Clinics In Rural Areas Research Articles

Abstract 807: An ethno-phenomenology based approach to study breast cancer disparity in rural India

Abstract There are fundamental lack of right methodologies to study the breast cancer disparity in rural India. Here, we have used an ethnographic-phenomenology approach to study the disparity in breast cancer care in Assam by using retrospective database of a rural cancer care non-profit clinic, the KaviKrishna Telemedicine Care (KTC), set up 1994 to develop a CBPR based cancer care (Abstract 3342, AACR 2019). Methodology: For one and half years, the doctors, researchers, nurses, caregivers, and physician assistants of KaviKrishna Laboratory and KaviKrishna Telemedicine Care were interviewed (total number: 15), and plus literature of the lab and the clinic were studied. Then, the breast cancer patients (n=10) and the families were subjected to ethnographies-phenomenology study to find their experiences of treatment and suffering. Next, thematic analysis and grounded theory were applied to come up with novel approaches to reduce breast cancer disparity. For comparison, 5 patients from rich urban families were interviewed. Results: We found that 10/10 patients found it extremely difficult to navigate the complexity of care in urban hospitals, but found the KTC approachable and comfortable. Importantly, these 10 breast cancer patients were positively responding to our KTC based care services/focussed group discussion (https://zenodo.org/records/8062404). They revealed positive experiences in emotionally and psychologically dealing with diagnostic, surgery, and chemotherapy processes. Next, our analysis of the last 25 years of the care data at KTC showed that in rural population, the loweconomic status, inadequate access to breast cancer detection clinics, lack of awareness,indecisive treatment protocols and social stigma are the main reasons for breast cancer disparity. Grounded theory-based analysis indicates that cancer biomarker study in rural populations can be a suitable method for early detection. Whole genome sequencing of cancer tissue frombiopsy samples shall provide landscape of mutation in the entire coding as well as noncodingregions. Mutation profiling along with correlation studies from patients can lead to discoveryof novel marker(s). Primary health care clinics in rural areas can be trained to collect patientsamples, isolate genomic DNA and perform PCR for the markers (a similar model asfollowed during Covid-19). The PCR samples can be sent to non-profit advanced diagnostic center such as KaviKrishna Lab to perform sequencing to study mutation markers. The method is also cost effective to both thecare givers and the patients as compared to setting up advanced diagnostic lab in every part ofrural area. Conclusion: The community based participatory research based model developed by KTC can be an effective strategy to reduce breast cancer disparity in the rural population since the primary health clinics shall act as a bridge between geologically isolated areas and modern technology. Citation Format: Debduti Dutta, Rupam Das, Chayanika Das, Tulika Sarma, Sonali Das, Anuja Dutta, Tutumoni Baishya, Lekhika Pathak, Bikul Das. An ethno-phenomenology based approach to study breast cancer disparity in rural India [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 807.

How can we help doctors stay in rural areas of Japan? A comparison in medical students' attitudes toward general practice and clinical research of a medical school in Japan and in Sweden.

In Sweden, primary healthcare centers play an important role in the performance of general practice, education, and clinical research. In Japan, general physicians or general practitioners are expected to be more active in the small-scale hospitals and clinics in rural areas. This study aimed to explore the differences in attitudes toward general practice and clinical research among medical students in Japan and Sweden to present solutions to help doctors stay in rural areas of Japan. This cross-sectional study was conducted at two medical schools in Japan and Sweden in 2018, using an anonymous and self-administered questionnaire survey that comprised 16 items including 9 items on clinical research. Participants were 154 medical students (response rate: 69.4% for 222 students) in Japan and 56 (27.1% for 201 students) in Sweden. The proportion of medical students who wanted to become general physicians was greater in Japan than in Sweden (Japan:Sweden=36.4%:17.9%; P=0.012). Although fewer Japanese students wanted to conduct research in rural areas than Swedish students (43.5%:57.1%; P<0.001), the positive proportion of Japanese students working in clinical research and/or taking an academic degree in rural areas was greater than that of Swedish students (52.0%:23.2%; P=0.032). As Swedish medical students and young doctors learn considerably from primary healthcare centers, their attitudes toward clinical research are more developed than those of their Japanese counterparts. However, more Japanese medical students than Swedish students wish to become general practitioners, and they are likely to strive to conduct clinical research at small-scale hospitals/clinics in rural areas. Therefore, the improvement of the clinical research environment in small-scale hospitals and clinics in rural areas is needed at the earliest in Japan.

