The WAMI Rural Hospital Project. Part 6: Overview and conclusions.

The Rural Hospital Project (RHP) appeared to make a meaningful difference in the six Northwest rural communities that participated in this integrated community development and strategic planning effort. Although the methodological approach used in the evaluation precludes us from attributing observed changes in outcomes solely to the project interventions themselves, several elements of the process appear to be useful in stabilizing or expanding local health care systems. These include: (1) the involvement of outside organizations in fostering community change, (2) a high degree of community commitment and investment in all stages of the process, (3) comprehensive identification of problems in the health care system by outside consultants, (4) the use of periodic meetings of communities confronting similar issues, (5) identification and development of local leadership, (6) enhancing teamwork among local health care providers, and (7) the development of conflict-resolution mechanisms within health care organizations. Future attempts to use this strategy to strengthen rural health care systems can be enhanced by broadening the range of participation in health services planning, enlisting involvement of medical staff throughout the strategic planning cycle, addressing the issue of physician recruitment, and clarifying responsibility for implementation of community plans. Rural communities will predictably need to identify and resolve a set of core issues. To the extent that external organizations such as medical schools can strengthen the ability of rural health professionals and community leaders to identify and address these issues, the quality and viability of rural health care systems will be enhanced.     

The challenges associated with providing community care for people with complex needs in rural areas: a qualitative investigation

The aim of the present study was to explore the experiences of recipients and providers of community care in rural areas in Northern Ireland. Additionally, the authors sought to examine the impact of location, housing and environmental factors on the delivery of community care to older people with complex needs. Individual, semistructured interviews were held with service users (n = 17) and family carers (n = 14). Individual and focus group interviews were conducted with care assistants, health and social care professionals, and senior managers from a large health and social care trust and health and social services board in Northern Ireland. The importance of enabling older people to remain in their own homes and communities was emphasised by all participants. The main challenges associated with care provision in rural areas included: difficulties recruiting care assistants; lack of choice of care assistants; isolation; travel and distance between clients and their care assistants; and poor housing conditions. There was a general consensus among participants that the effectiveness of rural community care was perceived to be reliant upon the goodwill of the community. Additionally, changing demographic trends and the predicted shortfall in the number of formal and informal carers were considered key issues for service planners. A number of creative strategies could be used to address many of the limitations associated with rural isolation. These should involve capitalising on available community networks. However, planners should also acknowledge that additional resources are required to maintain older people in rural communities.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

The health service needs of small rural communities

ABSTRACT: In recent years econometric models used in health service planning have tended to encourage the downgrading or closure of small rural hospitals with the effect of reducing access to services and transferring costs from health authorities to consumers. These changes have occurred despite mounting evidence that people in rural communities have specific health service needs which require special attention. This study aimed to identify the perceptions of community members, health professionals and administrators regarding the health service needs in their small rural communities as a basis for developing a more comprehensive model of rural health service planning. Focus groups were held in three selected towns in Gippsland, exploring participants' perceptions of the meaning of health, health service needs, impact of health services, and the best set-up for health services. Consistent with previous research, key findings include: a broad conceptualisation of health; the perceived overwhelming importance of doctors, hospitals and chemists; the economic and social importance of a rural hospital; and a preference for all health services being provided under the one roof, funding and program flexibility, and local involvement in health service planning and implementation.     

Strengthening primary health care: building the capacity of rural communities to access health funding

ABSTRACT: Present health funding models can place onerous pressures on rural health services. Staff may lack the time, resources, access to data, and the expertise needed to complete complex and lengthy funding submissions. This present study describes an innovative capacity-building approach to working with Victorian rural communities seeking to access health care funding through the Regional Health Services Program. This approach used several strategies: engaging stakeholders in targeted rural communities, developing an information kit and running a workshop on preparing submissions to the Regional Health Services Program, facilitating community consultations, and providing ongoing support with submissions. Six rural communities were supported in this way. Four have been funded to date, with a combined annual recurrent budget for new primary health care services of over $2.5 million. Each community has developed a service delivery model that meets the particular needs of their local area. This capacity-building approach is both effective and replicable to other health funding opportunities.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

headspace: National Youth Mental Health Foundation: making headway with rural young people and their mental health

