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This article describes a program for legally mandated training of foster and adoptive applicants and parents across a vast rural territory. The development of this varied program and its funding sources can serve as an example for other rural areas.
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In the late 1970s China launched its agricultural reforms which initiated a decade of continued economic growth and significant transformation of the Chinese society. The agricultural reforms altered the peasants' incentives, weakened community organization and lessened the central government's control over local communities. These changes largely caused the collapse of the widely acclaimed rural cooperative medical system in China. Consequently China experienced a decreased supply of rural health workers, increased burden of illnesses, disintegration of the three tier medical system, reduced primary health care, and an increased demand for hospital medical services. More than ten years have elapsed since China changed its agricultural economic system and China is still struggling to find an equitable, efficient and sustainable way of financing and organizing its rural health services. The Chinese experiences provided several important lessons for other nations: there is a need to understand the limits of the market forces and to redefine the role of the government in rural health care under a market economy; community participation in and control of local health financing schemes is essential in developing a sustainable rural health system; the rural health system needs to be dynamic, rather than static, to keep pace with changing demand and needs of the population.
AIM: To develop a customised, portable, cost-effective (logarithmic minimal angle resolution) LogMAR chart with adjustable illumination for use as a mass vision-screening device in the rural population. MATERIALS AND METHODS: Visual acuity of 100 individuals was evaluated with a customised chart and compared with the standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart and Snellen's Chart. Bland and Altman analytical techniques were used for analysis. RESULTS: Test-retest variability of the customised chart was just a one-line difference (95% CI for agreement), and so were the results with the standard ETDRS charts; a variability of 3-line was noted with Snellen's chart. Two-line differences were observed when comparison was made with Standard ETDRS chart and 2 to 3-line differences with Snellen's chart. CONCLUSION: The customised portable LogMAR chart with adjustable illumination shows less test-retest variability and better agreement with standard ETDRS chart; therefore, it can be used as a mass vision-screening device in rural settings.
An expert panel of female rural and remote doctors have nominated updating professional skills as the most important strategy for sustainable rural general practice for women. The panel was comprised of members of the Australian College of Rural and Remote Medicine (ACRRM). The panel was asked to identify and prioritise strategies they had used to make rural practice work for them. They identified and ranked the following eight groups of strategies: (i) structure medical practice to work for you; (ii) implement personal strategies; (iii) obtain and update professional skills; (iv) establish professional and personal boundaries; (v) gain exposure to rural practice; (vi) engage with the community; (vii) implement professional strategies; and (viii) engage with women. Detailed strategies within these groups have been identified and will form the basis of grounded knowledge about how to structure rural and remote practice to work for women. This will complement the work of ACRRM, the Rural Doctors Association and workforce agencies in developing models of sustainable rural medical practice.
Organized delivery systems are becoming an increasingly important component of urban health care markets and are expanding their influence in rural areas as well. They also are developing new linkages with rural providers. This article, based on the experiences of 20 diverse organizations, identifies and describes the strategies being used by urban systems to redefine linkages with rural hospitals and, particularly, physicians.
Urban and rural elderly face a multitude of barriers to healthy aging and maintaining adequate nutrition. Looking at commonalties and differences between urban and rural elderly that are associated with nutritional risk is an important first step in identifying and correcting nutritional insufficiencies. To examine health behaviors and nutritional information associated with nutritional risk in urban and rural areas and to develop a profile of nutritional risk for rural and urban elderly, data from one retrospective and two prospective studies were analyzed. One hundred, eighty-three (183) urban-living and 167 rural-living older adults (average age 77 years old) participated in the studies. More than 60% of participants were women. Overall health ratings were significantly higher for urban than for rural elderly. Rural dwellers had significantly fewer dental visits (41% versus 76%) but higher albumin values than their urban counterparts. Results from the synthesis of these four studies indicate that as people become more physically debilitated and lose independence in daily activities, their risk for malnutrition increases and their quality of life decreases. Although rural residents are believed to be at higher risk of malnutrition, these results suggest that this may not be the case. Physical, social, and environmental factors may affect the nutritional status of seniors regardless of where they reside.