Challenges experienced by nurses in implementing Adolescent and Youth Friendly Services in clinics of the Limpopo province.

Effective implementation of Adolescent and Youth Friendly Services (AYFS) that are accessible, acceptable and effective for diverse youth population groups is significant to enhancing youth health. Because of various factors, improving youth health is a challenge in clinics in rural areas. This study aims to explore and understand the challenges nurses experience while implementing AYFS programmes in Kganya local area clinics of the Capricorn district, Limpopo province, South Africa. The study was conducted in the clinics of Kganya local area of Capricorn district, Limpopo province, South Africa. A qualitative, phenomenological, exploratory, descriptive design is employed in this study. Twelve nurses were selected using purposive sampling. Data were collected through semi-structured interviews with an interview guide. Notably, data were analysed using Tesch's open coding method. Two themes emerge from this study: 'Challenges experienced related to the implementation of Adolescent and Youth Friendly Services' and 'Suggestions to improve Adolescent and Youth Friendly Services'. The results of this study confirm that nurses experience diverse challenges while implementing AYFS. Challenges include a lack of trained staff and material resources and the negative attitudes of adolescents, parents and community members. This study's findings might help identify the gaps in implementing the AYFS programmes. The findings may assist policymakers and the National Department of Health (NDoH) to monitor and review the effectiveness of the AYFS programme standards.

Government Health Expenditure and Policy for Public Health Outcomes: A Systematic Literature Review

INTRODUCTION: The level of good governance, the efficiency of the healthcare system, and socioeconomic vulnerabilities all affect public health outcomes. Despite potential gains in terms of health outcomes, public healthcare investment has been extremely low in low-income countries. By improving the consolidation of healthcare system performance, this study helps the government and policymakers improve the quality of life in developing countries. MATERIALS AND METHODS: This study aims to assess the government health expenditure and policy for public health outcomes. The research is based on a review of empirical studies and reports. The PubMed search engine was used to locate research publications on government health expenditure and policy for public health outcomes. The PubMed Open Database was applied to find the publications using the keywords “health expenditure” and “health policy”. All papers that were published from January 1, 2013, to January 31, 2024, were checked for the study. 121 research papers were discovered during the initial inquiry; five duplicate articles were eliminated, and 84 were irrelevant to the study. Finally, 25 research papers and reports were selected for evaluation with the study titled “ Government Health Expenditure and Policy for Public Health Outcomes: A Systematic Literature Review”. RESULTS: Raising the nation’s social health insurance (SHI) coverage does not guarantee universal health care (UHC) or improved financial security. Extremely few people in poverty have health insurance and attempts to give them coverage through exemptions and waivers have not had the intended effect. To prevent families from being ruined due to family health problems, an innovative insurance plan needs to be created. Supply-side strategies, or health infrastructure, are needed to expand access to high-quality medical treatment. CONCLUSIONS: The quality of life in developing nations is directly improved by the consolidation of healthcare system performance, suggesting that policymakers should step in and offer financial and political help through a variety of policy options. Curative and preventive care are provided by health systems, which can greatly enhance people’s health. Developing a robust health finance system has been a primary objective for numerous countries worldwide, as increased public spending on healthcare leads to better health outcomes and more effective healthcare services. Financial limitations are one of the largest barriers to obtaining high-quality healthcare. A national health insurance program increased public financing for healthcare, and the construction of community-based clinics in rural areas could all contribute to the nation’s transition to universal health care. Policymakers ought to pay greater attention to the quality of care since it significantly affects the amount of money that patients must pay out-of-pocket. Governments must develop new internal financing sources and devise strategies to refocus on health promotion and prevention.

Lived experiences of diabetic outpatients attending clinics in rural areas of Limpopo province in South Africa.

Prevalence of diabetes mellitus is increasing in South Africa (SA), with many people unknowingly living with undiagnosed diabetes. Living with a long-term illness like diabetes significantly impacts every aspect of one's life. It is essential to understand the lived experience of patients to ensure better management and intervention. To explore the lived experiences of diabetic outpatients. Clinics of Senwabarwana, in Blouberg Local Municipality of the Capricorn District Municipality in Limpopo province of SA. Qualitative phenomenological exploratory descriptive study design was adopted to collect data from 17 diabetic patients. Purposive sampling was utilised to choose respondents. Data were collected through one-to-one interviews using voice recorders and field notes for nonverbal cues. Data were analysed using the eight steps of Tesch's inductive, descriptive and open coding technique. Respondents detailed difficulty disclosing their diagnosis due to feelings of shame. They also experienced stress and an inability to perform duties they used to perform before diagnosis. Male respondents detailed their experiences of sexual problems and a fear of losing their wives to other men as a result. Patients living with diabetes are unable to perform some tasks that they were able to perform before diagnosis. This could be attributed to poor dietary choices and a lack of social support, leading to patients missing critical elements of diabetes care. Quality of life of patients who are unable to perform their daily tasks should be assessed, with appropriate interventions introduced to curb further deterioration. Male diabetes patients experience sexual dysfunction and a fear of losing their wives, which exacerbates their stress. This study encourages the adoption of a family-centred approach, partnering with family members in the care of diabetic outpatients since most of the care takes place at home. Further studies are also recommended to design interventions which would address the experiences of patients for better outcomes.

