Community perspectives on roles and responsibilities for strengthening primary health care in rural Ethiopia

Abstract

Government–community partnerships are central to developing effective, sustainable models of primary health care in low-income countries; however, evidence about the nature of partnerships lacks the perspective of community members. Our objective was to characterise community perspectives regarding the respective roles and responsibilities of government and the community in efforts to strengthen primary health care in low-income settings. We conducted a qualitative study using focus groups (n=14 groups in each of seven primary health care units in Amhara and Oromia, Ethiopia, with a total of 140 participants) in the context of the Ethiopian Millennium Rural Initiative. Results indicated that community members defined important roles and responsibilities for both communities and governments. Community roles included promoting recommended health behaviours; influencing social norms regarding health; and contributing resources as feasible. Government roles included implementing oversight of health centres; providing human resources, infrastructure, equipment, medication and supplies; and demonstrating support for community health workers, who are seen as central to the rural health system. Renewed efforts in health system strengthening highlight the importance of community participation in initiatives to improve primary health care in rural settings. Community perspectives provide critical insights to defining, implementing and sustaining partnerships in these settings.     

Perceptions of the Environment for Eating and Exercise in a Rural Community

ObjectiveTo understand how members of a rural community perceive the effect of the built, natural, and social environments on their food choice and physical activity behaviors.MethodsA constructivist community environmental assessment was conducted including 17 individual qualitative interviews, 2 focus groups, and photo elicitation (n = 27) in a rural northeastern community where over 60% of the adult population is overweight or obese.ResultsParticipants described social, natural, and physical environmental factors that influenced their food choice and physical activity behaviors. Overweight and obesity were variably presented as an individual and/or a collective problem. Participants described conflicting goals for food choice and physical activity in the community, and an interrelationship between the social and physical environments.Conclusions and ImplicationsA community environmental assessment provides a view of the physical and social environments from the perspective of community residents that can serve as a foundation for locally tailored, community-based approaches to obesity prevention.     

Collaboration Challenges and Opportunities: A Survey of School Foodservice Directors and Community Health Coalition Members

BACKGROUND

The Healthy, Huger‐Free Kids Act (HHFKA) presents challenges for foodservice directors (FSDs) in sourcing and preparing foods that meet nutrition standards. Concurrently, community health coalition members (CHCs) are engaging schools through community and school nutrition initiatives. We hypothesized significant differences in perceptions between FSDs and CHCs related to implementation of HHFKA such that FSDs would perceive greater foodservice challenges, while CHCs would be more supportive of community nutrition initiatives.

METHODS

A perceptions survey was administered by email to 528 FSDs and 334 CHCs during summer 2016. Experience, education level, urban/rural differences, school demographics, and involvement between FSDs and CHCs were compared.

RESULTS

Overall, 132 FSDs and 80 CHCs responded (29.5% FSDs, 24.7% CHCs). Overall perception of HHFKA foodservice challenge ranged between neutral (eg, neither challenging nor unchallenging) to somewhat challenging, and did not differ between groups. CHCs were significantly more supportive of community nutrition initiatives, while FSDs responded neutrally.

CONCLUSIONS

FSDs awareness of CHCs desire for collaboration may increase FSDs support for broader school nutrition initiatives such as school gardens, farm to school, and student/community engagement. There is great potential for integrating student and community health programs through partnerships.

     

Key Focus Group Themes to Inform Weight Management Interventions in Deep South African Americans

