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PubMed2005

Rural proofing for health: a commentary.

CONTEXT: Health services policies in the UK have traditionally been developed as a 'one size fits all' approach usually based on urban models. This approach can be problematic for primary care agencies involved in the delivery of services in rural and remote areas, due to difficulties with access and also the differences in the nature of urban and rural communities. The Countryside Agency in England has developed a rural proofing framework which will assess the impact that new policies may have in rural areas. This process is currently being applied across all government departments. This article sets out the context of the National Health Service (NHS) in the UK and describes the process of Rural Proofing for Health and how it can be used to improve equity of access to care for people living in rural and remote communities in Britain and across the international healthcare community. ISSUES: There has been a considerable increase in investment in the NHS in recent years with consequent improvements such as reductions in waiting times for treatment. Despite tangible improvements there are still inequalities in health and inequities in healthcare provision, which include parts of the population who live in rural areas. The Rural Proofing for Health project has been developed and carried out by the Institute of Rural Health as a methodology to help Primary Care Organisations implement policies and methods of service delivery that take into account the needs of people living in rural and remote areas. A toolkit has been developed that adopts a solutions-based approach to healthcare delivery in rural areas and which will help people living in rural areas to have equity of access to care with their counterparts living in urban Britain. Rural proofing policies before implementation ensures that the possible impacts of the policy are measured and so that adjustments can be made to ensure that the service will be appropriate for rural communities, and that it can be delivered effectively and efficiently in a rural context. LESSONS: It is important that development of new healthcare policies includes a process that ensures such policies are rurally sensitive. Involving stakeholders at a strategic level ensures that the initiative becomes embedded into policy-making within each department. Rural proofing is a systematic methodology that will help policy makers take account of health needs in rural areas and will hold public bodies accountable to their rural communities.

Community Health Planning↗
PubMed1975

Nutrition, behavioral development, and mother-child interaction in young rural children.

In a poor rural community two groups of 17 mother-child units each were studied longitudinally. One group followed the usual feeding habits of the community which result in undernutrition of the child. The other group was provided food supplementation which was sufficient to provide an adequate diet for the child. From the 24th week on, the supplemented children developed a different pattern of interaction with mother and the environment: they slept less, barely used the cradle during the day, played more in the yard, and refused to be carried wrapped up. After the 36th week they received more stimuli and more deferences and rewards, not only from the mother but from the father as well. At 18 months the supplemented children moved about six times as much as the nonsupplemented and exhibited more complex behavior. They were more restless, playful, demanding, disobedient. It is concluded that better nutrition caused an increase in the activity of the child, which made him more demanding, which in turn increased interaction with his mother and established a feedback system, which in turn modified his behavior.

Breast Feeding↗
PubMed1994

Lipoprotein lipids and the prevalence of hyperlipidaemia in rural India.

