Research and rural; EGPRN and EURIPA—finding common ground. October 2013, Malta

Abstract

The European General Practice Research Network (EGPRN) and the European Rural and Isolated Practitioner Association (EURIPA) convened a historic joint meeting in Malta in October 2013. Speakers reviewed the inadequacies of the current system and conduct of clinical science research and the use and misuse of the resulting findings. Rural communities offer extraordinary opportunities to conduct more holistic, integrative, and relevant research using new methods and data sources. Investigators presented exciting research findings on questions important to the health of those in rural areas. Participants discussed several strategies to enhance the capacity and stature of rural health research and practice. EGPRN and EURIPA pledged to work together to develop rural research courses, joint research projects, and a European Rural Research Agenda based on the most urgent priorities and the European definition of general practice research in rural health care.     

农村基层医疗卫生机构视力检查服务提供与利用

目的:分析农村基层医疗卫生机构视力检查服务的可及性对居民视力检查服务利用的影响。方法:利用医疗卫生机构和农户调查数据,采用描述统计和多元回归分析。结果:样本中33.2%的居民自报告视力不良,22.1%的居民曾做过视力检查,86%样本乡镇的卫生院和44%样本村的村卫生室可以提供视力检查服务;回归结果显示,乡镇卫生院提供视力检查服务将显著增加居民进行视力检查的可能性,但村卫生室是否提供视力检查服务对居民视力检查的利用没有显著影响。结论:农村居民对视力检查服务需求很大,但是利用率低。基层医疗卫生机构服务供给不足可能是导致农村居民服务利用率低的重要因素。建议国家继续推进基本公共卫生服务,加强基层医疗卫生服务机构开展基本视力检查的能力,促进农村居民对视力检查服务的利用,改善农村居民视力健康水平。     

Spatial barriers as moral failings: What rural distance can teach us about women's health and medical mistrust

Policy attention to growing rural “health care deserts” tends to identify rural distance as a primary spatial barrier to accessing care. This paper brings together geography, health policy, and ethnographic methods to instead theorize distance as an expansive and illuminating concept that highlights place-based expertise. It specifically engages rural women's interpretations of rural distance as a multifaceted dimension of accessing health care, which includes but is not limited to women's health services and maternity care. Presenting qualitative research with 51 women in a rural region of the U.S., thematic findings reveal an interpretation of barriers to rural health care as moral failings rather than as purely spatial or operational challenges, along with wide communication of negative health care experiences owing to spatially-disparate but trusted social networks. Amid or owing to the rural crisis context, medical mistrust here emerges as a meaningful but largely unrecognized barrier to rural women's ability—and willingness—to obtain health care. This underscores how a novel interpretation of distance may inform policy efforts to address rural medical deserts.     

Health Care Services for HIV-Positive Substance Abusers in a Rural Setting: An Innovative Program

ABSTRACT

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care–related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

“People are struggling in this area:” a qualitative study of women’s perspectives of telehealth in rural South Carolina

ABSTRACT

Rural communities face disparities and barriers to health care access that may be addressed through telehealth programs; yet little research is available detailing rural women’s attitudes toward telehealth. Researchers partnered with a women’s reproductive health organization to conduct formative audience research to understand rural women’s perspectives of telehealth in their communities. Qualitative research was conducted to improve understandings of women’s perceptions of telehealth in rural South Carolina. In-depth interviews with 52 women aged 18–44 years were conducted in five rural counties in South Carolina during June – August 2015. Analytical techniques from grounded theory methodology were used throughout data collection and analysis. Participants believed a telehealth intervention would benefit the community by addressing reproductive health barriers, such as cost, transportation, and long wait times at local health care facilities. Participants’ concerns included issues of confidentiality in a small town, discomfort with mediated communication, privacy, and the importance of relationship-centered care, including patient-provider communication and approachability of health care providers. Findings provide insight to design and implement telehealth interventions to improve women’s health in rural communities.     

Rural maternity care and health policy: parents' experiences

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty‐three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re‐evaluated in order to improve rural Australians' access to vital health services such as maternity care.     