An interactive geographic information system to inform optimal locations for healthcare services.

Large health datasets can provide evidence for the equitable allocation of healthcare resources and access to care. Geographic information systems (GIS) can help to present this data in a useful way, aiding in health service delivery. An interactive GIS was developed for the adult congenital heart disease service (ACHD) in New South Wales, Australia to demonstrate its feasibility for health service planning. Datasets describing geographic boundaries, area-level demographics, hospital driving times, and the current ACHD patient population were collected, linked, and displayed in an interactive clinic planning tool. The current ACHD service locations were mapped, and tools to compare current and potential locations were provided. Three locations for new clinics in rural areas were selected to demonstrate the application. Introducing new clinics changed the number of rural patients within a 1-hour drive of their nearest clinic from 44·38% to 55.07% (79 patients) and reduced the average driving time from rural areas to the nearest clinic from 2·4 hours to 1·8 hours. The longest driving time was changed from 10·9 hours to 8·9 hours. A de-identified public version of the GIS clinic planning tool is deployed at https://cbdrh.shinyapps.io/ACHD_Dashboard/. This application demonstrates how a freely available and interactive GIS can be used to aid in health service planning. In the context of ACHD, GIS research has shown that adherence to best practice care is impacted by patients' accessibility to specialist services. This project builds on this research by providing opensource tools to build more accessible healthcare services.

Application of Artificial Intelligence in Assessing the Self-Management Practices of Patients with Type 2 Diabetes.

The use of Artificial intelligence in healthcare has evolved substantially in recent years. In medical diagnosis, Artificial intelligence algorithms are used to forecast or diagnose a variety of life-threatening illnesses, including breast cancer, diabetes, heart disease, etc. The main objective of this study is to assess self-management practices among patients with type 2 diabetes in rural areas of Pakistan using Artificial intelligence and machine learning algorithms. Of particular note is the assessment of the factors associated with poor self-management activities, such as non-adhering to medications, poor eating habits, lack of physical activities, and poor glycemic control (HbA1c %). The sample of 200 participants was purposefully recruited from the medical clinics in rural areas of Pakistan. The artificial neural network algorithm and logistic regression classification algorithms were used to assess diabetes self-management activities. The diabetes dataset was split 80:20 between training and testing; 80% (160) instances were used for training purposes and 20% (40) instances were used for testing purposes, while the algorithms' overall performance was measured using a confusion matrix. The current study found that self-management efforts and glycemic control were poor among diabetes patients in rural areas of Pakistan. The logistic regression model performance was evaluated based on the confusion matrix. The accuracy of the training set was 98%, while the test set's accuracy was 97.5%; each set had a recall rate of 79% and 75%, respectively. The output of the confusion matrix showed that only 11 out of 200 patients were correctly assessed/classified as meeting diabetes self-management targets based on the values of HbA1c < 7%. We added a wide range of neurons (32 to 128) in the hidden layers to train the artificial neural network models. The results showed that the model with three hidden layers and Adam's optimisation function achieved 98% accuracy on the validation set. This study has assessed the factors associated with poor self-management activities among patients with type 2 diabetes in rural areas of Pakistan. The use of a wide range of neurons in the hidden layers to train the artificial neural network models improved outcomes, confirming the model's effectiveness and efficiency in assessing diabetes self-management activities from the required data attributes.

Lived experiences of diabetic outpatients attending clinics in rural areas of Limpopo province in South Africa

Health SA Gesondheid promotes communication, collaboration and teamwork between professions and disciplines within the health sciences to address problems that cross and affect disciplinary boundaries.

Pulmonary hypertension in developing countries: Limiting factors in time to diagnosis, specialised medications and contextualised recommendations.

