Access In Rural Areas Research Articles

Introduction to the digital health divide

Abstract This presentation will introduce the concept of digital health divide. It refers to inequalities in accessing and using digital technologies, leading to digital exclusion. Digital inclusion is defined by the United Nations as “equitable, meaningful, and safe access to use, lead, and design of digital technologies, services, and associated opportunities for everyone, everywhere”. Indeed, digitalisation is a worldwide phenomenon that permeates all levels of determinants of health inequities, leading to several populations being more adversely affected. Age, gender, education, and economic status are significant determinants amplifying the digital divide’s impact, with older individuals, women, less educated individuals, and economically disadvantaged populations bearing disproportionate effects. The relationship between the digital divide and health leading to the digital health divide can be direct and indirect. Here, access to the latest advancements in health technologies used along the health span (eHealth, mHealth) - from health prevention to patient care - can directly influence the user’s health. However, the lack of access to or use of existing technologies can also indirectly affect their well-being. A globally informative example of this indirect association is the lack of internet access in rural areas during the hard COVID-19 lockdowns, leading to the loss of a school year for many pupils. Indeed, school attendance and attainment are associated with better physical and mental health. Currently, there is a lack of operationalisation of the digital health divide, making it difficult to measure it accurately. The absence of a standardised evaluation and therefore evidence-based information hinders governments and organizations’ efforts to effectively address digital health divide.

People at Risk of, or with Cardiovascular Diseases’ Perspectives and Perceptions of Physiotherapist-Led Health Promotion in Cameroon: A Mixed-Methods Study

Cardiovascular diseases (CVDs) and their risk factors are a major cause of illness and death worldwide, especially in low- and middle-income countries like Cameroon. Physiotherapist-led health promotion (PLHP) has proven effective in improving health and reducing CVD risks. Understanding patient perspectives is crucial for designing effective, context-specific PLHP interventions. This study explored patients’ views, experiences, perceived usefulness, acceptability, and preferred methods of PLHP, through a sequential explanatory mixed-methods approach. The quantitative data highlights a significant burden of CVD conditions and risk factors among patients seen in physiotherapy services. Qualitatively, three themes were identified and included: (1) perspectives and experiences of people at risk or with CVDs (pwCVDs) on PLHP; (2) perceived usefulness and acceptability of PLHP; (3) preferred delivery methods of PLHP. Participants reported positive feedback on PLHP and physiotherapy services. Barriers to effective PLHP included high workloads for physiotherapists, limited service access in rural areas, and prohibitive costs. Despite these challenges, participants expressed strong confidence in physiotherapists’ competence, though they also called for improved regulation and ongoing professional development. PLHP components, especially physical treatment and dietary advice, were deemed highly useful and acceptable. Patients suggested various delivery methods, including peer support groups, home visits, and mass media interventions. This study highlights the need to improve the scope of practice, competence of physiotherapists, and accessibility of physiotherapy services in Cameroon for pwCVDs. It is necessary to adopt multidisciplinary approaches to achieve better outcomes for risk factors like diabetes and hypertension in context.