BACKGROUND: The prevalence of hyperlipidaemias has been inadequately studied in rural populations of developing countries. No significant data exist on the population levels of serum cholesterol, cholesterol subclasses or triglycerides in these countries. METHODS: We studied fasting blood samples of 300 apparently healthy adults (202 men and 98 women, age range 20-73 years) randomly selected from a larger sample of 3148 individuals during a comprehensive cardiovascular risk-factor survey in Rajasthan, India. Levels of serum total cholesterol, its subfractions [low-density-lipoprotein (LDL) cholesterol, very-low-density-lipoprotein cholesterol and high-density-lipoprotein (HDL) cholesterol] and triglycerides were measured and correlated with age and anthropometric data. RESULTS: The mean +/- SD serum total-cholesterol levels were 4.39 +/- 1.0 mmol/l in men and 4.37 +/- 1.0 mmol/l in women, the mean LDL-cholesterol levels 2.51 +/- 1.0 mmol/l in men and 2.62 +/- 0.9 mmol/l in women, the mean HDL-cholesterol levels 1.15 +/- 0.4 mmol/l in both mean and women and the mean fasting serum triglyceride levels 1.63 +/- 0.6 mmol/l in men and 1.48 +/- 0.7 mmol/l in women. Age correlated positively with total-cholesterol, LDL-cholesterol, HDL-cholesterol and triglyceride levels in both men and women. Levels of the cholesterol subtypes did not differ between the sexes (P > 0.01), although triglyceride levels were significantly higher in men (P < 0.01). Lipoprotein lipids did not correlate significantly with height, weight, body-mass index or waist:hip ratio. When classified according to the recommendations of the US National Cholesterol Education Program for the determination of the prevalence of hyperlipidaemia, 43 individuals (14.3%; men 14.4% and women 14.3%) had borderline high cholesterol levels (5.20-6.18 mmol/l) and 24 (8%; men 7.9% and women 8.2%) had high cholesterol levels (> or = 6.21 mmol/l). Forty-five participants (15%) had borderline high LDL-cholesterol levels (3.36-4.11 mmol/l) and 20 (6.7%) had high LDL-cholesterol levels (> or = 4.14 mmol/l); low HDL-cholesterol levels (< 0.9 mmol/L) were found in 89 (29.7%). Eighteen participants (6%) had mild hypertriglyceridaemia (2.82-5.64 mmol/l) and two (0.7%) had severe hypertriglyceridaemia (> 5.64 mmol/l). CONCLUSION: Total-cholesterol and LDL-cholesterol levels are low in a rural Indian population, although an atherogenic lipid profile is present in a significant proportion.

Adult↗
PubMed2004

Educational needs of rural and remote Australian non-specialist medical practitioners for obstetric ultrasound.

OBJECTIVE: To determine the educational needs of rural and remote non-specialist Australian doctors for obstetric ultrasound. DESIGN: Survey design. SETTING: The study surveyed rural and remote doctors practising in a variety of settings including general practice, rural hospitals, Aboriginal communities and flying doctor organisations throughout Australia. SUBJECTS: Subjects included 314 solo and group practice rural general practitioners, rural hospital medical superintendents, senior medical officers, Aboriginal community controlled health service doctors, flying doctors, rural locums, registrars and two rural obstetricians. A total of 55% of the subjects were general practitioners in group practice. Respondents included 68 (22%) women and 246 (78%) men. RESULTS: The response rate was 32%. The highest priority areas of need for education included detecting foetal abnormalities and anomalies (19.1%), basic routine ultrasonography (17.17%), placental position (17.17%), dating (17.17%), foetal viability (12.88%) and morphology scan (12.26%). The main areas where doctors stated they lacked confidence included detecting foetal abnormalities (29.09%), basic routine ultrasonography (including machine use), such as, carrying out and interpreting obstetric ultrasound scans (27.27%), morphology scans (16.36%) and placental position (14.54%). CONCLUSION: The study showed there was a large unmet need for education in obstetric ultrasound among rural and remote non-specialist doctors. Information from the needs assessment was used to develop the Australian College of Rural and Remote Medicine national obstetric ultrasound professional development program. WHAT IS ALREADY KNOWN: The authors could not find any published work on the educational needs of Australian non-specialist rural and remote doctors for obstetric ultrasound. There is research about the outcome of obstetric ultrasound education for urban family physicians in the USA, but no information about rural doctors' educational needs or education outcomes. The study needed to be done so that obstetric ultrasound professional development program of the Australian College of Rural and Remote Medicine could be based on the real needs of the target group. WHAT THIS PAPER ADDS: As a result of this research, there is now information on the educational needs of rural and remote Australian non-specialist medical practitioners that can be used by education providers to develop quality education programs in obstetric ultrasound.

Adult↗
PubMed1992

Social indicators and the prediction of psychiatric inpatient service utilisation.