Pulmonary hypertension (PH) is a fatal disease with no cure. Combination therapy that includes several specialised medications can improve survival and quality of life. However, there are many challenges, and these include a lack of effective screening tools, misdiagnosis and late diagnosis, a lack of awareness among clinicians and patients, expensive PH medication and the unavailability of these medications in many developing countries. Based on the literature, this paper provides helpful approaches and 'out of the box' ideas to try to surmount these challenges. We make the following recommendations: develop better (contextually fitting) screening tools, investigate novel therapeutics or novel drug targets, implement incentivised and accredited training for clinicians and implement awareness campaigns (by using traditional and social media and promoting awareness at healthcare or educational institutions). Other recommendations include greater advocacy that engages public and private funders, combine scarce skills and networks of social sciences and implementation sciences and invite non-profit organisations to the fight against PH in conjunction with researchers. Furthermore, the implementation of breathlessness clinics in rural areas can be helpful, as well as the investigation of the biomarker potential of genetic mutations or unique gene signatures of patients during research. We hope that healthcare professionals, researchers, scientists and regulatory authorities or research bodies, can use our recommendations in a practical setting, especially in developing countries where resources are limited and the healthcare burden is high.

Identifying the Roles of Medical Providers when Addressing Barriers to HPV Vaccination Rates in Rural NE Clinics

Background: Although many interventions to address vaccine hesitancy until now have operated on the presumption that misperceptions are due to a lack of knowledge about HPV and the vaccine, this may not always be the reason behind vaccine hesitancy. Nyhan et. al found [1] that correcting myths about vaccines- such as autism links or vaccine side effects- do not increase vaccine rates among adolescents. Medical providers play a crucial role on influencing parents’ decision to vaccinate. In a study exploring how vaccination coverage among children 19-35 months old is associated with health care providers' influence on the parents' decision to vaccinate, parents who report their providers as being influential in the study are twice as likely to respond that vaccines are safe for children [2]. In the 2016 Clinical Report on Countering Vaccine Hesitancy by the American Academy of Pediatrics, motivational interviewing is listed as a potential communication technique that may be useful as pediatricians discuss vaccines with vaccine-hesitant parents. Research Question: The research attempting to find the best approaches to reverse the increasing rates of unvaccinated minors is limited and inconclusive. This project addressed the impact of medical providers’ attitudes of HPV vaccination on their early adolescent patient populations. Methods: Our cohort prospective study first examined medical providers’ baseline attitudes and approaches of HPV vaccination in privately insured clinics in rural areas of Nebraska. A survey was sent to eleven Phase III patient centered medical home (PCMH) NE clinics. The survey assessed medical staffs’ attitudes and approaches to HPV vaccination, particularly among specific patient age groups. In addition to each clinic’s collective survey responses, baseline HPV vaccination data was collected at eleven Phase 3 PCMH rural clinics in Nebraska for pediatric patients 11-15-years-old. The follow-up intervention implemented educational interventions in the clinics to increase HPV vaccination rates for pediatric patients 9-15-years-old. Our educational outreach program at the selected 10-13 clinics will serve as these rural clinics’ first efforts to selectively work toward improving HPV vaccination rates. Results: America’s Health Rankings (2017) found 42.4% of adolescents living in rural areas compared to 52.4% in urban areas are up-to-date on their HPV immunizations. The eleven rural clinics selected for the study show only a 0.9% completion of the vaccine series for 9-11-year-old patients (n=855), and 25.0% completion of the series for 12-15-year-old patients (n=1268) as of 2019. This implies a pressing health disparity that needs addressing in rural Nebraskan communities. 92.6% of all respondents chose the 12-15 age range as the patient population the clinics would typically ask about the vaccine versus 59.6% who chose the 9-11 age range. The most chosen reason for not mentioning the HPV vaccine is “parents previously voiced vaccine hesitancy” (33.3%) followed by “not enough clinic time” (22.2%). The most popular reason contributing to parental hesitancy is “they have concerns the vaccine is not safe for their child” (70.4%). The greatest benefit of the HPV vaccine was listed as “prevention from multiple forms of cancer” (33.3%) and the greatest drawbacks were both “multiple dose series completion” (40.7%) and “difficulty in convincing parents to vaccinate minors” (40.7%). The 9-11 age range was chosen as the most difficult age group to vaccinate (33.3%). The most difficult scenarios when addressing HPV vaccination concerns were “lack of vaccine education” (55.6%), “religious reasons against the vaccine (44.4%), and “language/cultural barriers” (37%). Qualitative results were also analyzed separately and focused on each individual clinic’s strengths and weaknesses regarding vaccination encouragement. Discussion: The baseline patient data show that clinics selected for the study exhibit a large disparity of HPV vaccination rates among a vulnerable age group. Survey responses show both a clinical observation regarding parents’ low-level education levels about the HPV vaccine as well as a lack of comfort engaging in open dialogue between patients and healthcare personnel. Focusing on these two variables alone could help increase rates of vaccination significantly. Survey results ultimately illustrate the urgent need for empirically-supported educational resources that will enhance communication- both within individual clinics among staff as well as between medical staff and patients’ families- to sustainably increase HPV vaccination rates across rural clinics.