ObjectiveTo understand African Americans’ perceptions, barriers, and facilitators to recruitment, enrollment, adoption, maintenance, and retention in a nutrition and physical activity promotion program.DesignFour focus groups were conducted.SettingTwo community settings located in Jackson and Hattiesburg, Mississippi.ParticipantsParticipants (n = 28) were aged 18–50 years.Main Outcome Measure(s)Barriers and facilitators associated with healthy eating, physical activity, achieving a healthy weight, and participation in a health behavior change program.AnalysisA conventional thematic content analysis approach includes data familiarization, initial code generation, initial theme generation, themes review, and team review for finalization of themes.ResultsMajor themes related to health behaviors and participation in a behavior change program were identified by participants, including time constraints, costs, social support, consistency and self-efficacy, motivation for longevity and disease prevention, physical appearance, fear of injury/pain, social norms/stigma associated with outdoor physical activity, body criticism from family members, and having empathic and validating program staff support.Conclusions and ImplicationsSeveral social determinants of health were identified as essential considerations for promoting healthy nutrition and physical activity behaviors among African American adult Mississippians. Cultural and spiritual implications were also identified. Study insights inform policy approaches for designing culturally appropriate health behavior change programs in the Deep South.     

Theory-based physical activity beliefs by race and activity levels among older adults

Objective. Given the benefits of physical activity and the high proportion of inactivity among older adults, the purpose was to elicit theory-based behavioral, normative, and control physical activity beliefs among 140 educationally and economically diverse older adults and compare their beliefs by race (Blacks vs. Whites) and physical activity levels (inactive/underactive vs. highly active individuals).Design. This was an elicitation study that took place in eight, mostly rural community settings in a Southeastern US state, such as Council of Aging Offices, retirement centers, and churches. Participants’ behavioral, normative, and control beliefs were elicited via in person interviews. A valid and reliable questionnaire was also used to assess their physical activity levels.Results. According to the content analysis, inactive/underactive participants reported fewer physical activity advantages than highly active participants. Common physical activity advantages between the two groups were overall health, emotional functioning, and physical functioning. Similar physical activity advantages were reported among Blacks and Whites with overall health being the most important advantage. The most common physical activity disadvantages and barriers for all four groups were falls, injuries, pain, and health issues. Inactive/underactive individuals and Blacks tended to report more disadvantages and barriers than their peers. Common physical activity supporters were family members, friends and peers, and health-care professionals.Conclusion. In their physical activity motivational programs, health promoters should reinforce physical activity benefits, social support, access to activity programs, and safety when intervening among older adults.     

“The Closer,the Better:” The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina

Background

Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception.

Objective

To understand women’s contraceptive needs and perceptions of accessing contraception through telehealth services.

Methods

Researchers conducted 52 in-depth interviews with women ages 18–44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2.

Results

Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women’s complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women’s overall health and well-being.

Conclusions for Practice

Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women’s access to contraceptive methods in rural areas.

     

Influence of socioeconomic and cultural factors on rural health

Objective:  To provide a framework for investigating the influence of socioeconomic and cultural factors on rural health.
Design:  Discussion paper.
Results:  Socioeconomic and cultural factors have long been thought to influence an individual's health. We suggest a framework for characterising these factors that comprises individual-level (e.g. individual socioeconomic status, sex, race) and neighbourhood-level dimensions (population composition, social environment, physical environment) operating both independently and through interaction. Recent spatial research suggests that in rural communities, socioeconomic disadvantage and indigenous status are two of the greatest underlying influences on health status. However, rural communities also face additional challenges associated with access to, and utilisation of, health care. The example is given of procedural angiography for individuals with an acute coronary event.
Conclusions:  Socioeconomic and cultural factors specific to rural Australia are key influences on the health of residents. These range from individual-level factors, such as rural stoicism, poverty and substance use norms, to neighbourhood-level social characteristics, such as lack of services, migration out of rural areas of younger community members weakening traditionally high levels of social cohesion, and to environmental factors, such as climate change and access to services.     