Bridging the Gap: Analyzing Healthcare Access and Inequalityin Ghana

Ghana’s National Health Insurance Scheme (NHIS) has made tremendous progress towards the aimof obtaining universal healthcare coverage. By boosting access to key healthcare services, the NHIS hasplayed a vital role in improving healthcare outcomes across the country. However, despite these advancements, major discrepancies in healthcare access exist, especially among low-income households and rural communities. These inconsistencies show fundamental injustices in the distribution of healthcare services and raise doubts about the NHIS’s potential to effectively serve themost vulnerable parts of society. This research tries to explore the difficulties of healthcare access in Ghana by delving into NHIS membership data. Through an analysis of this data, the study shows patterns of inequality related to both economic status and geographic location. By concentrating on how different economic quintiles connect with the NHIS, the research highlights important hurdles to enrollment and continuing access to healthcare. Additionally, the spatial research indicates considerable inequalities, illustrating how rural residents often experience more severe obstacles in getting healthcare compared to their urbancounterparts. Furthermore, the quality of healthcare services given under the NHIS is severely assessed. Issues such as inconsistent service delivery, poor resource allocation, and different levels of patient satisfaction emerge as important concerns that must be addressed to increase the overall success of the plan. Beyond Ghana’s boundaries, the research encompasses a comparative review of health insurancemodels from Rwanda, South Africa, Mexico, and Kenya—each country presenting a unique approach to healthcare funding and insurance coverage. Rwanda’s community-based health insurance, South Africa’s progressive changes, Mexico’s focus on service quality, and Kenya’s required enrollment offer useful lessons for resolving the inadequacies in Ghana’s NHIS. By drawing on these different models, the study intends to highlight best practices and lessons that could drive policy suggestions customizedto Ghana’s specific social, political, and economic setting. The study offers three critical policy reforms that might strengthen the NHIS and improve healthcare access across the country. Enhancing community participation is regarded as a critical way to enhance NHIS enrollment, particularly among underrepresented populations. Moreover, improving the subsidy mechanisms to better support low-income households is advocated as a manner of eliminating financial obstacles to healthcare. The study also advocates for specific measures to addressthe regional imbalances in healthcare infrastructure, noting the need for increased access in rural areas. Ultimately, these steps are not only meant to eliminate the gaps in coverage but also to secure the long-term sustainability of the NHIS, positioning it to continue offering fair healthcare to all Ghanaians. By tackling these problems and implementing targeted changes, Ghana can make considerable steps toward obtaining true universal healthcare coverage. The NHIS has the potential to become amore inclusive and resilient healthcare system, capable of fulfilling the requirements of the entire population.

Designing state-level policies to support independent pharmacies in providing specialty care services in rural regions

This review paper explores the critical role of independent pharmacies in rural regions, emphasizing their potential to deliver specialty care services despite facing significant challenges. These challenges include financial constraints, regulatory barriers, and limited specialized training and resource access. The paper argues that comprehensive state-level policies are necessary to support these pharmacies, enabling them to overcome these obstacles and enhance healthcare access in rural areas. Key policy recommendations include providing financial incentives such as grants and subsidies, regulatory reforms to streamline licensing processes and expand the scope of practice for pharmacists, and promoting partnerships between pharmacies, healthcare providers, and telehealth services. The paper also highlights the importance of integrating independent pharmacies into state health programs and adopting advanced technologies like telepharmacy and electronic health records. Future research directions are suggested, focusing on the impact of digital health technologies and evolving healthcare payment models on independent pharmacies in rural regions. The paper concludes by underscoring the need for targeted policy interventions to strengthen the role of independent pharmacies in rural healthcare, thereby improving health outcomes and quality of life for rural populations.

Measuring and optimizing the spatial accessibility of primary health care in remote and rural areas: a case study of Liannan Yao Autonomous County in China

The need for equitable access to primary healthcare services in the current global context has attracted widespread attention, prompting nations to continuously enhance their grassroots medical service levels. In response, China launched the "Healthy China" initiative, which prioritizes the enhancement of national health as a core goal of the healthcare system and uses this opportunity to deepen reforms aimed at strengthening primary care. However, in remote and rural areas, the optimization of medical resource allocation and the achievement of balanced service development remain critical challenges owing to limited resources. This study selected Liannan Yao Autonomous County, which is situated in the northwestern corner of Guangdong Province, as a case study due to its remote mountainous location, underdeveloped economy, and minority region characteristics. Through field research and interviews, this study thoroughly explored the needs of both supply and demand, factoring in elements such as the service capability of healthcare facilities and residents' travel thresholds to enhance the two-step floating catchment area model, thus making it more applicable to remote villages. By integrating electric bikes and cars, which are the primary means of transportation in rural areas, this study conducted a thorough analysis and comparison of the accessibility of medical services in Liannan Yao Autonomous County (Liannan County) . The results reveal significant disparities in healthcare accessibility, an uneven distribution of medical resources, and varying impacts of transportation conditions and facility service capabilities on accessibility. Notably, the study revealed that improving transportation conditions alone has limited effects in rural areas; the key lies in balancing medical service capabilities and the rationality of overall layouts. From the perspectives of equity and efficiency, this study employs the equitable coverage model and the efficiency-driven model to construct two scenarios, comparing accessibility changes in Liannan County under both conditions and proposing strategies to improve the spatial layout of local healthcare facilities. This research not only deepens the understanding of healthcare service accessibility in rural areas but also provides a scientific basis for optimizing resource allocation and enhancing primary medical services, offering valuable guidance and reference for Liannan County and other similar rural regions.