A Case Study on Gastric Cancer in South Korea versus France

Noncommunicable diseases (NCDs) unveil the stark disparities to health equity between developed countries across the globe. Although prevention, treatment, and research of certain NCDs are well-established and funded, others, specifically gastric cancer (GC), do not share the same notoriety. In particular, GC killed more than 768,793 people globally with 1.09 million GC diagnoses in 2020 alone (The Global Cancer Observatory, 2020). This data elucidates the merit of GC for the United Nations Sustainable Development Goal (SDG) initiatives. By examining social determinants between two economically similar countries through an evidence-based case methodology, the results may gleen into avoidable mortality and economic burden, successful prevention, and more favorable prognosis in decreasing the prevalence of GC. This review aims to compare South Korea and France which have one of the highest and lowest prevalence of GC, respectively. The concluding model will serve as a recommendation for countries with high prevalence of GC towards achieving SDG 3, which promotes health and wellbeing across the life course, while advocating for the declaration of health as a human right (United Nations, 2020). Pragmatic, tangible recommendations include partnerships with media to reduce alcohol consumption, sodium reduction campaigns and nutrition programs to promote healthy diets, and expansion of medical clinics in rural areas to reach those who lack access to proper healthcare.

Prevalence of Dyslipidemia and Availability of Lipid-Lowering Medications Among Primary Health Care Settings in China

Dyslipidemia, the prevalence of which historically has been low in China, is emerging as the second leading yet often unaddressed factor associated with the risk of cardiovascular diseases. However, recent national data on the prevalence, treatment, and control of dyslipidemia are lacking. To assess the prevalence, treatment, and control of dyslipidemia in community residents and the availability of lipid-lowering medications in primary care institutions in China. This cross-sectional study used data from the China-PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project, which enrolled 2 660 666 community residents aged 35 to 75 years from all 31 provinces in China between December 2014 and May 2019, and the China-PEACE primary health care survey of 3041 primary care institutions. Data analysis was performed from June 2019 to March 2021. Study period. The main outcome was the prevalence of dyslipidemia, which was defined as total cholesterol greater than or equal to 240 mg/dL, low-density lipoprotein cholesterol (LDL-C) greater than or equal to 160 mg/dL, high-density lipoprotein cholesterol (HDL-C) less than 40 mg/dL, triglycerides greater than or equal to 200 mg/dL, or self-reported use of lipid-lowering medications, in accordance with the 2016 Chinese Adult Dyslipidemia Prevention Guideline. This study included 2 314 538 participants with lipid measurements (1 389 322 women [60.0%]; mean [SD] age, 55.8 [9.8] years). Among them, 781 865 participants (33.8%) had dyslipidemia. Of 71 785 participants (3.2%) who had established atherosclerotic cardiovascular disease (ASCVD) and were recommended by guidelines for lipid-lowering medications regardless of LDL-C levels, 10 120 (14.1%) were treated. The overall control rate of LDL-C (≤70 mg/dL) among adults with established ASCVD was 26.6% (19 087 participants), with the control rate being 44.8% (4535 participants) among those who were treated and 23.6% (14 552 participants) among those not treated. Of 236 579 participants (10.2%) with high risk of ASCVD, 101 474 (42.9%) achieved LDL-C less than or equal to 100 mg/dL. Among participants with established ASCVD, advanced age (age 65-75 years, odds ratio [OR], 0.63; 95% CI, 0.56-0.70), female sex (OR, 0.56; 95% CI, 0.53-0.58), lower income (reference category), smoking (OR, 0.89; 95% CI, 0.85-0.94), alcohol consumption (OR, 0.87; 95% CI, 0.83-0.92), and not having diabetes (reference category) were associated with lower control of LDL-C. Among participants with high risk of ASCVD, younger age (reference category) and female sex (OR, 0.58; 95% CI, 0.56-0.59) were associated with lower control of LDL-C. Of 3041 primary care institutions surveyed, 1512 (49.7%) stocked statin and 584 (19.2%) stocked nonstatin lipid-lowering drugs. Village clinics in rural areas had the lowest statin availability. These findings suggest that dyslipidemia has become a major public health problem in China and is often inadequately treated and uncontrolled. Statins were available in less than one-half of the primary care institutions. Strategies aimed at detection, prevention, and treatment are needed.