Disparities in Health Care Access and Receipt of Preventive Services by Disability Type: Analysis of the Medical Expenditure Panel Survey

ObjectiveTo examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities.ConclusionsThere are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups.     

Palliative care in public health: a formal and content-related analysis of European journals

Public health and health care science take on an important role in the further development of palliative care. This study examines to what degree palliative care is represented in the pertinent academic journals of public health and health care science and what the major subjects are. We analysed the European journals that were listed in the Journal Citation Reports in the categories health care science and services, public, environmental and occupational health, as well as health policy and services. The literature search was conducted in the journals identified for the years 1996 through 2005, using the terms palliative care*, palliative medicine*, terminal care* and hospice care*. The analyses were based on the quantity of publications in the journals, the publication years, the impact factors and the subjects focused on. There were 82 journals included. Altogether, 57,737 publications appeared during the analysis period; 166 papers were on palliative care (0.3% of all papers). The majority of palliative care articles (55%, n = 91) were concentrated in a very small circle of journals (4%, n = 3). The absolute quantity of palliative publications and their percentage among all publications have continuously increased from 0.1% in 1996/1997 to 0.4% in 2004/2005. The largest group of papers on the subject (42%, n = 70) appeared in journals with impact factors less than 1, whereas the largest group of all papers was found in journals with impact factors of 1–1.999 (51%, n = 15,732). Most papers focus on patient orientation and health professionals’ perspective and education; subjects such as health care utilization and barriers are less frequently covered. There is need for more research on palliative care relevant for public health and health care science in terms of reach and top-level impact. For example, the research questions should deal with health care utilization and potential social and cultural barriers. The interdisciplinary community of public health sets the stage for the required collaborative research activities.     

‘Just doing the best we can’: health care providers’ perceptions of barriers to providing care to Marshallese patients in Arkansas

ABSTRACT

Introduction: Marshallese migrating to the United States encounter challenges in accessing health care. Previous literature has investigated Marshallese participants’ perceptions of the barriers they face in accessing health care. For this study, health care providers managing the care of Marshallese patients were interviewed to understand the providers’ perception of barriers that their Marshallese patients encounter.

Methods: A qualitative research design was utilized to explore health care providers’ perceptions of and experiences with the barriers faced by their Marshallese patients when accessing the US health care system.

Results: The primary barriers identified were: (1) economic barriers; (2) communication challenges; (3) difficulty understanding and navigating the western health care system; and (4) structural and system barriers.

Conclusion: This study provides insight on the barriers Marshallese patients face in accessing health care as well as the barriers providers face in delivering care to Marshallese patients. A better understanding of these barriers can help health care providers and educators to begin initiating improvements in the delivery of care to Marshallese patients.     

Health Needs and Health Care Utilization Among Rural,Low-Income Women

ABSTRACT

This study examined the correlates of health service utilization in a sample of low-income, rural women. Self-reported data were from Rural Families Speak (N = 275), a multi-state study of low-income, rural families in the U.S. collected in 2002. Findings indicated that women with health insurance, a regular doctor, and poorer overall physical health had higher incident rates of physician visits. Women who were divorced, separated or widowed and had more chronic health problems had higher incidence rates of emergency department (ED) use, while women living in counties with higher primary care physician rates had lower incidence rates of ED use. Future research and policies should focus on improved access to health insurance, increasing physician availability in rural areas, and providing rural women with a usual source of care, so as to reduce emergency services utilization for non-emergent needs and improve health status for this population.     

基本卫生服务中政府补偿的方式选择

由于基本卫生服务的特殊性,政府需要对此进行干预以保证居民享有基本卫生服务,可选择的方式主要有补供方和补需方.运用卫生经济学理论和公共经济学理论,阐述了补供方和补需方的理论依据,分析了两者的特点和适用条件.以农村基本卫生为例,分析了农村卫生中财政补助的政策选择.强调无论是补供方还是补需方,都需制定适宜的配套政策和监管措施,才能保证政策的效果.     

Continuous Palliative Sedation Until Death: The Development of a Practice Protocol for Nursing Homes

ObjectivesChallenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes.MethodsThe development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels.ResultsThe final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying.Conclusions and ImplicationsThis study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.     

