Appropriate training and retention of community doctors in rural areas: a case study from Mali

Background  

While attraction of doctors to rural settings is increasing in Mali, there is concern for their retention. An orientation course for young practicing rural doctors was set up in 2003 by a professional association and a NGO. The underlying assumption was that rurally relevant training would strengthen doctors' competences and self-confidence, improve job satisfaction, and consequently contribute to retention.     

Evaluation of an ultrasound program (intermediate obstetric and emergency medicine) for Australian rural and remote doctors

INTRODUCTION: This paper describes the evaluation of an intermediate obstetric ultrasound and emergency medicine ultrasound education workshop for rural and remote Australian doctors, which was developed in response to an educational needs assessment that showed an unmet need in this area. The workshop was held in four Australian states. The participants were 61 rural and remote doctors. METHODS: Data from pre- and post-workshop knowledge tests and general workshop evaluation were analysed. RESULTS: Sixty-one doctors attended an ultrasound workshop and self-reported increases in knowledge, confidence and expertise in ultrasound. The mean pretest score for 56 doctors who completed both the pre- and post-workshop knowledge tests was 31.6 and the post-test score mean was 33.3 out of a possible score of 44, which demonstrated a statistically significant increase in knowledge (P = 0.003). DISCUSSION AND IMPLICATIONS FOR PRACTICE: The evaluation of the workshop demonstrated that it was an effective way of increasing knowledge and confidence in intermediate obstetric ultrasound and emergency medicine ultrasound. The workshop was popular and received very positive feedback from the attendees.     

Reproductive tract infection: an experience in rural West Bengal

A community based cross-sectional study was conducted in the villages of Singur block, Hooghly district, West Bengal during September 2000 to February 2001. The objectives of the study were to find out the magnitude of Reproductive Tract Infections (RTI) among reproductive age group women, their knowledge about RTI and utilization of service available locally. Out of an estimated 896 women of reproductive age group in the study area, 186 women were selected by multistage random sampling technique. The study revealed that 66.1% respondents experienced one or more symptoms of RTI in four weeks recall period of this study. There was significant association (p < 0.01) between literacy status and their experiences of reproductive illness. 57% had knowledge about RTI. This increased gradually with increase of their ages (p < 0.01); literacy status (p < 0.01) and their socio-economic condition (p < 0.05). 27.6% of RTI patient did not receive any treatment, and majority of those received treatment (41.5%) sought advice from private practitioners.     

Work of female rural doctors

Objectives: To identify the impact of family life on the ways women practice rural medicine and the changes needed to attract women to rural practice.
Design: Census of women rural doctors in Victoria in 2000, using a self-completed postal survey.
Setting: General and specialist practice.
Subjects: Two hundred and seventy-one female general practitioners and 31 female specialists practising in Rural, Remote and Metropolitan Area Classifications 3–7. General practitioners are those doctors with a primary medical degree and without additional specialist qualifications. Main outcome measure: Interaction of hours and type of work with family responsibilities.
Results: Generalist and specialist women rural doctors carry the main responsibility for family care. This is reflected in the number of hours they work in clinical and non-clinical professional practice, availability for oncall and hospital work, and preference for the responsibilities of practice partnership or the flexibility of salaried positions. Most of the doctors had established a satisfactory balance between work and family responsibilities, although a substantial number were overworked in order to provide an income for their families or meet the needs of their communities. Thirty-six percent of female rural general practitioners and 56% of female rural specialists preferred to work fewer hours. Female general practitioners with responsibility for children were more than twice as likely as female general practitioners without children to be in a salaried position and less likely to be a practice partner. The changes needed to attract and retain women in rural practice include a place for everyone in the doctor's family, flexible practice structures, mentoring by women doctors and financial and personal recognition.     