The Impact of Digital Health Solutions on Bridging the Health Care Gap in Rural Areas: A Scoping Review.

Digital health tools can improve health care access and outcomes for individuals with limited access to health care, particularly those residing in rural areas. This scoping review examines the existing literature on using digital tools in patients with limited access to health care in rural areas. It assesses their effectiveness in improving health outcomes. The review adopts a comprehensive search strategy to identify relevant studies from electronic databases, and the selected studies are analyzed descriptively. The findings highlight the advantages and barriers of digital health interventions in rural populations. The advantages include increased access to health care practitioners through teleconsultations, improved health care outcomes through remote monitoring, better disease management through mobile health applications and wearable devices, and enhanced access to specialized care and preventive programs. However, limited internet connectivity and a lack of familiarity with digital tools are barriers that must be addressed to ensure equitable access to digital health interventions in rural areas. Overall, digital tools improve health outcomes for individuals with limited health care access in rural areas.

Enhancing rural healthcare through internet-based remote collaborative outpatient services: A comprehensive evaluation in Changzhi, Shanxi Province.

The advancement of digital technology, particularly telemedicine, has become crucial in improving healthcare access in rural areas. By integrating cloud computing and mHealth technologies, Internet-based Collaborative Outpatient Clinics offer a promising solution to overcome the limitations of traditional healthcare delivery in underserved communities. A trial was conducted in 4 counties of Changzhi City in Shanxi Province, China. The system extended to 495 rural communities and served over 5000 rural residents. Deep learning algorithms were employed to analyze medical data patterns to increase the accuracy of diagnoses and the quality of personalized treatment recommendations. After the implementation of the system, there was a significant improvement in the satisfaction levels of rural residents regarding medical services; the accuracy of medical consultations increased by 30%, and the convenience of medical access improved by 50%. There was also a notable enhancement in overall health management. Satisfaction rates among healthcare professionals and rural inhabitants were over 90% and 85%, respectively, indicating that the system has had a significant positive impact on the quality of health-care services. The study confirms the feasibility of implementing telemedicine services in rural areas and offers evidence and an operational framework for promoting innovative healthcare models on a large scale.

Access to Decentralised Public Healthcare Service Delivery in Rural Areas of Lesotho

Despite being a basic right for all citizens of every country, access to healthcare has been a challenge for many people globally. However, the emergence of the COVID-19 pandemic has heightened the need for improvedhealthcare service delivery and access to healthcare globally. The need for improved access to healthcare is especially critical for developing countries as theywere the worst affected in terms of healthcare service delivery by the pandemic. This study, which sought to assess healthcare accessibility in rural areas of Lesotho, is relevant because Lesotho is a country with high poverty levels, and most of the poor people in Lesotho live in the rural areas. The study employed a quantitative design and sampled 200 healthcare users from the rural areas of Lesotho to measure the dimensions of access to healthcare (which refer to the affordability, availability, acceptability and accessibility / accommodation of healthcare) on a 5-point Likert-type scale. The study’s findings showed that healthcare affordability remains a barrier to access in rural Lesotho. This was followed by accessibility and accommodation, then acceptability and availability of healthcare in rural Lesotho. The study then made recommendations to guide health policy makers in Lesotho.