Physical activity promotion as a strategic corporate priority to improve worker health and business performance

BackgroundThe increasingly sedentary nature of work and its impact on health and productivity indicators demands the promotion of physical activity at the worksite.PurposeThis paper aims to present considerations for broad-scale application of corporate strategies designed to promote physical activity among employees and their families through employer-sponsored initiatives.ApproachThe benefits of physical activity are multifold, including health and wellbeing and productivity related outcomes. The workplace setting may be leveraged to promote physical activity levels through frequent and sustained exposures to effective interventions that reach employees and, indirectly, their families. Furthermore, employers represent a powerful stakeholder group that should leverage its influence on health policy initiatives designed to create supportive environments inside the workplace as well as the broader community. Specific principles, recommendations for action, and considerations for the prioritization of initiatives are provided based on essential elements for comprehensive programs and health policy initiatives and in the context of a social–ecological model and supportive research.ConclusionsPhysical activity promotion at the worksite should be an integrated initiative that measurably improves worker health and enhances business performance.     

Evaluation of the Reaching People with Disabilities through Healthy Communities Project

BackgroundPeople with disabilities experience disparities in chronic diseases, such as obesity, heart disease, and diabetes, in disproportionate numbers. Research suggests that healthy communities initiatives that work to implement policy, systems and environmental (PSE) changes can help reduce these disparities by improving access to healthy choices for community residents with disabilities. However, healthy communities efforts to implement PSE changes are often not inclusive of people with disabilities.ObjectiveThe purpose of this paper is to evaluate the implementation of an Inclusive Healthy Communities Model that was designed to reach people with disabilities through inclusive PSE changes.MethodsProfessionals from local public health agencies and disability organizations in 10 diverse communities worked to infuse disability inclusion into PSE changes promoting healthy living. Data on PSE implementation was collected and coded into categories to describe the nature of the inclusive PSEs.ResultsCommunities implemented 507 inclusive PSEs, 466 of which were environmental changes, 25 systems changes, and 16 policy changes. A large majority of PSEs were related to improving the built environment to facilitate access to public spaces, such as parks, playgrounds, and community gardens. Many communities also implemented policy and systems changes related to the addition of inclusion into existing policies, community plans, and ongoing training of staff.ConclusionIntegrating disability inclusion into traditional healthy communities efforts can facilitate improved access and opportunity for healthy living among people with disabilities. This pilot project has implications for public health workforce training, current practices, and PSE development with interdisciplinary teams and multisectoral coalitions.     

Does availability of physical activity and food outlets differ by race and income? Findings from an enumeration study in a health disparate region

ABSTRACT: BACKGROUND: Low-income, ethnic/racial minorities and rural populations are at increased risk for obesity and related chronic health conditions when compared to white, urban and higher-socio-economic status (SES) peers. Recent systematic reviews highlight the influence of the built environment on obesity, yet very few of these studies consider rural areas or populations. Utilizing a CBPR process, this study advances community-driven causal models to address obesity by exploring the difference in resources for physical activity and food outlets by block group race and income in a small regional city that anchors a rural health disparate region. To guide this inquiry we hypothesized that lower income and racially diverse block groups would have fewer food outlets, including fewer grocery stores and fewer physical activity outlets. We further hypothesized that walkability, as defined by a computed walkability index, would be lower in the lower income block groups. METHODS: Using census data and GIS, base maps of the region were created and block groups categorized by income and race. All food outlets and physical activity resources were enumerated and geocoded and a walkability index computed. Analyses included one-way MANOVA and spatial autocorrelation. RESULTS: In total, 49 stores, 160 restaurants and 79 physical activity outlets were enumerated. There were no differences in the number of outlets by block group income or race. Further, spatial analyses suggest that the distribution of outlets is dispersed across all block groups. CONCLUSIONS: Under the larger CPBR process, this enumeration study advances the causal models set forth by the community members to address obesity by providing an overview of the food and physical activity environment in this region. This data reflects the food and physical activity resources available to residents in the region and will aid many of the community-academic partners as they pursue intervention strategies targeting obesity.     

Primary Prevention for Resettled Refugees from Burma: Where to Begin?

