The pioneers of rural Pakistan: The lady health visitors

Since 1978, when the World Health Organization and the United Nations International Children's Emergency Fund called for urgent action by all governments to provide appropriate health care for the underprivileged, the world community has attempted to implement primary health care strategies. Pakistan, with a population of 118 million people, is one of those countries where the rural population and the underprivileged groups in the katchi‐abadis (squatter settlements) of the urban areas lack appropriate and accessible health services. This article highlights the community experiences of a remarkable group of young Muslim women, the Lady Health Visitors (LHVs) of the Aga Khan Health Services, who deliver primary health care services to disadvantaged women and children in the northern mountainous areas and rural villages of Pakistan. The LHVs are the first contact with the health care system that these underprivileged women experience. The LHVs cure, care, teach, and train traditional birth attendants. In addition, they perform health promotion and document their findings. To provide their maternal and child health services, the LHVs travel by foot through miles of rough terrain to settlements and villages. Prenatal and postnatal care, anemia, diarrhea, and malnutrition are among the major health care problems of these rural women and their children under 5 years of age.     

International Perspective: RURAL NURSING IN THE UNITED STATES: WHERE DO WE STAND AS WE ENTER A NEW MILLENNIUM?

ABSTRACT: Approximately one-fourth of all Americans live in rural communities; and, of the 50 States, 31 have more than 60% of their counties designated as rural. No matter what indicator is used, United States residents in non-metropolitan areas have less than metropolitan counterparts (e.g. per capita income, health status, access to care, level of education and employment opportunities) and are more likely to need help from human services and health professionals. Additionally, rural people often must confront unique obstacles not experienced by most urban residents to access those services. As nurses live and work in rural communities they, too, must be aware of and contend with similar factors in their practice settings. In some ways rural nursing practice has changed dramatically over the last decade but in other ways things remain much the same. This article will examine common nursing issues associated with caring for clients in a rural environment. The information in this article is based on a review of the literature and the author's personal and professional nursing experiences.     

转型期萝岗区社区护理管理的难点及对策

目的探讨萝岗区内3家社区卫生服务中心在由医院统筹管理的模式转变为独立法人单位的过程中由此带来的社区护理管理方面的难点,并提出相应的对策。方法回顾性总结和分析转型期萝岗区社区护理管理工作中的难点问题。结果转型期萝岗区社区护理管理工作存在以下的问题:人才培训不到位,缺乏完善的社区护理质量考评制度,社区护理安全意识薄弱。结论通过加强社区护理人才的培训,建立完善的社区护理考核评价体系,树立社区护理安全意识,提高了社区卫生服务机构的服务能力,满足了广大群众基本的医疗护理服务需求。     

Indigenous Peoples,settler colonialism,and access to health care in rural and northern Ontario

In Canada rural and northern communities, particularly Indigenous communities, face challenges disproportionate to their urban counterparts in accessing health care services. Existing health research on rural communities has tended to emphasize and reinforce the rural/urban dichotomy in access to and delivery of services, leaving the notion of “rural” as an under-interrogated concept. Drawing on a qualitative study of health care providers, community members, and Indigenous Elders, we explore Indigenous people's beliefs about vaccination to complicate notions of rurality in order to illuminate the ways in which space and settler colonialism both shape and limit choices around health care access.     

非公有制社区卫生服务机构参与公共卫生服务补偿机制研究

目的调查珠海市非公有制卫生服务机构参与公共卫生的基本情况,总结政府补偿的经验。方法采用描述性统计分析方法,对珠海市非公有社区卫生服务中心(站)、农村卫生站和医疗机构提供公共卫生服务的种类与数量及补偿情况进行了分析。结果 (1)非公有制社区卫生服务中心开展了6大项公共卫生服务全部项目,所有农村卫生服务机构基本上只开展公共卫生中的医疗项目及很少的预防服务,非公有制医院参与6大项公共卫生服务部分项目,但工作量极少仅占总量的3.42%,未参与预防服务。但都参与了突发性公共卫生事件处理如禽流感、非典和三聚氰氨奶粉等检查、治疗和预防。(2)政府对城市社区开展公共卫生服务的情况进行了部分补偿,补偿幅度与公有社区相当,但对农村社区和公有制医疗机构参与公共卫生服务补偿教少。结论珠海市非公有制社区卫生服务中心(站)农村卫生站和医疗机构在公共卫生服务中承担着重要的角色和作用,政府在补偿城市社区参与的公共卫生方面已经初步探索出成功的经验,但尚无对医疗机构、农村社区参与公共卫生服务的补偿政策。     

Assessing Health Disparities in Rural Hawaii Using the Hoshin Facilitation Method