Mental health is the number one health issue affecting young people in Australia today, yet only one in four of these young people receive professional help. Approximately 14% of 12- to 17-year-olds and 27% of 18- to 25-year-olds experience mental health problems each year. However, many do not have ready access to treatment or are reluctant to seek that help. These issues might be exacerbated in the rural and remote regions of Australia where sociocultural barriers such as stigma, lack of anonymity and logistic difficulties including cost and availability of transport can hinder young people accessing mental health services. headspace: the National Youth Mental Health Foundation has been funded to address these issues. headspace will provide funding for the establishment of communities of youth services across Australia, provide national and local community awareness campaigns and plans, establish a centre of excellence that will identify and disseminate evidence-based practice in addressing youth mental health issues, and translate findings into education and training programs that are targeted at service providers to work with youth mental health. The communities of youth services will build the capacity of local communities to identify early, and provide effective responses to, young people aged 12-25 years with mental health and related substance use disorders. Specific approaches in rural, regional and remote areas will be developed as well as specific programs to involve young Indigenous people.     

上海农村围绝经期妇女健康状况及保健需求的分析

目的:了解农村社区40~55岁围绝经期妇女健康状况和保健服务需求,阐述在农村社区妇女中开展围绝经期保健的重要性和必要性,探讨在农村社区中开展围绝经期保健的适宜技术。方法:选择上海市嘉定区某社区40~55岁妇女1667人进行问卷调查,了解其健康状况、围绝经期相关保健知识知晓情况和保健服务需求。结果:48.59%的被调查者至少有一种及以上围绝经期相关症状。34.5%的被调查者对围绝经期综合征有认知。15.9%的有围绝经期症状妇女接受过医疗保健服务,其中到社区医院就诊的仅占13.4%,到妇科就诊的占70.1%,而其余的去内外科或精神科就诊。结论:①农村社区40~55岁妇女中将近半数有不同程度围绝经期综合征症状。②围绝经期妇女缺乏相关保健知识,不能及时就医及有乱投医情况。③社区围绝经期保健服务滞后。总之,在农村社区开展围绝经期妇女保健工作相当重要和必要,顺应农村妇女的需求,是妇女保健工作内涵的深入,也是社区六位一体功能的体现。     

Development of an integrated diabetes prevention program with First Nations in Canada

Type 2 diabetes mellitus is a major cause of morbidity and mortality among First Nations in Canada. We used multiple research methods to develop an integrated multi-institutional diabetes prevention program based on the successful Sandy Lake Health and Diabetes Project and Apache Healthy Stores programs. In-depth interviews, a structured survey, demonstration and feedback sessions, group activities, and meetings with key stakeholders were used to generate knowledge about the needs and resources for each community, and to obtain feedback on SLHDP interventions. First Nations communities were eager to address the increasing epidemic of diabetes. Educating children through a school prevention program was the most popular proposed intervention. Remote communities had poorer access to healthy foods and more on-reserve media and services than the smaller semi-remote reserves. While the reserves shared similar risk factors for diabetes, variations in health beliefs and attitudes and environmental conditions required tailoring of programs to each reserve. In addition, it was necessary to balance community input with proven health promotion strategies. This study demonstrates the importance of formative research in developing integrated health promotion programs for multiple communities based on previously evaluated studies.     

COMMUNITY COMPETENCE AND EMPOWERMENT: STRATEGIES FOR RURAL CHANGE IN WOMEN'S HEALTH SERVICE PLANNING AND DELIVERY

ABSTRACT: Rural women face a variety of health-related problems, some of which they share with their city sisters. However, the multiple responsibilities of women on the land, and their geographical isolation and lack of support, can lead to physical decline and increased mental strain. It is these factors which are often overlooked in the planning and allocation of funding and services to rural areas. This paper examines the application of community competence and empowerment measures in developing and implementing health services for women in rural Australian communities. A study conducted in the south-west region of Western Australia illustrates the ability of women within rural communities to identify and respond constructively to health issues of concern.     

Community participation in organising rural general practice: Is it sustainable?