Paradox in treatment seeking: an experience from rural Sri Lanka

Sri Lanka has had a pluralist health care system for centuries, in which Western biomedicine coexists with the Ayurveda system. However, recent studies suggest a declining trend in the use of the Ayurveda system. This study provides insights into the reasons for the low utilization of the Ayurveda system at present. The study findings reveal that low utilization of the Ayurveda system can be attributed to several factors, including the quick effect of Western medicines, the perception of being accustomed to Western medicines, a lack of competent Ayurveda practitioners, the high cost and low quality of Ayurveda medicines, and the rapidly changing lifestyles of villagers. However, for certain conditions such as fractures, snakebite, and paralysis, the majority of the Sri Lankan population still uses Ayurveda treatment. In conclusion, we suggest that health authorities should take into account these changes for future health planning in Sri Lanka.     

Obstetric outcomes in a rural family practice: an eight-year experience

There has been debate in some quarters of whether family physicians should do obstetrics and of whether rural hospitals should provide obstetric services. Forks, Washington, is a remote logging town where family physicians and midlevel practitioners have been the sole providers of labor and delivery services. Forks offers an opportunity to evaluate the quality of an isolated rural family practice obstetric service. A retrospective audit of all labor and delivery patient charts at Forks Community Hospital from 1975 to 1983 was undertaken; 1,052 charts were abstracted with 36 factors of morbidity, mortality, and intervention examined. The results, when compared with similar studies in the literature, provide evidence of good performance. In addition, a relatively high-risk obstetric population was served with favorable outcomes. Family physicians and rural hospitals can provide high-quality obstetrical services.     

Nutrient adequacy and dietary diversity in rural Mali: association and determinants

OBJECTIVE: To examine the association between nutrient adequacy and dietary diversity, and to assess and compare the determinants for the two constructs in an adult population in rural Mali. DESIGN: Cross-sectional study assessing food intake by a validated 7-day quantitative food frequency questionnaire. Two different dietary diversity indexes were created: food variety score (FVS), a simple count of food items, and diet diversity score (DDS) a count of food groups. Mean adequacy ratio, the mean ratio of intake to recommended intake (each truncated at one) of energy and nine nutrients, was calculated as an indicator of nutrient adequacy. Information on household and individual characteristics, including demography, socioeconomic conditions and food production strategies was obtained using precoded questionnaires. SETTING: Bafoulabé district, Kayes region, Western Mali. SUBJECTS: In total, 502 subjects (55% women) aged 15-45 y from 319 different households. RESULTS: Both FVS and DDS had a positive correlation with mean adequacy ratio (MAR). Multivariate analysis (linear regression) showed that the most important factors explaining MAR was the number of milk products, vegetables and green leaves consumed, as well as sex and the number of crops produced in the household. Dietary diversity was associated with socioeconomic status, residence and age. CONCLUSION: Dietary diversity is useful as an indicator of nutrient adequacy. It is important to examine how various food groups contribute to the nutrient adequacy of the diet in an area.     

Ten years experience in Mali community health centers

At the end of 10 years' existence, the community health centres of Mali show a way of organisation which meets the public health requirements and demands of financial viability of any health establishment. Their originality lays in several factors: their legal personality, their private status, their financial support of the medical staff, their management by a users association and the public utilities agreement they have signed with the department. In spite of their success which makes their numbers reach 350, they suffer from great deficiencies, which are resulted by the lack of democratic traditions within the associations, a inappropriate transparency of their accounts and an inefficient supervision from the part of the department. The main questions posed by this new experience concern the limits of the concept of community, the importance of citizenship in the development dynamics, the participation of private institutions in the accomplishment of public utilities, the jacobin and authoritarian attitude of the department representatives, the contradictions between multiplication of centres to improve geographic access and the requirements of financial viability.     

Devolution and human resources in primary healthcare in rural Mali

Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. The key question of this article is: what does devolution mean for human resources for health in Mali? This article assesses the key advantages and dilemmas associated with devolution such as responsiveness to local needs, downward accountability and health worker retention. Challenges of politics and capacities are also addressed in relation to human resources for health at the local level. Examples are derived from experiences in Mali with a capacity development programme and from case studies of other countries. It is not research findings that are presented, but highlights of key issues at stake aimed at inspiring the debate in Mali and elsewhere. A first lesson from the discussion suggests that in the context of human resources for health, decentralization of authority and resources is not the main issue. The challenge is to develop or strengthen accountability of those who decide and act, whether they are local politicians, bureaucrats or community representatives. If decentralization policies do not address public accountability, they will not fundamentally change human resource management, quality and equity of staffing. A second lesson is that successful devolution requires innovations in capacity development of all actors involved and in designing effective incentive measures. A final key conclusion is that the topic of devolution policy and its effects on human resources for health, and vice versa, merit more attention. A better understanding may lead to more appropriate policy designs and better preparation for the actors involved in countries that are embarking on decentralization, as is the case in Mali.     