Pediatric subspecialty outreach clinics: reach and impact on access to care

BackgroundRecent research highlighting a shortage of pediatric subspecialists in the United States has shown wide variations in the distance from children to the nearest subspecialists but has not accounted for subspecialty outreach clinics, in which specialists may improve access in rural areas by periodically staffing clinics there. This study aimed to determine the impact of pediatric subspecialty outreach clinics on the driving times to the nearest pediatric subspecialists for children in Maine.MethodsThis cross-sectional study utilized administrative data on the schedule and location of pediatric subspecialty clinics in Maine in 2022 to estimate the driving time from each ZIP-code tabulation area to the nearest subspecialist, with and without the inclusion of outreach clinics. Using 2020 census data, we calculated the median and interquartile ranges of driving times for the state’s overall child population, as well as for children living in urban and rural areas.ResultsOf 207,409 individuals under 20 years old in Maine, 68% were located closer to an outreach location than to a clinical hub. Across the seven subspecialties offering outreach clinics, outreach clinics decreased median driving times to the nearest pediatric subspecialist by 5 to 26 minutes among all children, and by 16 to 46 minutes among rural children.ConclusionsPediatric subspecialty outreach clinics can substantially reduce the driving time to the nearest pediatric subspecialist , especially for children living in rural areas. The use of outreach clinics should be accounted for in research describing the geographic access or barriers to care. Expanding the number of outreach clinics should be considered by policymakers hoping to improve access.

Rehabilitation after musculoskeletal injury: an overview of systems in the United States and Canada.

As North America is largely industrialized with a variety of available private transportation options, trauma is a common occurrence, resulting in significant burdens of disability and costs to the health care system. To meet increasing trauma care needs, there is a robust organization of trauma and rehabilitation systems, particularly within the United States and Canada. The American and Canadian health care systems share multiple similarities, including well-equipped Level I trauma centers, specialized inpatient rehabilitation units for polytrauma patients, and thorough evaluations for recovery and post-discharge placement. However, they also have several key differences. In Canada, the criteria for admission to inpatient rehabilitation vary by location, and inpatient rehabilitation is universally accessible, whereas outpatient rehabilitation services are generally not covered by insurance. In the United States, these admission criteria for post-acute inpatient rehabilitation are standardized, and both inpatient and outpatient services are covered by private and government-funded insurance with varying durations. Overall, both health care systems face challenges in post-acute rehabilitation, including benefit limitations and limited provider access in rural areas, and must continue to evolve to meet the rehabilitation needs of injured patients as they reintegrate into their communities.

Use of artificial intelligence‐guided echocardiography to detect cardiac dysfunction and heart valve disease in rural and remote areas: Rationale and design of the AGILE‐echo trial

Transthoracic echocardiography (TTE) is essential in the diagnosis of cardiovascular diseases (CVD), including but not limited to heart failure (HF) and heart valve disease (HVD). However, its dependence on expert acquisition means that its accessibility in rural areas may be limited, leading to delayed management decisions and potential missed diagnoses. Artificial intelligence-guided (AI)-TTE offers a solution by permitting non-expert image acquisition. The impact of AI-TTE on the timing of diagnosis and early initiation of cardioprotection is undefined. AGILE-Echo (use of Artificial intelligence-Guided echocardiography to assIst cardiovascuLar patient managEment) is a randomized-controlled trial conducted in 5 rural and remote areas around Australia. Adults with CV risk factors and exercise intolerance, or concerns regarding HVD are randomized into AI-TTE or usual care (UC). AI-TTE participants may have a cardiovascular problem excluded, identified (leading to AI-guided interventions) or unresolved (leading to conventional TTE). UC participants undergo usual management, including referral for standard TTE. The primary endpoint is a composite of HVD or HF diagnosis at 12-months. Subgroup analysis, stratified based on age range and sex, will be conducted. All statistical analyses will be conducted using R. Of the first 157 participants, 78 have been randomized into AI-TTE (median age 68 [IQR 17]) and 79 to UC (median age 65 [IQR 17], P = .034). HVD was the primary concern in 37 participants (23.6%) while 84.7% (n = 133) experienced exercise intolerance. The overall 10-year HF incidence risk was 13.4% and 20.0% (P = .089) for UC and AI-TTE arm respectively. Atrial remodeling, left ventricular remodeling and valvular regurgitation were the most common findings. Thirty-three patients (42.3%) showed no abnormalities. This randomized-controlled trial of AI-TTE will provide proof-of-concept for the role of AI-TTE in identifying pre-symptomatic HF or HVD when access to TTE is limited. Additionally, this could promote the usage of AI-TTE in rural or remote areas, ultimately improving health and quality of life of community dwelling adults with risks, signs or symptoms of cardiac dysfunction.