BACKGROUND: A large proportion of women in most developing countries, particularly in rural areas, have never had cervical cancer screening. This paper reports the effect of a cervical cancer screening programme using a mobile unit on changes in knowledge and use of Papanicolaou (Pap) smear screening among rural Thai women. METHODS: Health education and collection of Pap smears were carried out by the mobile unit throughout the 54 rural villages in Mae Sot District, Tak Province, between January and February 1993. To determine the extent of changes, we compared the results of two interview surveys of women 18-65 years old in the villages selected by systematic sampling for each survey, first in January 1991 and then in January 1994. RESULTS: A total of 1603 and 1369 women participated in each survey respectively. The proportion of women who knew of the Pap smear test increased from 20.8% in the first survey sample to 57.3% in the second survey sample. The proportion of those who had even been screened increased from 19.9% in the first survey sample to 58.1% in the second survey sample. These increases were observed solely among ever-married women and there were no significant changes among single women, most of whom remained unscreened. Of ever-married women, the magnitude of increase was highest in the age group 25-34 years, and declined with increasing age. CONCLUSIONS: Greater efforts should be made to encourage the use of screening among the older women. The use of mobile units may be helpful for rapid achievement of higher screening coverage in rural areas, where existing screening services cannot effectively cover the female population at risk.
A prerequiste for effective and efficient medical care to be carried out by auxiliary staff at health centres in rural areas in developing countries is the standardization of the medical, technical and administrative procedures that they have to undertake. A record for antenatal care in rural health centres was designed to facilitate the selection of high risk cases. Several features of this record - which has been successfully used since 1972 in several rural health centres in Kenya - are described.
The Arizona Telemedicine Program was established in July 1996 by the Arizona state legislature. The organizational center for the program is the Arizona Health Sciences Center in Tucson. Key goals for the program include increased access to specialty services for rural, underserved populations; development of cost-effective telemedicine services; and expansion of opportunities for education of health professionals in rural areas. The program provides several levels of services based on both store-and-forward and real-time interactive applications. The telecommunication infrastructures is provided by two methods: The first is a private asynchronous transfer mode network established and operated by program personnel. The second is dial-up access via the public switched telephone network. After an extensive period of organization and vendor evaluations, most of the private network was implemented between June and December 1997. This paper describes experiences establishing the asynchronous transfer mode network.
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In developing countries, dietary diversity is usually assessed during a single yearly period and the effects of seasonal variations remain unknown. We studied these variations in women living in a Sahelian rural area (Burkina Faso). A representative sample of 550 women was surveyed at the beginning and at the end of the seasonal cereal shortage in April and September 2003, respectively. For each season, a dietary diversity score (DDS) representing the number of food groups consumed over a 24-h period, was computed and nutritional status was assessed by the BMI. The DDS increased from 3.4 +/- 1.1 to 3.8 +/- 1.5 food groups between the beginning and the end of the shortage season (P < 0.0001), and the proportion of women exhibiting low DDS decreased from 31.6 to 8.1%. This was due to the consumption of foods available during the cereal shortage season and despite the decrease in the consumption of some purchased foods. The increase in DDS was lower in women for whom DDS was already high in April and vice versa. Over the same period, the percentage of underweight women (BMI <18.5 kg/m(2)) increased from 11.1 to 17.1%. The relation between DDS and the women's socioeconomic characteristics or nutritional status was weakened in September. Thus, in April, fewer women were underweight when their DDS was high than when it was medium or low [odds ratio = 0.3 (0.2; 0.6)], but not in September [odds ratio = 0.6 (0.3; 1.0)]. In such a context, it would be useful to measure dietary diversity at the beginning of the cereal shortage season, when many women exhibit low DDS.
A prominent American thoracic surgeon, Leo Eloesser, while serving with UNICEF, contributed significantly to the health care of the Chinese people in the late 1940s, during the final years of the civil war and before the establishment of the People's Republic of China. The concepts he developed, especially concerning rural health service in poor, medically deprived nations, and the factors he felt must be taken into account in developing a health care system in any nation had lasting value. The story of the origin of his plan and his efforts to implement it is briefly related.