The relationship between social variables and psychiatric service use in Victoria was investigated using a social indicators approach. Indicators were developed separately for the urban and rural areas of the state using 1986 census data. Principal components analysis was employed to reduce the data. Simple, unit weight indicators were developed and explained a considerable proportion of the variation in the rate of persons admitted to psychiatric facilities, the rate of admission episodes and the rate of occupied bed days for urban areas; a moderate amount of variation for these measures was accounted for by indicators developed for rural areas. The findings were considered in relation to both methodological issues and the role of other factors (e.g., accessibility and availability of psychiatric services) which may contribute to service use.

Adolescent↗
PubMed1999

Mechanical ventilation in rural ICUs.

BACKGROUND: In recent years, rural hospitals have expanded their scope of specialized services, which has led to the development and staffing of rural intensive care units (ICUs). There is little information about the breadth, quality or outcomes of these services. This is particularly true for specialized ICU services such as mechanical ventilation, where little, if any, information exists specifically for rural hospitals. The long-term objectives of this project were to evaluate the quality of medical care provided to mechanically ventilated patients in rural ICUs and to improve patient care through an educational intervention. This paper reports baseline data on patient and hospital characteristics for both rural and rural referral hospitals. RESULTS: Twenty Iowa hospitals were evaluated. Data collected on 224 patients demonstrated a mean age of 70 years and a mean ICU admission Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22, with an associated 36% mortality. Mean length of ICU stay was 10 days, with 7.7 ventilated days. Significant differences were found in both institutional and patient variables between rural referral hospitals and rural hospitals with more limited resources. A subgroup of patients with diagnoses associated with complex ventilation had higher mortality rates than patients without these conditions. Patients who developed nosocomial events had longer mean ventilator and ICU days than patients without nosocomial events. This study also found ICU practices that frequently fell outside the guidelines recommended by a task force describing minimum standards of care for critically ill patients with acute respiratory failure on mechanical ventilation. CONCLUSIONS: Despite distinct differences in the available resources between rural referral and rural hospitals, overall mortality rates of ventilated patients are similar. Considering the higher mortality rates observed in patients with complicated medical conditions requiring complex ventilation management, the data may suggest that this subgroup could benefit from treatment at a tertiary center with greater resources and technology.

Journal Article↗
PubMed1988

An hierarchical location-allocation model for primary health care delivery in a developing area.

Location-allocation models can play an important role in making primary health care facilities more accessible to rural populations in the developing world. Traditional models, however, have failed to deal realistically with the fact that health care systems are hierarchical in nature, and that benefits and utilization decline with distance. In this paper, an hierarchical location-allocation model in which benefits accrue to facility level and decline exponentially with distance is presented as a possible approach to ameliorating problems of rural accessibility to health care in Third World settings. The model is subjected to sensitivity analysis with reference to data for Salcette Taluka, Goa, India. The analysis suggests that the traditional P-median model may be a much less appropriate solution to the problem than a simple strategy of locating facilities from the highest to the lowest level in centers of strictly decreasing population.

Delivery of Health Care↗
PubMed1988

The suitability of saliva for detection of glucose-6-phosphate dehydrogenase deficiency.

Saliva was investigated for its suitability as a biopsy tissue for the determination of glucose-6-phosphate dehydrogenase deficiency. It appears that there is a significant difference between the activity of the enzyme in patients and controls. However, some controls have very low values making discrimination between patients and controls using a qualitative method impossible. Glucose-6-phosphate dehydrogenase deficiency is a relevant clinical problem in many rural areas in developing countries. Existing methods for determination of the deficiency in blood and hair follicles do not meet the criteria necessary for their large scale introduction in the areas of the world that are concerned by the problem. The present study shows that saliva is not a suitable alternative. Between the three biopsy tissues compared: blood, hair follicles and saliva, hair follicles remain most attractive since their isolation hardly involves the risk of infection. A simplified method for the detection of glucose-6-phosphate dehydrogenase activity in hair follicles that would allow health service workers in the field to determine the carrier status of pregnant women might form the basis for a future kernicterus prevention programme.