The perceptions of professional nurses regarding factors affecting the provision of quality health care services at selected rural public clinics in the Capricorn district, Limpopo Province.

BackgroundDespite many initiatives made by the National Department of Health through the Minister of Health, the provision of quality health care services remains a serious challenge in South Africa, especially in public rural clinics.AimThe study aims to determine the perceptions of professional nurses on the factors affecting the provision of quality health care services at selected public primary health care clinics in rural areas of the Capricorn District, Limpopo Province.SettingThe study was conducted at selected public primary health care clinics in rural areas of the Capricorn District, Limpopo Province.MethodsThis study utilised a quantitative method, descriptive and a cross-sectional study conducted for three months at the selected public primary health care clinics. A structured self-administered questionnaire was used to collect data from 155 professional nurses who met the selection criteria. Data were analysed using Statistical Package for Social Sciences programme version 26.0.ResultsThe results of 155 professional nurses were only 116 (74%) and reported that the use of modern technology such as electronic blood pressure, sonar machines and pulse reading computers improves the quality of health care services. Also 129 (84%), 124 (77%) and 118 (76%) reported that they were overwhelmed by the workload, the staff attitude and cleanliness of the clinic, respectively, which all affect the quality of health care services rendered. Moreover, only about 29 (19%) were satisfied with the salary they earned.ConclusionDespite the effort and interventions put in place by the Department of Health with regard to the Ideal Clinic Realisation and Maintenance in response to the current deficiencies in the quality of primary health care services and to lay a strong foundation for the implementation of National Health Insurance. The quality of health care services is still hindered by several factors such as an overwhelming workload, the attitude of the staff and cleanliness in the work environment, poor infrastructure and the professional nurses perceive the environment as lacking equipment.

Psychological Experiences and Vulnerability of Lesbians, Gay, Bisexual, Transgender (LGBTI) in Access to Quality Health Care Services in Rural Areas of Zimbabwe

LGBT is an acronym for lesbians, gay, bisexual and transgender individuals who are characterised by sexual behaviour, identity, and desire. These individuals are most discriminated and stigmatised as a result of legal, cultural and religious landscape. LGBT are a hidden or invisible population with disproportional risks to health infections. The LGBT are placed outside prime laws of the land hence they are vulnerable to abuse, rejection and face some hindrances in accessing quality health care, education, and other social services. Accessing needed health care services is among the most daunting challenges that LGBT community confronts especially in the rural settings. Religiosity and cultural values, acts as a bigger impediment to access health care of people who practice ‘same gender loving’ in Sanyati rural areas of Zimbabwe. The LGBT experience sexual act through intercrural sex, fellatio, hand-jobs, foot-jobs, inter-gluteal sex, mammary sex, oral and axillary sex. The study used the Transformative Paradigm (TP) and Critical Emancipatory Research (CER) as the beacon of the research. This research design enables the researcher to explore the problems faced by LGBT population in accessing the much-needed health care services and their vulnerability. Data was gathered from the lesbians, gays, transgender and bisexual on their experience and vulnerability in accessing health care services in rural areas. Data was collected through social medial platforms and face to face through a snowball sampling and opportunistic sampling technique. The research findings revealed that LGBT face challenges of accessing the needed health care services due to fear of coming out, discriminatory and incompetent healthcare, lack of information, underrepresentation and lack of confidence. The study recommends opening up referral clinics in rural areas and offer education on the effects of not seeking health care services. The study also predicts that HIV/AIDS will not end so early due since the key population are left out as a result of legal and cultural issues.