OBJECTIVE: We analysed community participation in organising rural general medical practice in order to suggest ways to extend and sustain it. DESIGN: A multisite, embedded case-study design collecting data through semistructured interviews, non-participation observation and a document analysis. SETTING: One remote and two rural communities in Australia. PARTICIPANTS: Community members, GPs, health professionals, government officers and rural medical workforce consultants. RESULTS: High levels of community participation in recruiting and retaining GPs, organising the business model, and contributing to practice infrastructure were evident. Community participation in designing health care was uncommon. Participation was primarily to ensure viable general practice services necessary to strengthen the social and economic fabric of the community. There were factors about the decision-making and partnership processes in each of the communities that threatened the viability of community participation. CONCLUSIONS: We recommend that a concept of community development and explicit facilitation of the processes involved is necessary to strengthen participation, create effective partnerships and ensure inclusive decision-making.     

Ambulatory turning point and family home care: a gamble in public health

CONTEXT: Family caregivers are now considered an at-risk population in Canada. As hospital stays have been gradually reduced, family caregivers of the elderly are burdened with complex responsibilities. This change in care delivery was implemented with little consideration for services offered to this specific population. INTERVENTION AND DISCUSSION: The purpose of this study was to explore the perceptions of four groups of stakeholders towards services as determinants of health: family caregivers, professionals, community organizations and health care administrators. Focus groups (FG) were conducted (n=11 with 49 participants), followed by semi-structured interviews with key informants (n=29), in urban and rural areas. Results of content analysis were categorized according to the Donabedian model. Congruent perceptions between groups pinpointed the following: A limited accessibility of services, a lack of flexibility and coordination of services, a disregard for health promotion of caregivers and a lack of preventive services. Transportation problems and geographical distance to access services were specific to rural area. CONCLUSION: Results provide evidence-based data for public health. They suggest insights for the development of preventive interventions and services for this increasing at-risk population of family caregivers in Canada.     

'Shared Care - Shared Dream': Model of shared care in rural Australia between mental health services and general practitioners

OBJECTIVE: To identify a working model between rural and remote mental health services and the local GPs in Australia. DESIGN: Postal questionnaire to assess the GPs' satisfaction level with the involvement of the mental health services in their ongoing management of mentally ill in the community. RESULT: There was a greater sense of satisfaction with the mental health services over the five years this program was implemented. CONCLUSION: This study offers a model on how a rural mental health service could enter into a shared care program with the local GP practice and achieve a greater level of satisfaction in serving the rural communities in Australia.     

Empowering communities to remove the pump handle. An emerging role in epidemiology

PURPOSE: The epidemiologist's role in relation to the populations they study needs to be reconsidered in order to maximize the contribution of epidemiology to public health, and to balance science with social responsibility.METHODS: Historical analysis and a case study of community-based, collaborative epidemiology conducted in Eastern Virginia as the basis for identifying and improving child health outcomes.RESULTS: The origins of epidemiology in Snow's work on cholera provides a dynamic model of etiologic research combined with community intervention to prevent disease. While in past decades, epidemiology was excessively objectivist and focused on identifying individual-level risk factors, epidemiologists are now reclaiming a vital role in community health promotion. Yet the historic role of the epidemiologist, whether as the white knight who saves the community from an epidemic, or alternatively, as the remote scientist who studies populations but bears no responsibility for improving their health, is no longer viable. The emerging role is that of collaborator, a scientist working in partnership with communities. In Eastern Virginia, academic epidemiologists work closely with diverse community-based coalitions to assess child health needs, prioritize health problems, design and enact interventions, and monitor health outcomes. Diagnostic studies of child health outcomes, published in peer-reviewed journals and in community reports, have identified serious health needs in Eastern Virginia, e.g., under-immunization, attention deficit hyperactivity disorder, asthma, and adverse perinatal health indicators. Epidemiologic research is being used to guide interventions planned and enacted by the community, with evidence of improved outcomes in certain indicators.CONCLUSIONS: A vitally important, emerging role for epidemiologists in the 21(st) century is to empower communities to identify and effectively address their own health needs. Epidemiologic data not only evaluates health status, but should be used to guide community action.     

