Barriers in implementing evidence-informed health decisions in rural rehabilitation settings: a mixed methods pilot study

OBJECTIVES

Literature on the barriers to implementing research findings into physiotherapy practice are often urban centric, using self report based on the hypothetical patient scenario. The objective of this study was to investigate the occurrence of barriers, encountered by evidence informed practice-trained physiotherapists in the management of "real world" patients in rural rehabilitation settings.

METHODS

A mixed-methods research design was used. Physiotherapists working in rural outpatient rehabilitation settings participated in the study. In the first phase, we asked all participants (N = 5) to maintain a log book for a 4-week period to record questions that arose during their routine clinical encounters and asked them also to follow first four of the five steps of evidence-informed practice (ask, access, appraise and apply). In the second phase (after 4 weeks), we conducted a semistructured, direct interviews with the participants exploring their experiences involved in the process of implementing evidence-informed clinical decisions made during the study period.

RESULTS

At the end of 4 weeks, 30 questions were recorded. For 17 questions, the participants found evidence but applied that evidence into their practice only in 9 instances. Being generalist practitioners, lack of outcomes specific to the patients were reported as barriers more so than time constraints in implementing evidence-informed practice.

CONCLUSIONS

Practice setting, lack of patient-centered research and evidence-informed practice competency of physiotherapists can be significant barriers to implementing evidence-informed health decisions in rural rehabilitation setting.