Dementia care in rural areas: A cross‐sectional study from the Wisconsin Alzheimer’s Institute (WAI) Dementia Diagnostic Clinic Network

AbstractBackgroundThe Wisconsin Alzheimer’s Institute (WAI) Dementia Diagnostic Clinic Network includes 38 affiliated clinics across 24 healthcare systems in Wisconsin. Its purpose is to promote the use of evidence‐based strategies to provide high quality care for people with dementia across the state. The clinics follow a set of guidelines that are tailored to address the challenges of providing specialized care in rural areas (e.g. travel burden, transportation, limited resources, lack of trained healthcare providers, social isolation, among others). The purpose of this study is to describe the characteristics of patients seen in rural areas of Wisconsin, the care provided and how it compares to the models of care seen in urban areas.MethodsCross‐sectional study including the patients seen at the WAI’s Clinic Network between September 2018 and January 2020. Demographics, clinical diagnosis, and quality of care provided were compared according to rurality (metropolitan, micropolitan, rural) using the Urban‐Rural Classification Scheme for Counties (URCSC) which was assigned using the location of the submitting clinic.ResultsOver the study period, 1,769 patients were identified: 61% female, 69% between 65 and 84 years old, and 78% diagnosed with dementia or mild cognitive impairment. Overall, 15% of the patients were seen in rural areas, 8% in micropolitan areas, and 76% in metropolitan areas. Patients in rural areas were older, drove longer distances to the clinic, had lower educational attainment level, and were more likely to be self‐referred than those in metropolitan areas. Clinics in rural areas were more likely to provide educational materials, referrals to local resources in the first visit, and to refer patients for further neuropsychology or specialty evaluation before an etiology was identified. As a result, these clinics were less likely to provide a complete diagnosis in the first visit, but provide more caregiver support and management of behavioral symptoms.ConclusionsWAI’s affiliated clinics in rural areas of Wisconsin use referral patterns that differ from their counterparts in metropolitan areas, including making more connections to local resources. More research is needed to identify additional resources and clinic models to improve dementia care in rural areas.

Prevalence of speech language and hearing impairment in school going children of rural area: a longitudinal study

Background: This study aimed on identifying children with hearing, speech and language disorders in rural population that are not identified, diagnosed or rehabilitated yet. The study also focused on collecting a large data with increased study duration to give an appropriate representation of the findings in a rural population.Methods: Subjective tests were used to screen for hearing, speech and language disorders.Results: On performing audiological and speech language tests, 130 children were found to have hearing, speech and language disorders out of 1,453 children.Conclusions: The findings of this study indicate that there is a need to create an awareness and importance in identifying hearing and speech language disorders. This can be done by setting up clinics in rural areas, thus improving the accessibility of these diagnostic and rehabilitative services.

Nursing activities at clinics in rural areas in Japan: gaps between recognition of importance and implementation.

ABSTRACTThis study determined the level of implementation and the importance placed on various nursing activities at clinics in rural areas of Japan in order to explore the achievement and perceived importance of implementing certain nursing roles and activities at such clinics. To identify these items, a questionnaire was administered to 40 nurses working in rural clinics. The results showed that activities related to “Basic Nursing Practice” and “Community Understanding” were recognized as important and were performed by almost all nurses. Some activities related to “Administration and Operation” and “Cooperation with Local Government” were recognized as important, but were not implemented, thereby hampering the continuum of care across the health system. These activities, which are related to collaboration with hospitals and local governments that support the clinics, included adjustment of staff inside and outside the facilities to guarantee the use of paid holidays, as well as collaboration with acute care, remote medical systems, and local governments during emergencies and for disaster preparation. Additional support for nurses in collaboration between clinics in rural areas, hospitals, and regional administrations that support the clinics remains a challenge to be addressed.

Decentralized Health Service Delivery System in Bangladesh: Evaluating Community Clinics in Promoting Healthcare for the Rural Poor

The Awami League government of Bangladesh has established community clinics as decentralized healthcare units at the village level to ensure smooth and equal access to family planning, preventive health services, and limited curative care for the local community. The primary aspiration of this study is to evaluate the dynamics of service delivery systems under decentralized community clinics in rural areas of Bangladesh. It also aims to explore the challenges of accessing healthcare services and the impacts of decentralization on the promotion of the service delivery system of the community clinics. A qualitative field study was conducted in Sylhet District in the northeastern part of Bangladesh to collect the necessary data regarding the study objectives. The respondents were sampled through a purposive sampling method. Data collection was done through in-depth interviews and focus group discussions. The study findings revealed that the aspect of services in community clinics is being questioned due to different sociocultural, political, economic, and administrative stumbling blocks. If the government ensures skilled workforce, structural and technical support, locallevel planning, adequate funding, strategic coordination, and delegation of functions to address the challenges in providing health services to community clinics, then it is believed that these community-knit clinics would be considered as the lighthouse for providing primary healthcare for the disadvantaged rural sections of Bangladesh.

