Perceptions of community leaders and the merger of rural health services

The merger of rural primary care and home health services offers the potential of increasing the administrative efficiency of health care, and thereby enhancing quality of care and increasing access to services, particularly health promotion. In a merger of rural health services in Northeastern Vermont, a survey of key community leaders revealed that improved organization of services, improved health status and greater accessibility of services were benefits expected and to some extent realized as a result of the merger process. The desire to preserve community-based services and having a common philosophy were important factors which served to initiate the merger. The actions of a few key individuals and the support of involved organizations were instrumental in continuing the process.Dr. Smith is an Assistant Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.Dr. Zuckerman is an Associate Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.This study was supported by a grant from the W.K. Kellogg Foundation (UHG0001L/RAD).     

Measuring quality of life in rural Uganda: reliability and validity of summary scores from the Medical Outcomes Study HIV Health Survey (MOS-HIV)

Purpose

Summary scores derived from the Medical Outcomes Study HIV Health Survey (MOS-HIV) are used to assess treatment impacts among HIV-infected patients in Western settings, but have yet to be validated in rural, African settings. We examined the reliability, validity and responsiveness of scores among a prospective cohort of 947 HIV-1-infected adults initiating antiretroviral therapy between May 2003 and May 2004 in rural Uganda.

Methods

Physical (PHS) and mental health (MHS) summary scores were developed from baseline MOS-HIV sub-domains using exploratory factor analysis. Construct and discriminant validity were established by comparing mean summary scores across known groups of sociodemographic, clinical and health status characteristics. Effect sizes were calculated to assess responsiveness to therapy.

Results

Reliability of the PHS and MHS scores was 0.79 and 0.85, respectively. Mean baseline PHS and MHS scores varied significantly by CD4 cell count, HIV viral load, WHO stage of disease and Karnofsky performance status scores. By 12?months on antiretroviral therapy, PHS and MHS scores improved by 14.6 points (P?P?Conclusions PHS and MHS scores can be derived from the MOS-HIV and used to assess health status among cohorts of patients taking antiretroviral therapy in rural Uganda.     

The Establishment of the School of Public Health at the State University of New York,Downstate Medical Center: The First Nationally Accredited School of Public Health in a Public University in New York City

The State University of New York (SUNY), Downstate Medical Center initiated a Master of Public Health (MPH) degree program in July 2001 following planning efforts that began in 1995. Twelve students entered the program in June 2002, and currently some 110 MPH students and 12 Doctor of Public Health (DrPH) students are enrolled. This article describes the long and complex process of transforming the original MPH degree program, with its single focus on urban and immigrant health, with a student enrollment of 12 and 8 full-time faculty, into a school of public health with a large student enrollment of 122 students, 25 full-time faculty, five MPH degree tracks, and four DrPH degree tracks. The process of establishing the SUNY Downstate School of Public Health in 2009 from its inception as an MPH program in 2001 spanned a period of 8 years. This process was guided by a commitment to two basic principles. The first was to maintain the original 2005 program accreditation by the Council on Education for Public Health (CEPH). The second was to sequentially secure accreditation for all subsequent four MPH and four DrPH degree tracks through CEPH’s procedure of substantive change approval. This policy assured continuous national CEPH accreditation of the original Urban and Immigrant Health MPH degree track and all added degree programs. The 5-year period following the initial CEPH accreditation of the MPH program in 2005 was one of intense development during which all of the essential elements for CEPH accreditation of a school of public health were put into place. This rapid development was made possible by the vision and full support of Downstate’s president, John C. LaRosa, MD, FACP, and the dedicated efforts of many. This included the students, faculty, staff, and administrators of the School of Public Health, the school’s Community Advisory Group, several external advisors, and many in the medical center’s Central Administration, College of Medicine, School of Graduate Studies, College of Nursing, College of Health Related Professions, and the University Hospital of Brooklyn. From the very beginning of the planning phase for an MPH program and through the ultimate accreditation of the School of Public Health in 2010, broad participation was solicited from all major units in the medical center. Thus, the MPH program became a center-wide initiative and not merely that of the College of Medicine’s Department of Preventive Medicine and Community Health. This broad participation has been continuously maintained through the involvement of leaders of other medical center academic units and the University Hospital of Brooklyn in the program’s and then the school’s standing and ad hoc committees, and in other activities as well. Similarly, community representation has been maintained, some through formal linkages relevant to the practical field experiences required of all students. In October 2010, the Board of Councilors of CEPH accredited the SUNY Downstate School of Public Health for a 5-year period through 31 December 2015. The accreditation of the school was a major milestone for Downstate, Brooklyn, and New York City. The SUNY Downstate School of Public Health is the first CEPH accredited school of public health in the history of Brooklyn, and only the second such school in New York City. It is also the first CEPH accredited school of public health at a publicly supported university in New York City. The school has already had a major impact on improving the health and well-being of the people of Brooklyn through its numerous collaborative community-based health promotion and disease prevention programs.     

