The Need to Train Physicians for Rural Primary Health Care in Latin America: Some Family Medicine Experiences*

ABSTRACT: Training strategies to prepare physicians for rural primary care generally have not been a feature of medical education in Latin America. The emergence of family medicine as a specialty discipline has resulted in a number of primary care educational initiatives which are designed to give students or residents the knowledge and skills necessary to practice in rural settings. Specific programs in Mexico, Colombia, Chile, and Argentina are identified and discussed. These programs were selected because they raise a number of educational and manpower planning issues which teachers of family medicine and rural primary care need to address if the long-term viability of these programs is to be achieved. These issues include: the role of the community as an educational laboratory, the supervision of community-based learning experiences, the development of strong clinical and community health promotion skills, the reinforcement of positive primary care learning throughout training, and the development of rural health role models. Manpower planning issues to be addressed include: developing a more precise identity for the primary care physician, a re-examination of the pasantia or year of required community service, developing closer ties between the medical schools and the Ministries of Health and other institutional employers of physicians, and encouraging successful programs to share their experiences with others.     

Federal Programs Affecting Rural Perinatal Health Care

Access to perinatal health care in rural communities often depends on such factors as the availability, cost, and acceptability of services. The federal government has been providing rural perinatal health care both directly and indirectly, through grants for service delivery or research and through direct payment for service. The various federal programs supporting perinatal health care in rural communities are described, and what may need to be done in the future is discussed.     

Rural Health Care in Bolivia*

ABSTRACT: Eighty percent of Bolivians live in rural areas. However, because of a lack of resources and an urban / curative health sector orientation, rural primary health care services are woefully inadequate. Consequently, Bolivia has the worst health conditions of any of the Latin American countries. The broader factors which underlie Bolivia's poor health conditions, such as the low standard of living and impediments to socioeconomic development, are reviewed. Rural primary health programs are hampered by a lack of local support, overdependence on central and distant Ministry of Health supervisory staff, a lack of strong national political support for rural primary health care programs, the absence of public sector support for social programs, and a lack of appropriately trained health providers who are comfortable in the rural sociocultural mileu of community-oriented primary health care. The experience of Andean Rural Health Care is briefly described, and the potential contribution of private organizations working with local communities and with the Ministry of Health is addressed. The most viable option for improving rural primary health care in Bolivia is the census-based community-oriented approach.     

Rural Health Care in Chile*

ABSTRACT: The experiences of four years of applying a specific plan for improving rural health in Chile are discussed. These rural health initiatives have resulted in expanding the delivery of services; improvements in the health infrastructure for rural care; an important increase in the quality and the number of qualified health personnel; the creation of homes for pregnant women; the construction of latrines; improvements in the quality of life of the population through literacy activities; self-production of food; improved basic sanitation and active participation of the community in the solution of community health problems as well as those of personal well-being. An evaluation undertaken with a representative sample of families indicated that 83% rated the performance of the rural primary health center, and its team of health care professionals, from very good to excellent. Satisfaction with specific professionals was also high, although there were variations: physician (77.6%); midwife (86.4%); nurse (92%); “auxiliar” (93.6%) and nutritionist (75%).     

Diabetes Care and Outcomes: Disparities Across Rural America

We examined differences in receipt of diabetes care and selected outcomes between rural and urban persons living with diabetes, using nationally representative data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS). “Rural” was defined as living in a non-metropolitan county. Diabetes care variables were physician visit, HbA1c testing, foot examination, and dilated eye examination. Outcome variables were presence of foot sores and diabetic retinopathy. Analysis was limited to persons 18 and older self-reporting a diagnosis of diabetes (n = 29,501). A lower proportion of rural than urban persons with diabetes reported a dilated eye examination (69.1 vs. 72.4%; P = 0.005) or a foot examination in the past year (70.6 vs. 73.7%; P = 0.016). Conversely, a greater proportion of rural than urban persons reported diabetic retinopathy (25.8 vs. 22.0%; P = 0.007) and having a foot sore taking more than four weeks to heal (13.2 vs. 11.2%; P = 0.036). Rural residence was not associated with receipt of services after individual characteristics were taken into account in adjusted analysis, but remained associated with an increased risk for retinopathy (OR = 1.20, 95% CI = 1.02–1.42). Participation in Diabetes Self-Management Education (DSME) was positively associated with all measures of diabetes care included in the study. Availability of specialty services and travel considerations could explain some of these differences.     

Bridging Between Professionals in Perinatal Care: Towards Shared Care in The Netherlands

Relatively high perinatal mortality rates in the Netherlands have required a critical assessment of the national obstetric system. Policy evaluations emphasized the need for organizational improvement, in particular closer collaboration between community midwives and obstetric caregivers in hospitals. The leveled care system that is currently in place, in which professionals in midwifery and obstetrics work autonomously, does not fully meet the needs of pregnant women, especially women with an accumulation of non-medical risk factors. This article provides an overview of the advantages of greater interdisciplinary collaboration and the current policy developments in obstetric care in the Netherlands. In line with these developments we present a model for shared care embedded in local ‘obstetric collaborations’. These collaborations are formed by obstetric caregivers of a single hospital and all surrounding community midwives. Through a broad literature search, practical elements from shared care approaches in other fields of medicine that would suit the Dutch obstetric system were selected. These elements, focusing on continuity of care, patient centeredness and interprofessional teamwork form a comprehensive model for a shared care approach. By means of this overview paper and the presented model, we add direction to the current policy debate on the development of obstetrics in the Netherlands. This model will be used as a starting point for the pilot-implementation of a shared care approach in the ‘obstetric collaborations’, using feedback from the field to further improve it.     