乡村医生卫生适宜技术培训意愿及影响因素

目的了解辽宁省乡村医生参与农村卫生适宜技术培训的意愿及其相关影响因素。方法采用自填式问卷调查方法,随机抽取辽宁省6县3933名乡村医生进行基本情况和参加农村卫生适宜技术培训的意愿调查。结果有3846名乡村医生愿意参加适宜技术的培训,占97.79%,其中在2007年培训1～3次1809人,占98.37%;>3次1708人,占98.44%,与虽未培训但愿意参加培训的329人(占91.64%)比较,差异有统计学意义(P<0.05);对工作总体评价满意、在新农合定点卫生室工作、认为适宜技术推广必要并愿意参加推广是乡村医生参加适宜技术培训的积极因素。结论农村卫生适宜技术培训应择优选择培训对象,并要有针对性地制定出相应的管理和政策措施,以提高乡村医生参加培训的积极性。     

Estimation of the impact of the principal diseases in rural Mali

The authors assess the health impact of major diseases in the circles of Kita, Bafoulabé and Kenieba (Western Mali) by measuring, for each of them, the number of healthy days of life lost through illness, disability and death. Malaria, birth diseases, infant gastro-enteritis and pneumopathies, measles, malnutrition and hemoglobinopathies account for 58.1% of healthy life lost due to all studied diseases. Parasitic diseases (except malaria), tuberculosis, leprosy are less important than usually said; on the contrary, the impact of hepatic, cardiovascular, and eyes diseases is great. In developing countries assessing the number of healthy days lost by the community due to different diseases is usefull to choose the health priorities and to compare the cost/effectiveness ratio of different health programs.     

靖江市乡村医生的现状调查与对策研究

目的：通过对靖江市乡村医生队伍的现状调查,探讨目前靖江乡村医疗卫生工作中存在的问题,提出培养和建设靖江乡村医生队伍的对策。方法：采用回顾性分析及问卷调查的方法对靖江市乡村医生进行调查。调查内容为基层医生的年龄、学历、收入和保障等情况。结果：靖江市乡村医生队伍老龄化现象严重,学历偏低,知识陈旧。结论：需要提高乡村医生的地位和待遇,加强在职培训与管理,吸引各类医务人才。     

North-South exchange and professional development: experience from Mali and France

BACKGROUND: Developing countries are facing the challenge of developing a family practice culture in a context in which clinical practice remains strongly associated with hospital practice. To what extent can professional exchange between GPs from North and South fuel novel professional identities in family practice? OBJECTIVES: Assess to what extent a North-South professional exchange programme involving rural GPs from Mali and France affected practice development and professional identity formation of Malian GPs. METHODS: Qualitative analysis of 19 exchanges between rural GPs from Mali and France based on (i) interviews; (ii) retrospective report analysis; (iii) field observation of three exchanges; (iv) workshop with Malian GPs; and (v) workshop with French GPs. RESULTS: Malian GPs reported increased self-esteem, increased concern for doctor-patient communication and innovations in practice organization. Although Malian participants considered a transfer from France's general practice irrelevant, the experience was thought provoking. The interpersonal and professional interaction was crucial. The Malian Rural Doctors Association provided a platform to capitalize on individual experiences in a process of collective professional identity construction. Costs of the programme were kept low, limiting possible side expectations of participants. CONCLUSIONS: North-South professional exchange can contribute to professional development. Exchange programmes should be designed as mutual learning processes, rather than unilateral assistance or transfer of practice models. Southern family practitioners are likely to improve primary care to individuals and families, while Northern GPs can draw lessons from the community perspective of primary health care in the South. Recruitment and preparation of participants are crucial, as well as collective reflection upon return.     