Assuring public health professionals are prepared for the future: the UAB public health integrated core curriculum

In response to calls to improve public health education and our own desire to provide a more relevant educational experience to our Master of Public Health students, the University of Alabama at Birmingham (UAB) School of Public Health designed, developed, and instituted a fully integrated public health core curriculum in the fall of 2001. This curriculum combines content from discipline-specific courses in biostatistics, environmental health, epidemiology, health administration, and the social and behavioral sciences, and delivers it in a 15 credit hour, team-taught course designed in modules covering such topics as tobacco, infectious diseases, and emergency preparedness. Weekly skills-building sessions increase student competence in data analysis and interpretation, communication, ethical decision-making, community-based interventions, and policy and program planning. Evaluations affirm that the integrated core is functioning as intended: as a means to provide critical content in the core disciplines in their applied context. As public health education continues to be debated, the UAB public health integrated core curriculum can serve as one model for providing quality instruction that is highly relevant to professional practice.     

Pediatric Telepsychiatry in Ontario: Caregiver and Service Provider Perspectives

Families in rural areas face significant geographic and economic obstacles to obtaining pediatric mental health services. Telepsychiatry promises the possibility of extending specialized expertise into areas that have no resident psychiatrists. In this study, user perspectives and experiences of a pediatric telepsychiatry program serving rural communities in Ontario, Canada, were explored. Qualitative, exploratory methods were utilized because of the complex nature of mental health services needs and provision in rural communities. Focus groups with rural mental health service providers and interviews with family caregivers of children receiving a telepsychiatry consultation were conducted. The purpose of this research was to evaluate the benefits and limitations of providing pediatric psychiatric services via video-technology to inform future program development and health policy. Whereas participants in the study indicated that their experiences with the telepsychiatry service had been positive, the need for additional local services to support treatment recommendations was emphasized. Natasha Greenberg, MA, Community Health Systems Resource Group, The Hospital for Sick Children, Department of Public Health Sciences, University of Toronto, 555 University Avenue, Toronto, ON M6G 1X8, Canada. Tiziana Volpe, MSc, Community Health Systems Resource Group, The Hospital for Sick Children, Department of Public Health Sciences, University of Toronto, 555 University Avenue, Toronto, ON M6G 1X8, Canada.     

EMPLOYMENT AND HEALTH INSURANCE COVERAGE FOR RURAL LATINO POPULATIONS

Rural Latino populations continue to grow in part due to relocation of food processing industries to rural America along with other manufacturing and large retail stores. We use data from the Current Population Survey to examine the labor force participation of rural Latino population and the role rural employers play in providing health insurance coverage. We found that while rural Latinos are more likely to be uninsured, the meat packing industry has higher health insurance coverage rates than other rural employers such as construction and retail. Local communities recruiting new businesses to their rural communities need to explore the role that employers will play in providing health insurance coverage. Lack of adequate coverage will have an impact on the income, resources, and day-to-day activities of physicians, hospitals and traditional safety net providers.Lynn A. Blewett, PhD is Associate Professor in the Division of Health Services Research and Policy, School of Public Health, University of Minnesota and Director of the State Health Access Data Assistance Center (SHADAC), a research policy center supported by a grant from the Robert Wood Johnson Foundation. Michael Davern, PhD is Assistant Professor in the Division of Health Services Research and Policy, School of Public Health, University of Minnesota and Research Associate with SHADAC. Holly Rodin, MPA is a Research Assistant with SHADAC     

UNC certificate program in core public health concepts: lessons learned.