CONTEXT: Health disparities between rural and urban communities are well documented. There are many suggested causes and many proposed solutions but no one-size-fits-all answer. The most successful community interventions have been introduced by communities themselves. However, before communities invest in such interventions, each group must identify and prioritize their needs. PURPOSE: This article describes the Hoshin facilitation method as a practical option assisting communities in assessing their needs and gaining consensus for future steps. METHODS: Thirty-four meetings were held in 11 rural communities in Hawaii using the Hoshin process to identify factors that impact rural health. Themes were identified by constant comparative analysis and thematic frequency described. Commonality of responses between communities was examined. Informal feedback was collected from meeting participants. FINDINGS: There was a great deal of commonality between community responses, with economic factors, drug use, lack of community leadership, lack of health care services and access to services, lack of healthy activities for youth, and poor public education being the most common issues noted. Group involvement in the meetings was high, and the facilitation method received positive feedback from participants. CONCLUSIONS: The Hoshin facilitation method is a very useful tool to help communities rapidly identify and prioritize areas for programmatic attention.     

Issues with medication supply and management in a rural community in Queensland

Objective: To identify the key issues reported by rural health‐care providers in their provision of medication supply and related cognitive services, and in order to advise health workforce and role development and thus improve the quality use of medicines in rural communities. Design: Exploratory semistructured interview research. Setting: A rural community comprising four towns in a rural health service district in Queensland, Australia. Participants: Forty‐nine health‐care providers (medical practitioners, pharmacists, nurses and others) with medication‐related roles who serviced the study community, identified through databases and local contacts. Main outcome measures: Medication‐related roles undertaken by the health‐care providers, focusing on medication supply and cognitive services; challenges in undertaking these roles. Results: Medical and nursing providers reported challenges in ensuring continuity in supply of medications due to their existing medical workload demands. Local pharmacists were largely involved in medication supply, with limited capacity for extended cognitive roles. Participants identified a lack of support for their medication roles and the potential value of clinically focused pharmacists in medication management services. Conclusions: Medication supply may become more efficient with extended roles for certain health‐care providers. The need for cognitive medication management services suggests potential for clinical pharmacists' role development in rural areas.     

Perceptions of Local Health Care Quality in 7 Rural Communities with Telemedicine

CONTEXT: Rural health services are difficult to maintain because of low patient volumes, limited numbers of providers, and unfavorable economies of scale. Rural patients may perceive poor quality in local health care, directly impacting the sustainability of local health care services. PURPOSE: This study examines perceptions of local health care quality in 7 rural, underserved communities where telemedicine was implemented. This study also assesses factors associated with travel outside of local communities for health care services. METHODS: Community-based pretelemedicine and posttelemedicine random telephone surveys were conducted in 7 northern California rural communities assessing local residents' perceptions of health care quality and the frequency of travel outside their community for health care services. Five-hundred rural residents were interviewed in each of the pretelemedicine and posttelemedicine surveys. Between surveys, telemedicine services were made available in each of the communities. FINDINGS: Residents aware of telemedicine services in their community had a significantly higher opinion of local health care quality (P =.002). Satisfaction with telemedicine was rated high by both rural providers and patients. Residents with lower opinions of local health care quality were more likely to have traveled out of their community for medical care services (P =.014). CONCLUSIONS: The introduction of telemedicine into rural communities is associated with increases in the local communities' perception of local health care quality. Therefore, is it possible that telemedicine may result in a decrease in the desire and need for local patients to travel outside of their community for health care services.     

The growing importance of dental services in rural America

As the science of medicine progresses, associations between good oral health and improved health status are being documented. However, the data would suggest that individuals in America's rural communities are experiencing dramatic health problems because they are not receiving dental treatment. This article addresses the importance of dental services in rural communities and highlights the importance of cooperation among hospitals, individual clinical providers, community health care organizations, and governmental entities. It will also discuss why there is a shortage in these rural areas and how the shortage is affecting rural communities and will address some strategies for solving this crisis. This research on the availability of dental care in rural communities will provide a framework for community leaders, elected officials, and health care providers to collect and analyze data to support future decision making in response to community health care needs. Such decisions increase the quality and efficiency of health care services, thereby safeguarding the health status of the population. This study found that the capability for hospital-based dental care services is greater in urban communities, whereas rural communities have significantly less capability for hospital dental care. This would support the premise that the availability of dental services is inconsistent across the United States and that dental care resources could be allocated to provide a consistent level of services across the population. It also emphasizes the importance of building innovative partnerships among local, state, and national organizations to ensure that an appropriate level of dental care is available in rural America. The study has managerial implications on meeting the demand for dental care in rural communities and policy implications on future resource allocation.     