Treatment with phenobarbital and monitoring of epileptic patients in rural Mali

OBJECTIVE: To assess the efficacy of phenobarbital treatment for epileptic patients in rural Mali. METHODS: Epileptic patients were treated at home with phenobarbital at daily dosages ranging from 50 mg for children to 200 mg for adults and their condition was monitored. Advice was given to patients, their families, and the village authorities in order to achieve compliance. An uninterrupted supply of generic phenobarbital was provided and a rural physician made two follow-up visits to each village to ensure that the drug was taken in the correct doses. The physician gave information to the population, distributed the phenobarbital in sufficient quantities to cover the periods between visits, and monitored the patients' responses to treatment. During the first year the physician visited the patients every two months. The frequency of visits was subsequently reduced to once every four months. FINDINGS: In the six months preceding treatment the average rate of seizures among patients exceeded four per month. After a year of treatment, 80.2% of the patients experienced no seizures for at least five months. A total of 15.7% of patients experienced a reduction in seizures. In many cases no further seizures occurred and there were improvements in physical health, mental health and social status. There were very few side-effects and no cases of poisoning were reported. The cost of treatment per patient per year was 7 US dollars for generic phenobarbital and 8.4 US dollars for logistics. CONCLUSION: Low doses of phenobarbital were very effective against epilepsy. However, there is an urgent need for programmes involving increased numbers of physicians in rural areas and, at the national level, for the inclusion of epilepsy treatment in the activities of health care facilities. Internationally, an epilepsy control programme providing free treatment should be developed.     

Barriers to the utilization of maternal health care in rural Mali

This study used data from the 2001 Demographic and Health Survey and multilevel logistic regression models to examine area- and individual-level barriers to the utilization of maternal health services in rural Mali. The analysis highlights a range of area-level influences on the use made of maternal health services. While the dearth of health facilities was a barrier to receipt of prenatal care in the first trimester, transportation barriers were more important for four or more prenatal visits, and distance barriers for delivery assistance by trained medical personnel and institutional delivery. Women's odds of utilizing maternal health services were strongly influenced by the practices of others in their areas of residence and by living in close proximity to people with secondary or higher education. Household poverty and personal problems were negatively related to all outcomes considered. The results highlight the importance of antenatal care and counseling about pregnancy complications for increasing the likelihood of appropriate delivery care, particularly among women living 15-29 km from a health facility. Area-level factors explained a greater proportion of the variation in delivery care than in prenatal care However, significant area variation in the utilization of maternal health services remained unexplained.     

Long-term care experience in an internal medicine residency program

OBJECTIVES: To assess the impact of long- term care experience on internal medicine residents through prequestionnaires and postquestionnaires. DESIGN: A prospective study conducted from February 1999 to March 2000. SETTING: "Daughters of Israel," a 300-bed, long-term care institution in West Orange, New Jersey. PARTICIPANTS: Twenty-five 3rd-year medical residents (PGY3) from Saint Barnabas Medical Center, Livingston, and Newark Beth Israel Medical Center, Newark, New Jersey, who each rotated in a long-term care setting. INTERVENTION: Medical residents completed validated questionnaires before and after their rotation. MEASUREMENTS: The questionnaire integrated three subcategories: self-reported skills, knowledge, and attitudes.RESULTS: Self-reported skills in performing: (a) Histories and physicals increased from mean of 3.65 to 4.48 (1 = low; 5 = high). P < 0.0005; (b) Functional assessment from mean of 3.47 to 4.53, P < 0.0005; and (c) Advance directive discussion from 3.78 to 4.37, P < 0.0005. All self-reported measures of knowledge in geriatrics increased significantly. All self-reported measures of attitudes toward the elderly also improved significantly. Career choice of geriatrics was not significantly altered by this experience. CONCLUSIONS: There was improvement in self-reported skills, knowledge, and attitudes for medical residents completing a rotation in the nursing home. These conclusions were based on validated questionnaires and prospective data. Our results support recommendations by the American Medical Directors Association (AMDA)the American Geriatric Society (AGS) to include the long-term care setting as a site for the geriatric education of medical residents.