OBJECTIVES: Public health workers need to be trained in the core public health sciences. The University of North Carolina at Chapel Hill School of Public Health created a Certificate in Core Public Health Concepts to meet the training needs of public health workers, primarily those working in state or local public health agencies. METHODS: This article examines the demographic, educational, job classification, and workplace characteristics of certificate program applicants from the first 3 years of the program. In addition, this article assesses student performance and graduate satisfaction with the program. RESULTS: Among the 273 applications reviewed, the majority were from females. They worked in a variety of job classifications: 19% were public health agency workers, 64% were public health system workers, and 17% worked in other occupations. Nearly all students received High Pass or Pass grades on courses. Initial data on graduate satisfaction with the program are positive. CONCLUSIONS: Implications of the findings for training the public health workforce are discussed.     

Team Epi-Aid: graduate student assistance with urgent public health response

Team Epi-Aid provides graduate students with practical public health experience through participation in outbreak investigations and other applied projects with state and local health departments in North Carolina. It is an initiative of the North Carolina Center for Public Health Preparedness in the North Carolina Institute for Public Health at the University of North Carolina School of Public Health. The program allows state and local health departments access to volunteers and technical expertise from the university when they need assistance. It requires close collaboration with state and county health departments. Team Epi-Aid provides the opportunity for integrated learning with students and faculty within the departments of the School of Public Health, and through recent expansion, within the schools of Medicine and Pharmacy. Orientations are conducted each semester and formal training is provided as needed. Team Epi-Aid has been popular, with 58 active student participants contributing 1,465 hours of service during the initiative's first 21 months.     

Challenges in Evaluating Rural Health Programs

Complex community-based prevention programs are being held to scientific evidence of their effectiveness and rural public health departments that implement such programs often are not equipped to evaluate them. Rural public health departments are fettered by small budgets, small staffs, and less access to evaluation experts and similar resources. Community-based health promotion programs can include complex designs that may work differently in rural areas and evaluation of rural programs can be hampered by lack of control groups and the instability of results from small populations. The University of Kentucky has entered into a contract with the state Department for Public Health to implement an internal, participatory model of evaluation. In this model, the university evaluation expert trains local public health department staff in technical skills for program evaluation and acts as mentor and technical consultant to local public health departments on an ongoing basis. Through training and site visits, this model is one approach to addressing the challenges of evaluating rural health promotion programs.     

Defining Urban and Rural Areas in U.S. Epidemiologic Studies

Among epidemiologists, there has been increasing interest in the characteristics of communities that influence health. In the United States, the rural health disparity has been a recent focus of attention and made a priority for improvement. While many standardized definitions of urban and rural exist and are used by social scientists and demographers, they are found in sources unfamiliar to health researchers and have largely not been used in public health studies. This paper briefly reviews some available definitions of urban and rural for American geographic subunits and their respective strengths and weaknesses. For example, some definitions are better suited than others for capturing access to health care services. The authors applied different definitions to breast cancer incidence rates to show how urban/rural rate ratio comparisons would vary by choice of definition and found that dichotomous definitions may fail to capture variability in very rural areas. Further study of the utility of these measures in health studies is warranted. Hall and Kaufman are with the Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Ricketts is with the North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Hall is currently with Worldwide Epidemiology, GlaxoSmithKline, P.O. Box 13398, Five Moore Drive, Research Triangle Park, NC 27709-3398, USA.     

film review of the month: Children in the Hospital

Produced and filmed by Edward A. Mason, M.D., assistant professor of mental health, Harvard University School of Public Health. Made with the cooperation of Boston University School of Social Work, Children's Mission to Children, Harvard School of Public Health, and National Institute of Mental Health.     

Environmental justice research and action: a case study in political economy and community-academic collaboration

Community-university partnerships increasingly are being created to study and address environmental injustices. This article describes a case study of one such effort and its contributions to a decade-long community struggle to curb the growth of industrial hog operations and their adverse health effects in the United States' rural south. Worldwide transformation of livestock production from family farms to large-scale industrial agricultural complexes has resulted in the degradation of local environments, with negative impacts on public health. In the rural south, the concentration of industrial livestock operations has been most pronounced in low income African-American communities. Using political economy and community-based participatory research (CBPR) as a conceptual framework, this article explores the partnership between a strong community-based organization, Concerned Citizens of Tillery, and researchers at the University of North Carolina, Chapel Hill, School of Public Health to study and address this problem. The political, economic, and historical context of the partnership is examined, as are the challenges faced, and the partnership's contributions to maintaining grassroots community organizing and activism and affecting local policy change. Implications for other CBPR partnerships are discussed.     