Developing effective primary prevention initiatives may help recently arrived refugees retain some of their own healthy cultural habits and reduce the tendency to adopt detrimental ones. This research explores recent arrivals’ knowledge regarding eating behaviors, physical activity and sleep habits. Working collaboratively with community members, a healthy living curriculum was adapted and pilot tested in focus groups. A community-engaged approach to revising and implementing a health promotion tool was effective in beginning dialogue about primary prevention among a group of recently arrived refugees from Burma. Seven themes were identified as particularly relevant: food choices, living environment, health information, financial stress, mobility/transportation, social interaction and recreation, and hopes and dreams. Refugees desire more specific information about nutrition and exercise, and they find community health workers an effective medium for delivering this information. The outcomes of this study may inform future targeted interventions for health promotion with refugees from Burma.     

Contextualizing physical activity in rural adults: Do relationships between income inequality,neighborhood environments,and physical activity exist?

Objective

To examine if income inequality, social cohesion, and neighborhood walkability are associated with physical activity among rural adults.

Data Source

Cross-sectional data came from a telephone survey (August 2020–March 2021) that examined food access, physical activity, and neighborhood environments across rural counties in a southeastern state.

Study Design

Multinomial logistic regression models assessed the likelihood of being active versus inactive and insufficiently active versus inactive in this rural population. Coefficients are presented as relative risk ratios (RRRs). Statistical significance was determined using 95% confidence intervals (CIs). All analyses were performed in STATA 16.1.

Data Collection/Extraction Methods

Trained university students administered the survey. Students verbally obtained consent, read survey items, and recorded responses into Qualtrics software. Upon survey completion, respondents were mailed a $10 incentive card and printed informed consent form. Eligible participants were ≥18 years old and current residents of included counties.

Principal Findings

Respondents in neighborhoods with relatively high social cohesion versus low social cohesion were more likely to be active than inactive (RRR = 2.50, 95% CI: 1.27–4.90, p < 0.01), after accounting for all other variables in the model. Income inequality and neighborhood walkability were not associated with different levels of physical activity in the rural sample.

Conclusions

Study findings contribute to limited knowledge on the relationship between neighborhood environmental contexts and physical activity among rural populations. The health effects of neighborhood social cohesion warrant more attention in health equity research and consideration when developing multilevel interventions to improve the health of rural populations.     

Povl Heiberg's 1897 methodological study on the statistical method as an aid in therapeutic trials

ObjectiveTo examine the association between weight status and characteristics of the food and physical activity environments among adults in rural U.S. communities.MethodCross-sectional telephone survey data from rural residents were used to examine the association between obesity (body mass index [BMI] > 30 kg/m²) and perceived access to produce and low-fat foods, frequency and location of food shopping and restaurant dining, and environmental factors that support physical activity. Data were collected from July to September 2005 in Missouri, Arkansas, and Tennessee. Logistic regression models (N = 826) adjusted for age, education and gender comparing normal weight to obese respondents.ResultsEating out frequently, specifically at buffets, cafeterias, and fast food restaurants was associated with higher rates of obesity. Perceiving the community as unpleasant for physical activity was also associated with obesity.ConclusionAdults in rural communities were less likely to be obese when perceived food and physical activity environments supported healthier behaviors. Additional environmental and behavioral factors relevant to rural adults should be examined in under-studied rural U.S. populations.     

Assets, Challenges, and the Potential of Technology for Nutrition Education in Rural Communities

ObjectiveTo examine assets of and challenges to getting adequate nutrition and physical activity among low-income rural residents, and the potential for technology to provide health education.MethodsEnvironmental scans and community stakeholder interviews were conducted in 5 rural counties in Maryland. During environmental scans, stakeholders guided tours around each county to explore community services and resources for nutrition, physical activity and technology. In-depth interviews with stakeholders (n = 58) focused on nutrition, physical activity, and technology issues.ResultsLow-income residents both benefit from and face challenges in rural settings. Besides attitude and knowledge barriers, lack of affordable resources and public transportation contributed to inattention to nutrition and physical activity. Stakeholders' reactions to a proposed Internet-based intervention were mostly favorable, but questions emerged about providing computers and Internet to individual families.Conclusions and ImplicationsInternet-based education may be a viable option to help low-income rural residents overcome barriers to nutrition and physical activity.     