DAMPAK TELEMEDIS TERHADAP AKSES PELAYANAN KESEHATAN DI MASYARAKAT PEDESAAN

Telemedicine has emerged as a pivotal solution for addressing healthcare disparities in rural communities, where access to medical services is often limited. This study aims to evaluate the impact of telemedicine on healthcare access in rural areas, focusing on how residents perceive and utilize telemedicine, the effect on healthcare outcomes, and the barriers to its implementation. Using qualitative research methods, secondary data were collected from academic journal articles, government reports, and healthcare surveys. Findings reveal that rural residents generally perceive telemedicine positively, appreciating its convenience and accessibility, although technological literacy and trust in technology remain concerns. The impact on healthcare outcomes is significant, with improvements noted in chronic disease management, patient satisfaction, and cost savings. However, several barriers impede the widespread adoption of telemedicine, including technological infrastructure limitations, regulatory complexities, reimbursement issues, and the need for provider and patient education. The study concludes that while telemedicine has the potential to transform rural healthcare, addressing these barriers is crucial for optimizing its effectiveness and sustainability.

Delay in healthcare seeking and associated factors among patients presenting with sexually transmitted infection symptoms in the Horo Guduru Wollega Zone, Oromia, Western Ethiopia, 2022.

Sexually transmitted infections (STIs) are the most prevalent communicable diseases that impact people's health and wellbeing. One of the main obstacles to successful prevention and control of STIs is the delay in seeking healthcare, which can result in significant personal and economic losses. However, there are limited studies on the delay in healthcare seeking among STI patients in resource-limited countries such as Ethiopia. This study aims to assess delays in seeking healthcare and associated factors among patients presenting with STIs at public health facilities in the Horo Guduru Wollega Zone, Oromia, Western Ethiopia, 2022. A cross-sectional study was conducted at public health facilities in the Horo Guduru Wollega Zone from 15 March to 15 May 2022. The study included 507 participants and used a consecutive sampling method. The outcome variable of the study was the delay in seeking healthcare among STI patients. A binary logistic regression model was used to identify candidate variables with a p-value of less than 0.25 after analyzing each variable separately. Finally, a multivariable analysis was performed to determine statistically significant variables at a p-value of less than 0.05, and an adjusted odds ratio (AOR) was reported. The proportion of individuals with STIs who delayed seeking healthcare in the Horo Guduru Wollega Zone was 61.3% [95% confidence interval (CI): 57%-65.5%]. Factors such as age >35 years (AOR = 2.23, 95% CI: 1.26-3.95), higher educational level (AOR = 2.72, 95% CI: 1.55-4.74), lack of condom use (AOR = 1.63, 95% CI: 1.05-2.55), and travel time to health facilities of >1 h (AOR = 4.30, 95% CI: 1.70-10.89) were found to be significantly associated with delayed healthcare seeking. This study found that the magnitude of delay in seeking healthcare was higher than the national average and identified several contributing factors. Interventions such as developing educational programs and improving access to healthcare services are crucial for supporting patients with STIs. Enhancing healthcare accessibility in rural areas and promoting the use of condoms through targeted community outreach can reduce travel time and prevent delays in seeking healthcare for STIs.

Renewable energy potential assessment and modeling for improving electric energy accessibility in rural areas of northwest Ethiopia

Renewable energy potential assessment and modeling for improving electric energy accessibility in rural areas of northwest Ethiopia

Virtual Expansion of the YMCA's Blood Pressure Self-Monitoring (BPSM) Program: Using Telehealth to Adapt an Evidence-Based Program to Reach Rural Communities in South Carolina.