Educational and health services innovation to improve care for rural Hispanic communities in the US

BACKGROUND: Access to comprehensive and quality health care services is difficult for socioeconomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisciplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as Promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural health care initiatives targeting minority groups. This paper reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.     

Educational and health services innovation to improve care for rural Hispanic communities in the USA

BACKGROUND: Access to comprehensive and quality healthcare services is difficult for socioeonomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina, USA, is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations, in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural healthcare initiatives targeting minority groups. This article reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.     

In-country and community-based postgraduate family practice training for Micronesian physicians--the Palau AHEC: a collaborative effort

The U.S. Institute of Medicine in its 1998 review of the health care systems among the U.S.-Associated Pacific Islands (USAPI) identified promotion of primary health care (PHC) and training of the regional health workforce including postgraduate training for physicians as priorities. With the support of the health leadership of the USAPI and the Republic of Palau, the John A. Burns School of Medicine (JABSOM) of the University of Hawaii captured U.S. federal Area Health Education Center (AHEC) funds to implement a postgraduate program to train Family Practitioners - physician specialists in primary care for the region. The Palau AHEC has evolved into ajoint activity of JABSOM, the University of Auckland Faculty of Medicine and Health Sciences (UAFMHS), the School of Public Health & Primary Care--Fiji School of Medicine, and Palau Community College to provide Diploma-level training in Family Practice and Community Health for Micronesian physicians.     

Teaching community-oriented primary care (COPC): A practical approach

To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the University of California's School of Public Health in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. The School of Public Health designed a COPC track for graduate public health students from various departments of the school who wished to work in community health care. The track includes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty advisor and a clinic preceptor design COPC projects for the primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork requirement. This paper is a report of the first year's experience with this collaborative effort.Emilie H.S. Osborn, M.D., M.P.H. is Assistant Professor, Family and Community Medicine, University of California at San Francisco. Norman Hearst, M.D., M.P.H. is Assistant Clinical Professor, Clinical Epidemiology and Family and Community Medicine, University of California at San Francisco. Joyce C. Lashof, M.D., is Dean, School of Public Health, University of California at Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School of Public Health, University of California at Berkeley.This project has been supported in part with Federal funds from the Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Public Health Service, under contract #240-84-0124. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services.     

NEW APPROACHES TO EDUCATING SOCIAL WORK PROFESSIONALS FOR ADMINISTRATIVE ROLES IN A NATIONAL HEALTH SYSTEM

As national health insurance becomes a reality we can anticipate a shift in emphasis from delivery of acute in-hospital care to community-based care. Professional social work functions in the future will likely be increasingly directed toward the administration and management of supportive health care services. This paper describes an interdisciplinary graduate educational program in administration and management of social health care services, developed by the School of Social Work jointly with the Maxwell School of Citizenship and Public Affairs at Syracuse University and the Upstate Medical Center in Syracuse. The curriculum is designed to train future social work professionals in planning, evaluation, and managerial skills necessary to perform middle-management and decision-making functions. The curriculum is provided by an interdisciplinary faculty team, and implemented with a task-oriented problem-solving approach. The program is in its 3rd year and hsa graduated 20 students.     

Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

BackgroundIn low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations.MethodsA review of the published literature using mainly the Medline and Science Direct databases for the 1990–2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia.ResultsIn these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public–private partnerships.ConclusionThe type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public–private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.     

Practicing management and leadership: creating the information network for public health officials.

The Management Moment" is a regular column within the Journal of Public Health Management and Practice. Janet Porter, PhD, and Edward Baker, MD, MPH, MSc, are serving as The Management Moment Editors. Dr Porter is Associate Dean for Executive Education, The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill, and Dr Baker is Director of The North Carolina Institute for Public Health, School of Public Health, at the University of North Carolina at Chapel Hill. This column provides commentary and guidance on timely management issues commonly encountered in public health practice.