The Australian Commonwealth Department of Health and Ageing provided funds for the Australian medical schools to establish Rural Clinical Schools. This workforce initiative has enabled medical students to learn in a diverse range of rural and remote healthcare settings. A common questionnaire was developed and agreed on by all the directors of the Rural Clinical Schools. Use of this common questionnaire will facilitate reports on student attitudes and program outcomes, both within individual Rural Clinical Schools and at a national program level. The data analysis will inform the community and the Australian Government about the effectiveness of the national Rural Clinical School program in (1) meeting the primary aims of providing high quality rural medical education; and (2) addressing the medical workforce shortage in rural and remote areas.
We present a form of parametric survival analysis that incorporates exact, interval-censored, and right-censored times to deciduous tooth emergence. The method is an extension of common cross-sectional procedures such as logit and probit analysis, so that data arising from mixed longitudinal and cross-sectional studies can be properly combined. We extended the method to incorporate and estimate a proportion of agenic teeth. While we concentrate on deciduous tooth emergence, the method is relevant to studies of permanent tooth emergence and other developmental events. Deciduous tooth emergence data were analyzed from four longitudinal studies. The samples are 1,271 rural Guatemalan children examined every three months up to age two and every six months thereafter as part of the INCAP study; 397 rural Bangladeshi children examined monthly to age one and quarterly thereafter as part of the Meheran Growth and Development Study; 468 rural Indonesian children examined monthly as part of the Ngaglik study; and 114 urban Japanese children examined monthly in studies from 1910 and 1920. Although all four studies were longitudinal, many observations from the Guatemala and Bangladesh studies were effectively cross-sectionally observed. Three different parametric forms were used to model the eruption process: a normal distribution, a lognormal distribution, and a lognormal distribution with age shifted to shortly after conception. All three distributions produced reliable estimates of central tendencies, but the shifted lognormal distribution produced the best overall estimates of shape (variance) parameters. Estimates of emergence were compared to other studies that used similar methods. Japanese children showed relatively fast emergence times for all teeth. Bangladeshi and Javanese children showed emergence times that were slower than are found in most previous studies. Estimates of agenesis were not significantly different from zero for most teeth. One or two central incisors showed significant agenesis that ranged from 0.1 to 0.8% in three of the samples; even so, failure to model the agenic proportion did not seriously bias the estimates.
This article describes Intermountain Health Care's experience in rural health care and outlines the accomplishments and problems that a multihospital system has experienced in maintaining its commitment to rural health care. Development of services in both administrative and clinical functions shared between referral centers and the corporate office with rural hospitals is explained and the amount of savings generated described. The challenge of maintaining hospitals with 20 beds or fewer is explained as well as how hospitals with 50 beds or more are breaking even because of the support from the system. Strategies are described to address decreasing revenues in the environment and alternatives of care available from Intermountain Health Care to the communities that cannot sustain an acute care facility are identified.
The present paper looks at the challenges of palliative care delivery in rural and remote areas and proposes the establishment, education and coordination of a network of palliative care volunteers to assist in the delivery of non-clinical services. The development of a rural palliative care volunteer education and support training package is documented, together with details of the trailing of the package and its evaluation. Possible benefits of the program and some key issues to be considered when establishing a volunteer network are raised.
OBJECTIVE: To develop a method of addressing and minimizing the institutional, cultural, and regulatory barriers to the care of nursing facility residents in our community. METHODS: Nurses, administrators, and medical directors from all the nursing facilities in our community plus representatives from the community hospital participated in a monthly meeting where difficult issues in the care of nursing facility residents were discussed. The committee developed responses to these issues that were implemented throughout the community. RESULTS: This committee has provided an opportunity for the whole community to address problems in the care of the institutionalized elderly. Systems have been developed which have improved communication between nurses and physicians and between nursing facilities and the hospital. Community standards for the care of common problems in nursing facility residents have also been developed. Other unexpected benefits have included community discussion of regulatory concerns, nurse assistant education, and care at the end of life, as well as coordination of laboratory services in the nursing facilities. Other rural communities may find a similar approach useful.