Disparities in cardiovascular disease prevalence and death exist among South Carolina's rural residents. Blood pressure self-monitoring (BPSM), where individuals measure their own blood pressure outside of the clinical environment, coupled with additional support, is an evidence-based, cost-effective strategy that is underutilized at large. The YMCA's BPSM program is an evidence-based, 4-month program that includes 2 individualized office hours with a Healthy Heart Ambassador and 4 nutrition education sessions per month. Participants are provided with a blood pressure cuff and notebook to track their blood pressure at home in between sessions. The SC Department of Health and Environmental Control partnered with the SC Alliance of YMCAs to expand the YMCA's BPSM program virtually. The traditional program was adapted to allow for virtual participant encounters. To target rural communities, partnerships were leveraged or established with rural health centers, federally qualified health centers, free medical clinics, and other state health department regions for participant referrals into the program. A developmental evaluation design was utilized to monitor the virtual adaptation of the YMCA's BPSM program from April 2021 to May 2023. At the end of the project, 10 referral sources were identified to refer participants to the program. In total, 253 participants were referred to the program, 126 participants enrolled into the program, and 52 participants completed the program. Completers of the virtual program were successful in improving their blood pressure. Successes of the virtual program were not without challenges. Lessons learned from the virtual expansion of this program included ensuring participants' readiness to engage in a 4-month program, assessing participants' digital literacy, and considering broadband access in rural areas. Improvements in blood pressure and the program's reach demonstrate merit in continuing to scale the virtual adaptation of this program; however, contextual and structural factors should be considered.

Exploring rehabilitation providers’ perspectives of assistive technology access after the implementation of a paediatric AT provision program in rural South India

A paediatric Assistive Technology (AT) Provision Program was implemented by a non-governmental rehabilitation facility in rural South India to support rehabilitation providers in providing needed AT access for children with disabilities. Capacity-building measures for providers and other supports based on the AT needs, barriers, and facilitators to AT access were implemented that aligned with the AT global report for low-middle income countries (LMIC). This study explores how the initiatives from the AT Provision Program have influenced the perspectives of rehabilitation providers on AT access. Using a qualitative design eight paediatric rehabilitation providers were purposively sampled for virtual semi-structured interviews. Findings were analysed using thematic analysis. Six overarching themes were identified: (1) Stigma associated with AT use, (2) Organisational response to changing needs, (3) Financial factors related to family socioeconomic status and the organisation providing AT services, (4) Inequity of AT service access in rural areas, (5) Provider AT awareness and confidence and, (6) Quality assurance. Rehabilitation providers’ experiences informed future AT capacity-building strategies within a low-resource context. Our findings provide valuable insights for the development of comprehensive AT Provision Program initiatives to provide AT access for children with disabilities in LMIC settings.

Exploration of the Challenges in Adopting Smart Farming Among Smallholder Farmers: A Qualitative Study

Applications of smart farming have been introduced as a way out of various production issues in the agriculture sector, especially during the occurrence of COVID-19. Several technical studies have also been done to develop the modules that meet the operational requirements in Malaysia and determine their benefits and impacts on farmers. Despite the availability of smart farming technologies and their benefits to farmers’ productivity and profitability, adoption of smart farming among Malaysian farmers, especially in rural areas, remains a challenge. Therefore, a qualitative study among farmers in Sarawak and Sabah was conducted to determine the challenges that arise with the adoption of smart farming technologies. The results highlighted that farmer faced challenges in regard to the high startup cost of technology, lack of expertise and knowledge on technologies, connectivity and access in rural areas, farm size, and governmental support. In practice, this study also discussed the challenges of adopting smart farming mentioned by participants and some possible solutions for future attention.

Nutrition knowledge of caregivers and feeding practices of children 6-59 months in rural Kajiado central, Kenya