Glucosephosphate Dehydrogenase↗
PubMed1993

Hodgkin disease in Iranian children.

The epidemiological pattern of Hodgkin disease (HD) was studied in 139 Iranian children with an age range of 2.5-15 years (mean age 8.3) over a 17-year period (1972-1989). The main features observed were: a high male to female ratio of 3.2:1, a high frequency of HD in toddlers and young school children (73%), the prevalence of mixed cellularity subtype (74.5%) and rare occurrence of lymphocyte depletion subtype (2%) the high occurrence of constitutional symptoms (57%) and the high rate of stage III and IV patients (73.5%). Response to the treatment consisting mainly of chemotherapy and/or radiotherapy was favourable and overall and disease-free survival rates of 91.4% and 74.2% were achieved over a follow up period of 6 months-17 years. According to these findings the epidemiological pattern of Iranian children with HD is similar to that occurring in rural areas of developed countries.

Adolescent↗
PubMed1991

Short stature and cephalopelvic disproportion in Burkina Faso, West Africa. Operations Research Team.

In order to reduce maternal mortality due to cephalopelvic disproportion (CPD), it is important to screen women for short stature, especially in rural areas of developing countries. We measured the height of 1733 women as they left the maternity services in Ouagadougou and recorded the type of delivery. Women less than 155 cm tall were 4.9 times more likely to have a cesarean section delivery. We propose simplified screening criteria for use by traditional birth attendants.

Body Height↗
PubMed2004

The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria.

OBJECTIVE: The purpose of this study was to describe the characteristics of women with obstetric vesicovaginal fistulas at a hospital in north central Nigeria. STUDY DESIGN: A retrospective record review was conducted of all women who were seen with vesicovaginal fistulas at Evangel Hospital in Jos, Plateau State, Nigeria, between January 1992 and June 1999. RESULTS: A total of 932 fistula cases were identified, of which 899 cases (96.5%) were associated temporally with labor and delivery. The "typical patient" was small and short (44 kg and <150 cm); had been married early (15.5 years) but was now divorced or separated; was uneducated, poor, and from a rural area; had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus. CONCLUSION: Obstetric vesicovaginal fistula is extremely common in north central Nigeria. A complex interaction that involves multiple biologic and socioeconomic factors appears to predispose young women to this devastating childbirth injury.

Adolescent↗
PubMed2004

Self-inflicted cesarean section with maternal and fetal survival.

An unusual case of self-inflicted cesarean section with maternal and child survival is presented. No similar event was found in an Internet literature search. Because of a lack of medical assistance and a history of fetal death in utero, a 40-year-old multiparous woman unable to deliver herself alone vaginally sliced her abdomen and uterus and delivered her child. She was transferred to a hospital where she underwent repair of the incisions and had to remain hospitalized. Mother and child survived the event. Unusual and extraordinary measures to preserve their offspring sometimes moves women to extreme decisions endangering their own lives. Social, educational, and health measures should be instituted all over the world, particularly in rural areas of developing countries, to avoid such extreme events.

Adult↗
PubMed2004

Dietary intake in the lower Mississippi delta region: results from the Foods of our Delta Study.