Perceptions of the Community Food Environment and Related Influences on Food Choice Among Midlife Women Residing in Rural and Urban Areas: A Qualitative Analysis

Introduction: Qualitative research on food choice has rarely focused on individuals' perceptions of the community food environment. Women remain gatekeepers of the family diet and food purchasing. Therefore we assessed midlife, Southern women's perceptions of the food environment. Related influences on food choices at work and at home were also examined.

Methods: We recruited 28 low- and moderate-income, midlife (37–67 years) women from rural and urban areas of southeastern North Carolina, using typical case and snowball sampling. They responded to questions about multilevel influences on food choice in semi-structured, in-depth interviews.

Results: Women perceived differences between urban and rural food environments, with rural areas having fewer supermarkets and fast food restaurants compared to urban areas, which had fewer produce stands. Workplace food choices were affected by the social environment (co-workers), personal health concerns, and the surrounding food environment. Food chosen at home was primarily influenced by family members, health concerns, and convenient food sources.

Discussion: While future studies should explore findings in more representative populations, potential intervention strategies can be inferred, including emphasizing healthful aspects of the food environment. Intervention and advocacy efforts are needed to improve aspects of the food environment that make healthy choices difficult.     

Sugar-Sweetened Beverage Consumption,Perceptions, and Disparities in Children and Adolescents

ObjectiveTo examine the association between sugar-sweetened beverage (SSB) perceptions—knowledge, attitudes, and norms and media literacy—and beverage consumption, and to identify differences in beverage consumption and SSB perceptions by race/ethnicity and socioeconomic status.DesignCross-sectional.SettingDiverse California school district.ParticipantsA total of 992 fifth-grade (elementary), seventh-grade (middle), and ninth–12th-grade (high school) students.Main Outcome MeasuresQuestionnaire-assessed continuous beverage consumption and perceptions.AnalysisLinear regression adjusting for school, grade, gender, race/ethnicity, and free and reduced-price meal (FRPM) eligibility.ResultsKnowledge, attitudes, and norms, and media literacy items were associated with SSB consumption in expected directions (P < 0.05). Among elementary students, FRPM-eligible and Black students had higher SSB consumption (P < 0.01). In middle/high school, non-Hispanic White students consumed fewer SSBs than all other racial/ethnic groups (P < 0.01). There were differences in SSB-related perceptions by race/ethnicity and socioeconomic status (eg, Black students perceived sugary drinks as less unhealthy); Black, Hispanic, and FRPM-eligible students expressed less distrust of food/beverage advertisements; and Black, Hispanic, Asian, multirace, and FRPM-eligible students perceived more frequent SSB consumption among their peers (P < 0.05).Conclusions and ImplicationsSugar-sweetened beverage perceptions were associated with SSB consumption. There were racial/ethnic and socioeconomic disparities in SSB consumption and perceptions. Sugar-sweetened beverage perceptions and related social and commercial determinants like marketing may be useful targets for reducing SSB consumption.     

Evaluation of a Policy,Systems, and Environmental-Focused Faith-Based Health Promotion Program

ObjectiveThis study assessed the impact and lessons learned from implementing policy, systems, and environmental (PSE) changes through Faithful Families Thriving Communities (Faithful Families), a faith-based health promotion program, in 3 southern states.MethodsFaithful Families classes and PSE changes were implemented through a coordinated effort between the Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program–Education (SNAP-Ed). Changes were measured using a faith community assessment, site reports, and annual reporting.ResultsThirteen faith communities participated in the intervention. A total of 34 PSE changes were implemented across the 3 states, affecting 11 faith communities with 4,810 members across sites.Conclusions and ImplicationsPrograms such as Faithful Families can allow EFNEP and SNAP-Ed to coordinate to implement PSE changes in community settings. However, these types of coordinated programs to support faith communities require time for relationship building and trust, adequate training, and strong support for faith-based lay leaders as they carry out this work.