Abstract Introduction: Childhood malnutrition remains a critical public health concern, particularly in developing countries. This study explores the nutrition knowledge of caregivers and its association with feeding practices among children aged 6-59 months in the Maasai community of Rural Kajiado Central, Kenya. Traditional practices and cultural norms significantly influence daily life in this community, emphasizing the need to understand caregivers' nutritional knowledge and its association with child-feeding practices. Objective: The study aims to determine the association between nutrition knowledge of the caregivers and feeding practices among children aged 6-59 months in rural Kajiado Central, Kenya. Methods: A cross-sectional mixed study design was employed, with data collected from caregivers (N=294) using a pre-tested questionnaire. Nutrition knowledge was assessed through a nutrition test, and feeding practices were evaluated using a 24-hour recall and dietary diversity score. Focus Group Discussions provided qualitative insights. Data were analysed using SPSS V26, Nutri-survey software, and qualitative thematic analysis. Results: Caregivers demonstrated high nutrition knowledge (60.9% high, 3.4% very high), yet feeding practices revealed challenges. Most children consumed three meals daily, but dietary diversity was limited, focusing on cereals, milk, and fats. Despite high knowledge levels, there was no significant association between nutrition knowledge and several feeding practices (p>0.05). Conclusion: Improving dietary diversity requires addressing infrastructural barriers alongside nutrition education. The study emphasizes the complex interplay between nutritional practices, socio-economic factors, and educational opportunities, highlighting the need for holistic interventions. Recommendations: Infrastructure support is crucial to improving food accessibility in rural areas. Nutrition education alone may not suffice to enhance feeding practices and nutritional status.

An Innovative Retrofitting Technique of an Industrial Prefabricated Building Without Evacuation

This paper presents a seismic retrofit of an industrial-type precast reinforced concrete building structure using friction dampers. The project consisted of retrofitting two precast reinforced concrete buildings, one of which will be presented in this paper. Precast concrete is one of the industrial structures' most preferred construction methods due to its low cost, fast construction, and availability in rural areas. Unfortunately, most structures constructed before “Specification for Buildings to be Built in Seismic Zones(TBDY 2018)[5]” are not sufficiently engineered and are expected to perform poorly when exposed to a significant seismic event. The general characteristic of precast reinforced concrete buildings built before TBDY 2018 is their relatively high concrete quality (compared to cast-in-place reinforced concrete buildings) and better reinforcement workmanship. But they have some characteristic weaknesses as well. Weak beam-column connections, high drift ratios due to heavy beams, instability problems, and lack of frame behavior can be considered primary weaknesses. General classical retrofitting techniques include increasing beam/column sections or adding new reinforced concrete or steel members to the system or FRP(fiber-reinforced polymer) wrapping. Mostly classical retrofitting needs additional foundations. All these techniques require a long construction period, causing evacuation and stopping building usage. Because stopping the production cost can be tolerated by the owners, a retrofitting approach that can be assembled during the normal function of the industrial structures is required. As a result of this requirement, friction dampers are selected as the supplemental energy dissipation device. ASCE 41-17 [10] is employed for the building's damper design and performance evaluation. Before the damper study, some instability and weak connection problems are solved by traditional strengthening measures. The most effective damper configuration and capacities are selected after an iterative trial-and-error linear study using the simplified methods developed by PROMER. Nonlinear push-over analyses are conducted after linear prestudies. Finally, a nonlinear time-history analysis is performed for confirmation of the results. , It is shown that the proposed retrofit scheme satisfies the desired performance goals for both DBE and MCE events. Overall, it is considered that the proposed retrofit scheme with dampers provides the optimal solution for the Project stakeholders from a performance, design, constructability, and economic point of view. Some application photos will be presented, and methods will be explained in detail in the paper. The friction damper behavior is based on the rotational friction hinge concept. The dampers increase building damping, causing a decrease in earthquake demand. As a result, dampers provide passive energy dissipation and protect buildings from structural and nonstructural damage during moderate and severe earthquakes.

Rural healthcare access and supply constraints: A causal analysis

AbstractCertificate‐of‐Need (CON) laws require that healthcare providers receive approval from a state board before offering additional services in a given community. Proponents of CON laws claim that these laws are needed to prevent the oversupply of healthcare services in urban areas and to increase access in rural areas, which are predominantly underserved. Yet, the policy could lower rural access if used by incumbents to limit entry from competitors. We explore the repeal of these regulations in five U.S. states to offer the first estimate of the causal effects of CON laws on rural and urban healthcare access. We find that repealing CON laws causes a substantial increase in hospitals in both rural and urban areas. We also find that the repeal leads to fewer beds and smaller hospitals on average, suggesting an increase in entry and competition in both rural and urban areas.