Lipid Management in the Primary Health Care Settings in China: Results from the China-PEACE Million Persons Project and Primary Health Care Survey

Background: Dyslipidemia, historically rare in China, may be common but has not been well studied. Methods: We used data from the China-PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project, a national cardiovascular disease screening project that enrolled 2·6 million community residents aged 35-75 in all 31 provinces from September 2014 through November 2018, and the China-PEACE primary health care survey of 3 529 primary care institutions. We assessed the prevalence, treatment, and control of dyslipidemia in community residents and the availability of lipid-lowering medications in primary care institutions. Findings: Among 2 314 858 participants with lipid measurements, one third (782 184; 33·8%) had dyslipidemia. Of 71 793 participants who had established atherosclerotic cardiovascular disease (ASCVD) and were recommended by guidelines for lipid-lowering medications regardless of low-density lipoprotein cholesterol (LDL-C) levels, 10 121 (14 ·1%) were treated and of those treated, 4 535 (44·8%) achieved LDL-C ≤70 mg/dL. Of 236 666 participants who had high risk of ASCVD, 101 511 (42·9%) achieved LDL-C ≤ 100 mg/dL. Advanced age, female sex, non-Han ethnicity, lower income, smoking, alcohol consumption, non-diabetes in participants with established ASCVD and younger age, female sex, non-Han ethnicity in participants with high risk of ASCVD were associated with lower control of LDL-C (all p<0·01). Of 3 529 primary care institutions surveyed, 49·7% stocked statin and 19·2% stocked non-statin lipid-lowering drugs. Village clinics in rural areas had the lowest statin availability. Interpretation: Dyslipidemia has become a major public health problem in China and is often inadequately treated and uncontrolled. Strategies aimed at detection, prevention, and treatment are needed. Funding Statement: The National Key Research and Development Program from the Ministry of Science and Technology of China (2018YFC1312400, 2018YFC1312401, 2018YFC1312404, 2017YFC1310800); the CAMS Innovation Fund for Medical Science (2016-I2M-1-006, 2017- I2M-2-002, 2017-I2M-BR the Major Public Health Service Project from the Ministry of Finance and National Health and Family Planning Commission of China; the 111 Project from the Ministry of Education of China (B16005). Declaration of Interests: HMK discloses that he is a recipient of a research grant, through Yale, from Medtronic and the U.S. Food and Drug Administration to develop methods for post-market surveillance of medical devices; is a recipient of research agreements with Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing; works under contract with the Centers for Medicare & Medicaid Services, through Yale, to develop and maintain performance measures that are publicly reported; was a recipient of a research agreement, through Yale, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion, and collaborates with the National Center for Cardiovascular Diseases in Beijing; received payment from the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation and from the Ben C. Martin Law Firm for work related to the Cook IVC filter litigation; chairs a Cardiac Scientific Advisory Board for UnitedHealth; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Boards for Element Science and for Facebook, and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. WS is a consultant for Hugo, a personal health information platform. All other authors declare no competing interests. Ethics Approval Statement: The central ethics committee at the China National Center for Cardiovascular Disease and the Institutional Review Board at Yale University approved this project. All enrolled participants provided written informed consent.

Risk status of pregnant women in rural areas of Belagavi: a cross sectional study

Background: ‘High-risk’ pregnancies account for a significant proportion of perinatal morbidity and mortality worldwide. Simple prenatal scoring systems can be used to assess risk status of pregnancy and inform subsequent management. Their use in rural areas and low-resource settings could be of particular benefit. This study employed pregnancy risk status assessment in one such area of rural India. The objectives of the study were to estimate the prevalence of low, moderate and high-risk pregnancy among women in a rural area of Belagavi and to identify factors associated with high-risk pregnancy status.Methods: This community-based cross-sectional study was undertaken among 105 pregnant women of all trimesters presenting to antenatal clinics in the Kinaye area of Belagavi, Karnataka, during July 2018. Information on risk factors and socio-demographic details were collected using a questionnaire, and individual risk scores calculated through a scoring system. This was used to estimate prevalence of low, moderate and high-risk status among participants, and subsequently compared against selected variables to identify factors associated with high risk pregnancy status.Results: Prevalence of high-risk pregnancy among participants was 31.4%, moderate-risk 30.5%, low-risk 29.5% and ‘no risk’ 8.6%. Maternal undernutrition was an important factor associated with high-risk pregnancy.Conclusions: This study highlights the need for early identification and appropriate management of such cases, in order to prevent adverse perinatal outcomes. The prenatal scoring system used in this study offers a simple method for risk status assessment in pregnant women of all trimesters, suited for use in antenatal clinics in rural areas of India.