OBJECTIVE: To collect and evaluate food intake data from a culturally diverse population and compare with national survey data. DESIGN: The Foods Of Our Delta Study was a baseline, cross-sectional survey that utilized random-digit dialing methodology to identify the sample. Food intake was obtained from a 24-hour dietary recall administered by computer-assisted telephone interview using the multiple-pass method. SUBJECTS/SETTING: One thousand seven hundred fifty-one adults and 485 children in the Lower Mississippi Delta (Delta) of Louisiana, Arkansas, and Mississippi. STATISTICAL ANALYSES PERFORMED: Comparisons of subsets within the Delta were made using weighted t tests. Comparisons of the Delta with the overall US population from the US Department of Agriculture Continuing Survey of Food Intakes by Individuals and with the Dietary Reference Intakes were made using independent sample z tests of weighted estimates. RESULTS: Energy intake did not differ between the Delta and the US populations. Intakes of protein were lower, fat higher, and certain micronutrients lower in Delta adults than in US adults. Delta adults had a 20% lower intake of fruits and vegetables than the US adults and generally poorer adherence to recommendations of the Food Guide Pyramid. African American Delta adults generally consumed less-optimal diets than white Delta adults. Delta children had diets similar to children of the Continuing Survey of Food Intakes by Individuals sample population, but lower intakes were noted for vitamins A, C, riboflavin, and B-6, and for calcium and iron. APPLICATIONS/CONCLUSIONS: Data such as these will help drive intervention development in this rural region and perhaps set the stage for research in similarly impoverished areas.

Adolescent↗
PubMed2006

A practical demonstration of water disinfection using TiO2 films and sunlight.

The scope of this study is the assessment of the efficiency of solar disinfection by heterogeneous photocatalysis with sol-gel immobilized (titanium dioxide) TiO2 films over glass cylinders. The solar disinfection process known as SODIS was considered as a reference. Spring water naturally polluted with coliform bacteria was exposed to sunlight in plastic bottles with and without TiO2 over simple solar collectors and the disinfection effectiveness was measured. Total and fecal coliforms quantification was performed by means of the chromogenic substrate method in order to obtain the efficiency of each disinfection treatment. The disinfection with TiO2 was more efficient than the SODIS process, inactivating total coliforms as well as fecal coliforms. On a sunny day (more than 1000 W m(-2) irradiance), it took the disinfection with immobilized TiO2 15 min of irradiation to inactivate the fecal coliforms to make them undetectable. For inactivation of total coliforms, 30 min was required, so that in less than half the time it takes SODIS, the treated water complies with the microbial standards for drinking water in Mexico. Another important part of this study has been to determine the bacterial regrowth in water after the disinfection processes were tested. After SODIS, bacterial regrowth of coliforms was observed. In contrast, when using the TiO2 catalyst, coliforms regrowth was not detected, neither for total nor for fecal coliforms. The disinfection process using TiO2 kept treated water free of coliforms at least for seven days after sun irradiation. This demonstration opens the possibility of application of this simple method in rural areas of developing countries.

Disinfection↗
PubMed2003

[Imported hookworm infection in African immigrants in Spain: study of 285 patients].

BACKGROUND AND OBJECTIVE: Hookworm infection is a worldwide intestinal parasitic disease affecting more than one billion people. It represents an important public health problem in rural areas of developing countries. In our environment, it is generally considered an imported disease due to the immigration process. PATIENTS AND METHOD: Retrospective observational study of African immigrants diagnosed with hookworm infection at the Immigration and Tropical Medicine Unit of the Hospital of Mataró over the period 1984-1999. RESULTS: We identified 285 patients, mainly young males, from Gambia or Senegal, with a precarious job who had arrived in Spain 3 years earlier or less. Abdominal pain was the commonest reason for consultation (28.8%) cases. Non digestive symptoms were 35.6% and 4.6% remained assymptomatic. 60% had a concomitant infectious disease. Laboratory tests showed iron-deficiency anemia in 28.4% and eosinophilia in 52.3%. 70% of patients did not come to visit after treatment. CONCLUSIONS: Microbiologic stool examination is recommended as part of the health assessment of immigrants from countries where hookworm infection is highly prevalent, even in the absence of abdominal symptoms or abnormalities of the red and white blood series.

Africa South of the Sahara↗
PubMed2000

Insights from a large rural population laboratory. Health census '89 and '99.