Rural Community and Physician Perspectives on Resource Factors Affecting Physician Retention

This study was undertaken to investigate issues affecting recruitment and retention of physicians in a rural north Florida community. As part of this investigation, the authors examined the relevant context of medical care and physician practice for this community. The results identify a number of problems not uncommon in rural communities and supported by previous literature. Physicians felt isolated, dissatisfied with job security and professional autonomy, and frustrated by a lack of cooperation among the major providers of health care. More importantly, upon closer scrutiny, some of the most appealing characteristics of this community for incoming physicians become its weaknesses. Access to a regional medical center nearby and nearness to a metropolitan area were both cited as positive attributes to their choice of practice location. In this community, however, these appear to have resulted in a highly divided medical system. Many of the employed and insured patients in the county prefer to get their medical care in the nearby city. At the same time three separate entities within the community--a federally funded community health center, a county public health unit, and a community hospital--are expected to provide services for the poor and uninsured. The resulting lack of a comprehensive approach to provision of services contributes significantly to the dissatisfaction among providers and to their ultimate retention.     

“If Only Someone Had Told Me …”: Lessons From Rural Providers

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded. Findings: Emergent themes coalesced into 3 overarching themes addressing practice‐related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.     

Quality-of-Care Challenges for Rural Health

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

The Development of a State-level Health Manpower Database Using an Employer-based Survey: A Pilot Project

State health care reform may provide a better approach to meeting the health care needs of rural communities than does federal reform because the planning is closer to the needs of local communities. However, state health reform requires a health manpower database (along with other data) that includes all health occupations and such databases are often nonexistent. This study reports on one element of such a database--a survey of a wide range of rural health care employers covering the full range of health occupations in Alabama. Information on current and future employment of the most significant health occupations is reported here. It was found that the greatest numbers of new health personnel employees needed in the future were, in descending order, nursing assistants, registered nurses, licensed practical nurses, radiological technicians, specialist physicians, nurse practitioners, physical therapists, primary care physicians, and respiratory care therapists. While an employer survey has limitations and should be supplemented by data on community needs and health status indicators, it does provide useful information for planning educational programs to prepare health personnel.     

Study protocol: Evaluating the impact of a rural Australian primary health care service on rural health

Background  

Rural communities throughout Australia are experiencing demographic ageing, increasing burden of chronic diseases, and de-population. Many are struggling to maintain viable health care services due to lack of infrastructure and workforce shortages. Hence, they face significant health disadvantages compared with urban regions. Primary health care yields the best health outcomes in situations characterised by limited resources. However, few rigorous longitudinal evaluations have been conducted to systematise them; assess their transferability; or assess sustainability amidst dynamic health policy environments. This paper describes the study protocol of a comprehensive longitudinal evaluation of a successful primary health care service in a small rural Australian community to assess its performance, sustainability, and responsiveness to changing community needs and health system requirements.     

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。     

A Strategy to Increase the Number of Urban Family Practice Resident Physicians Who Enter Rural Practice

Physician geographic maldistribution is a problem in the United States health care system. Innovative strategies are needed to entice resident family physicians training in the larger, more numerous suburban and urban training programs to practice in rural areas upon completing their training. This paper describes a strategy used at St. Elizabeth Medical Center Family Practice Residency Program, Dayton, OH, to encourage rural practice. In the St. Elizabeth plan, the interested family practice resident moonlights in a rural practice provided by the local county hospital. The county medical staff covers the resident physician's practice during the frequent absences. The residency program faculty provide on-site supervision, telephone back-up coverage, and practice consultation. The county hospital provides billing services; the resident physician retains 100 percent of collections. The resident physician gains exposure to the knowledge, skills, and attitudes needed in rural practice. Upon completion of residency training, the physician remains in practice and is not required to pay back any expenses incurred by the hospital. Two resident physicians participate currently; three others have expressed interest in practicing in the community. A similar plan might work in parts of the United States where, like Ohio, training programs and rural communities are not far apart.     

我国基层卫生机构服务功能分析

基层卫生机构功能决定着基本卫生服务的供给。本文利用国家第四次卫生服务总调查以及专题调查资料,对城乡基层卫生机构服务开展情况进行了分析。根据经济社会发展水平、基层卫生机构服务能力和城乡居民需要解决的主要健康问题,本研究将基本卫生服务项目按照优先程度分为三个等级。约三分之一的城乡基层卫生机构尚不能提供最应优先开展的基本卫生服务;农村基层卫生机构服务能力与城市基层卫生机构相比更为薄弱,特别是村级卫生机构基本卫生服务能力需要加强;乡镇卫生院和社区卫生服务中心开展最优先项目的比例均不足70%;村卫生室和社区服务站开展最优先项目比例分别为62%和77%。影响基层卫生机构功能的主要因素为人员数量不足、人员能力不够、缺乏运转资金等。需要以基层卫生机构功能建设为核心,创新我国基本医疗卫生保健体系。     

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.