The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America

CONTEXT: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. PURPOSE: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. METHODS: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination). FINDINGS: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum. CONCLUSIONS: Urban-rural quality of care differences may be a function not just of geography but also of the presence of a large nonwhite population.     

Perinatal Care in Canada

HEALTH ISSUE: Canada's standard of perinatal care ranks among the highest in the world, but there is still room for improvement, both in terms of regional differences in care and global comparisons of approaches to care in Canada and elsewhere. Data from the Canadian Perinatal Surveillance System (CPSS) was used to evaluate morbidity and mortality among mothers and infants. KEY FINDINGS: Maternal mortality rates in Canada dropped to 4.4 per 100,000 live births in 1993-1997 and are among the lowest in the world. Rates of Caesarean section increased from 15.3 per 100 deliveries in 1994 to 19.1 in 1997. Although the infant mortality rate in Canada is among the lowest in the world (5.3-8.8 per 1,000 live births 1990-2000), there are unacceptable disparities between subpopulations. In Aboriginal populations, rates of stillbirth and perinatal mortality are 2-2.5 times the Canadian average. There has been a steady increase in the proportion of births among older women who have the highest risk of preterm births and pregnancy complications.The increasing rate of multiple births has accelerated recently and is of concern as these carry a higher risk of complications and are associated with an increased risk of preterm birth. The costs to the health care system are likely to be high. DATA GAPS AND RECOMMENDATIONS: CPSS data, including economic indicators, needs to be collected in a more timely and uniform manner across Canada. The CPSS should provide an evaluation of how well Canada fares in relation to international standards of perinatal care.     

陕西部分农村社区围产保健质量对母亲喂养行为的影响

为了解围产保健质量对母亲喂养行为的影响,分别对陕西省富平,澄城两县农村社区的围产保健质量和母亲喂养行为进行对比研究,结果显示澄城县围产保健质量较好,母乳喂养及辅食添加情况也优于富平县,经统计学处理,两者有显著性差异（P＜0．005）,故认为围产保健质量高可改进母亲喂养行为,应重视农村社区围产保健工作,特别应加强母乳喂养及辅食添加新知识的宣传教育工作。     

Faculty Time Allocation in Rural Primary Care Training Sites*

This investigation examined the allocation of time by medical school faculty who served as attending physicians on a rotating basis in rural primary care centers where medical students and house staff were trained. Two quite different methods of studying faculty time allocation produced relatively consistent results. Travel and direct care of patients (with no medical students present) accounted for the largest share of faculty time. Much of the teaching time was spent in direct student contact with no patient present. Simultaneous care of patients by an attending faculty member and a medical student accounted for less than ten percent of faculty effort. It appears that in a busy rural primary care center, faculty whose mission is intended to emphasize teaching may often be thrust into the role of care providers. Despite this problem, faculty-student contact appears to be greater than that which typically occurs in the tertiary care teaching hospital environment.     

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural,Small Town America

ABSTRACT: Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. Methods: A survey mailed in 2004‐2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.     

The Effect of Malpractice Liability on the Delivery of Rural Obstetrical Care*

A telephone survey of all non-governmental obstetricians, family physicians, general practitioners, and osteopathic physicians in rural Arizona was undertaken to determine the effect of medical liability issues on the availability of rural obstetrical services. One hundred ninety-one (88.8%) responded, and after exclusion of those who had never provided obstetrical care, 126 physicians remained for evaluation. These included 32 obstetricians, 55 family physicians, 25 general practitioners, and 14 osteopaths. During the past three years, 26 (20.6%) had discontinued providing obstetrical services, citing liability issues as the reason. An additional 12 physicians (9–5%) planned to discontinue obstetrics upon expiration of their 1986 malpractice insurance policy. By the end of 1986, the number of obstetrical providers in rural Arizona will have decreased by 30.1 percent. Women in many rural areas already have pregnancy outcomes that are inferior to their urban counterparts. A further decrease in the availability of obstetrical providers may have additional adverse effects on pregnancy outcomes.     

HMOs and Managed Care: Implications for Rural Physician Manpower Planning*

American health care is changing dramatically. Health maintenance organizations (HMOs) and other managed care plans are central to this change. Today, the majority of Americans living in metropolitan areas receive their care from these types of plans. The goal of this article is two-fold. First, it will discuss the potential implications of HMOs and managed care for physician needs and supply in rural regions. Second, it will derive insight into alternative approaches for meeting rural health manpower needs by analyzing HMO staffing patterns. As HMOs and other managed care plans expand, rural physicians, their practices, and their patients will almost certainly be affected. As described in this paper, most of these effects are likely to be positive. The staffing patterns used by HMOs provide an interesting point of comparison for those responsible for rural health manpower planning and resource development. HMOs appear to meet the needs of their enrollees with significantly fewer providers than are available nationally or suggested by the federal standards. Moreover, HMOs make greater use of nonphysician providers such as nurse practitioners and physician assistants.