PURPOSE: Data are limited on health status behaviors and use of health services for rural residents. Yet rural areas now have higher rates of chronic diseases, such as coronary heart disease, than urban areas.METHODS: A population laboratory (Health Census) was established in rural Central NY (Otsego County) to study these variables in this population. HC '89 was a door-to-door enumeration of all permanent households in the country. In 1989, 44,500 adults in 18,000 households provided data on individual health screenings, cancer and cardiovascular risk factors, health behaviors, chronic disease, access to care, preventive services use, health insurance and emergency department utilization. Data collection for HC '99 will identify 10-year trends; it also includes baseline data for children. Also, households in six surrounding rural counties (N = 10,000) were sampled; cost benefits of different survey methods were assessed. Questions about perceived health status, and special health and pediatric preventive care needs were included. After 10 years of social change, many limitations of traditional survey methods became apparent; much more varied and frequent types of follow-up were needed to achieve adequate response rates.RESULTS: The HC '89 final response rate was 86%. There were significant socioeconomic gradients in use of preventive services (blood pressure screening, rectal exams, mammograms and Pap smears). Adults without health insurance or Medicaid had much lower utilization rates of screening tests and higher rates of cigarette smoking and obesity. Several community intervention programs were implemented as a result of HC '89. HC '99 provides additional analyses to examine change in preventive service use, self-reported chronic disease, and health services use; it will likely verify the persistence of socioeconomic gradients. Response rates are similar to '89, but achieved only with more intensive reinforcement.CONCLUSIONS: HC '89 confirmed a lag in positive health indices in rural populations in Central NY. Both newer methodologies now needed and results of HC '99 will serve as guides for smaller rural counties to develop affordable local health surveys and plan intervention strategies.

Journal Article↗
PubMed2002

Stratum-specific likelihood ratios of the general health questionnaire in the community: help-seeking and physical co-morbidity affect the test characteristics.

BACKGROUND: In evidence-based medicine, stratum-specific likelihood ratios (SSLRs) are now being increasingly recognized as a more convenient and generalizable method to interpret diagnostic information than an optimal cut-off and its associated sensitivity and specificity. We previously examined the SSLRs of the General Health Questionnaire (GHQ) in primary care settings. The present paper aims to examine if these SSLRs are generalizable to the community settings. METHODS: The Composite International Diagnostic Interview (CIDI) and the GHQ were administered on a representative sample of the Australian population in the Australian National Survey of Mental Health and Well-Being. We first compared the SSLRs of GHQ in urban Australia with the estimates that we had previously obtained from the developed urban centres in the WHO Psychological Problems in General Health Care study. If the SSLRs in the community were found to differ significantly from those in the primary care, we sought for explanatory variables. RESULTS: The SSLRs in urban Australia and in the urban centres in the WHO study were significantly different for three out of the six strata. When we limited the sample to those with physical problems who visited a health professional, however, the SSLRs in the Australian study were strikingly close to those observed for primary care settings. CONCLUSIONS: Different sets of SSLRs apply to primary care and general population samples. For general population surveys in developed countries, the results of the Australian National Survey represent the currently available best estimates. For developing countries or rural areas, the results are less definitive and an investigator may wish to conduct a pilot study.

Adolescent↗
PubMed1998

A Model Rural Health Orientation Course Using Interdisciplinary, Community Oriented, Inquiry Based Strategies.

Introduction to Rural Health was developed as the introductory course for the Community Partnerships in Health Education - a new curriculum educating students using interdisciplinary, community oriented, and inquiry based strategies. Medical students, nursing students, and public health students participated in an elective curriculum designed to teach interdisciplinary groups of students to deliver primary health care in under-served communities. The curriculum began with an intensive one-week course designed to introduce students to the community, its people, their health care needs, and the process of working in interdisciplinary groups. The course was taught using a variety of community based activities. Student evaluations indicated that students strongly agreed that the course objectives were met using this nontraditional methodology. Qualitative analysis indicated that students regarded the team-building aspects of the course as the most influential. Community members indicated a high level of satisfaction with their input in the developmental process and with the extent to which community resources and interests were included.

Journal Article↗