社区卫生服务培训需求评价

目的：研究社区卫生服务培训需求，方法：深入访谈与问卷调查相结合。共走访了成都和攀枝花市的卫生管理干部和社区医生18人，了解社区卫生服务开展状况，用分层定额抽样的方法抽取了3个成都市的社区，入户调查居民1041人，了解其卫生服务需求和利用情况，以及对社区卫生服务的态度。结果：社区卫生服务内容以常见病的诊疗为主，预防保健，计划生育等服务较少，且缺乏协调，社区卫生服务模式多样，社区医生与服务对象的关系及服务方式正在发生转变，社区医生未能完全适应此转变，医院对社区卫生服务的认识存在误区，社区卫生服务缺乏有效的激励机制，多数居民尚未能接受目前的社区卫生服务。结论：社区卫生服务培训应与社区卫生工作者的实践相结合，社区卫生服务培训应区阶段，分层次，有目的，有针对性地开展，培训对象应包括：管理干部，师资，社区医生和社区护士。     

Quitting smoking and experience of smoking cessation interventions among UK Bangladeshi and Pakistani adults: the views of community members and health professionals

OBJECTIVE: To explore attitudes to quitting smoking and experience of smoking cessation among Bangladeshi and Pakistani ethnic minority communities. DESIGN: Qualitative study using community participatory methods, purposeful sampling, interviews and focus groups, and a grounded approach to data generation and analysis. SETTING: Newcastle upon Tyne, UK, 2000-2002. PARTICIPANTS: 53 men and 20 women aged 18-80 years, including smokers, former smokers, and smokers' relatives, from the Bangladeshi and Pakistani communities; and eight health professionals working with these communities. RESULTS: Motivation to quit was high but most attempts had failed. "Willpower" was the most common approach to quitting. For some, the holy month of Ramadan was used as an incentive, however few had been successful in quitting. Perceived barriers to success included being tempted by others, everyday stresses, and withdrawal symptoms. Few participants had sought advice from health services, or received cessation aids, such as nicotine replacement therapy (NRT) or buproprion. Family doctors were not viewed as accessible sources of advice on quitting. Health professionals and community members identified common barriers to accessing effective smoking cessation, including: language, religion and culture; negative attitudes to services; and lack of time and resources for professionals to develop necessary skills. CONCLUSIONS: High levels of motivation do not seem to be matched by effective interventions or successful attempts to quit smoking among Bangladeshi and Pakistani adults in the UK. There is a need to adapt and test effective smoking cessation interventions to make them culturally acceptable to ethnic minority communities. UK tobacco control policies need to give special attention to the needs of ethnic minority groups.     

Identifying and overcoming the barriers to Aboriginal access to general practitioner services in Rural New South Wales

ABSTRACT: The Wiradjuri General Practitioners and Aboriginal Health Workers Project aimed to help improve Aboriginal health in central western New South Wales (NSW) by identifying and overcoming the barriers to the Aboriginal population's access to general practitioner services.
The central strategy of the project was to convene three rounds of consultative meetings in five towns: Bathurst, Orange, Cowra, Forbes and Condobolin. These meetings brought together Aboriginal community members, general practitioners and Aboriginal health workers to express and define local issues and problems, and to propose solutions.
The solutions included general practitioner outreach clinics, a focus on prewinter immunisation, bulk-billing of Aboriginal patients, Aboriginal cultural awareness training for all general practice personnel, employing Aboriginal staff in general practice, and closer professional interaction between general practitioners and Aboriginal health workers.
Most participants evaluated the meetings as positive and constructive. The project substantiates the perceived need for alternative models for the funding and delivery of general practitioner services to Aboriginal communities.     

REFLECTIONS ON NATIONAL RURAL HEALTH POLICY: THE 'BIG PICTURE' FRAMEWORK

ABSTRACT: A major concern of many rural and remote communities, as they struggle to cope with the impacts of social, economic and demographic changes, is the effect of government policies on health services. The National Rural Health Strategy has evolved as the key framework guiding action for improving health services for people in rural and remote Australia. The importance of maintaining an awareness of the 'big picture' of rural health remains paramount if interventions designed to bring about improved health status are to tackle the underlying causes of the problems, minimise problems associated with lack of co-ordination between health authorities, and avoid duplication of activity. Given the communality of rural health problems across Australia, close co-operation and collaboration among rural health groups is vital in developing appropriate national rural health policy. At the same time rural communities must continue to participate actively in the policy formulation and implementation process.