The Relationships of Physician Practice Characteristics to Quality of Care and Costs

BackgroundMedical group practices are central to many of the proposals for health care reform, but little is known about the relationship between practice-level characteristics and the quality and cost of care.MethodsPractice characteristics from a 2009 national survey of 211 group practices were linked to Medicare claims data for beneficiaries attributed to the practices. Multivariate regression was used to examine the relationship between practice characteristics and claims-computable measures of screening and monitoring, avoidable utilization, risk-adjusted per-beneficiary per-year (PBPY) costs, and the practice''s net revenue.ResultsSeveral characteristics of group practices are predictive of screening and monitoring measures. Those measures, in turn, are predictive of lower values of avoidable utilization measures that contribute to higher PBPY costs. The effects of group practice characteristics on avoidable utilization, cost, and practice net revenue appear to work primarily through improved screening and monitoring.ConclusionsPractice characteristics influence costs indirectly through a set of statistically significant relationships among screening and monitoring measures and avoidable utilization. However, these relationships are not the only pathways connecting practice characteristics to cost and those additional pathways contain substantial “noise” adding uncertainty to the estimated direct effects. Some of the attributes thought to be important characteristics of accountable care organizations and medical homes appear to be associated with lower quality and no improvement in cost.     

Public perspectives on health improvement within a remote‐rural island community

BackgroundRural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health.ObjectiveTo identify and describe shared perspectives within a remote‐rural community on how to improve rural health.MethodUsing Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews.ResultsSixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services.Discussion and conclusionsFactors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice.Public ContributionMembers of the public were involved in the development and piloting of the statement set.     

The Effective Use of Psychiatric Mental Health Nurses in Integrated Care: Policy Implications for Increasing Quality and Access to Care

In the last ten years primary care providers have been encouraged to implement integrated models of care where individuals’ medical and mental health needs are addressed holistically. Many integrated models use Psychiatric Mental Health (PMH) nurses as case managers and select exemplars use PMH Advanced Practice Nurses (APNs) as providers. However, the potential value of PMH nurses in integrated health care remains unrealized by health care planners and payers, limiting access to services for the populations most in need of comprehensive care approaches. This current situation is partially fueled by insufficient knowledge of the roles and skill sets of PMH nurses. In this paper, the PMH RN and APN skill sets are detailed, demonstrating how effective use of these nurses can further the aims of integrated care models. Finally, outlined are barriers and enabling factors to effective use of PMH RNs and APNs and attendant policy implications.     

Developing Policies Responsive to Barriers to Health Care Among Rural Residents: WhatDo We Need to Know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies hove grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.     

Stuff you think you can handle as a parent and stuff you can’t’. Understanding parental health‐seeking behaviour when accessing unscheduled care: A qualitative study

BackgroundUnscheduled health care constitutes a significant proportion of health‐care utilization. Parental decision making when accessing unscheduled care for their children is multifaceted and must be better understood to inform policy and practice.DesignNineteen semi‐structured interviews and one focus group (n = 4) with parents of children younger than twelve in Ireland were conducted. Participants had accessed unscheduled care for their children in the past. Data were thematically analysed.ResultsParents accessed unscheduled care for their children after reaching capacity to manage the child''s health themselves. This was informed by factors such as parental experience, perceived urgency and need for reassurance. Parents considered the necessity to access care and situated their health‐seeking behaviour within a framework of ‘appropriateness’. Where parents sought unscheduled care was largely determined by timely access, and inability to secure a general practitioner (GP) appointment often led parents to access other services. Parents expressed a need for more support in navigating unscheduled care options.ConclusionsBetter resources to educate and support parents are required, and structural issues, such as accessibility to GPs, need to be addressed to enable parents to better navigate the unscheduled health system and manage their children''s health. The discourse around ‘appropriate’ and ‘inappropriate’ access to health care has permeated parental decision making when accessing unscheduled health care for their children. What constitutes appropriate access should be examined, and a shift away from this framing of health‐seeking behaviour may be warranted.Patient or Public ContributionThere was no explicit patient or public involvement. All authors hold experience as users of the health system.