Face Additional Challenges Research Articles

Menstrual Hygiene Management: Challenges and Coping Strategies for Adolescents with Disabilities in the Kumasi Metro of Ghana

Purpose: Effective menstrual hygiene management is vital to the health, well-being, dignity, empowerment, mobility and productivity of girls and women. This study was conducted to ascertain menstrual hygiene management challenges and coping strategies of adolescents with disabilities in the Kumasi Metro of Ghana. Method: An exploratory study design with qualitative approach was employed to select 18 participants. Data was collected through in-depth interviews and focus group discussions, and then transcribed and categorised into specific themes. Results: Females with visual impairment had difficulty in maintaining good menstrual hygiene because of problems in detecting menstrual blood, inability to fix sanitary pads appropriately and wash underwear properly, and anxiety and stress from not knowing whether their period has started. The problems of those with physical impairment were related to inaccessible washrooms, long hours of being seated on the part of wheelchair-users, and difficulty in fixing sanitary pads for those with upper limb impairment. For those with hearing impairment, the main challenge was the communication barrier between them and their significant others whenever they needed help. Conclusion: There are common challenges faced by all girls across the globe with regard to menstrual hygiene management. Adolescent females with disability however face additional challenges with regard to MHM. Those with physical disability encounter accessibility challenges, while the main challenge for the deaf and those with speech problems is communication. The visually impaired live in anxiety due to fear of staining their clothes.

Depression, Anxiety, and Lifestyle Among Essential Workers: A Web Survey From Brazil and Spain During the COVID-19 Pandemic.

BackgroundEssential workers have been shown to present a higher prevalence of positive screenings for anxiety and depression during the COVID-19 pandemic. Individuals from countries with socioeconomic inequalities may be at increased risk for mental health disorders.ObjectiveWe aimed to assess the prevalence and predictors of depression, anxiety, and their comorbidity among essential workers in Brazil and Spain during the COVID-19 pandemic.MethodsA web survey was conducted between April and May 2020 in both countries. The main outcome was a positive screening for depression only, anxiety only, or both. Lifestyle was measured using a lifestyle multidimensional scale adapted for the COVID-19 pandemic (Short Multidimensional Inventory Lifestyle Evaluation–Confinement). A multinomial logistic regression model was performed to evaluate the factors associated with depression, anxiety, and the presence of both conditions.ResultsFrom the 22,786 individuals included in the web survey, 3745 self-reported to be essential workers. Overall, 8.3% (n=311), 11.6% (n=434), and 27.4% (n=1027) presented positive screenings for depression, anxiety, and both, respectively. After adjusting for confounding factors, the multinomial model showed that an unhealthy lifestyle increased the likelihood of depression (adjusted odds ratio [AOR] 4.00, 95% CI 2.72-5.87), anxiety (AOR 2.39, 95% CI 1.80-3.20), and both anxiety and depression (AOR 8.30, 95% CI 5.90-11.7). Living in Brazil was associated with increased odds of depression (AOR 2.89, 95% CI 2.07-4.06), anxiety (AOR 2.81, 95%CI 2.11-3.74), and both conditions (AOR 5.99, 95% CI 4.53-7.91).ConclusionsInterventions addressing lifestyle may be useful in dealing with symptoms of common mental disorders during the strain imposed among essential workers by the COVID-19 pandemic. Essential workers who live in middle-income countries with higher rates of inequality may face additional challenges. Ensuring equitable treatment and support may be an important challenge ahead, considering the possible syndemic effect of the social determinants of health.

Mathematics home-school partnerships in diverse contexts

The school and the home are both influential contexts in which a child learns mathematics, and therefore schools and families should work collaboratively to achieve shared goals for children’s mathematics learning. In culturally and linguistically diverse areas, schools have richness to draw on but may face additional challenges in engaging with parents from varying backgrounds. To understand these challenges, this study undertook a culturally focussed investigation of mathematics home-school partnerships within one diverse school in a low socio-economic area of Auckland, New Zealand. Teachers responded to a questionnaire, and focus group interviews were held with diverse groups of parents. Findings indicated tensions regarding differing mathematics pedagogies used at school and by parents and different desires around formal communication about mathematics learning. The diversity of the school generated further challenges because different parent groups dealt with the tensions in different ways. Knowing more about these parental approaches may help diverse schools to design programmes and craft communication that include more of their community in mathematics teaching and learning.

Applying Psychotherapeutic Principles to Bolster Resilience Among Health Care Workers During the COVID-19 Pandemic.

The COVID-19 pandemic has affected the entire globe with overwhelming speed and impact. The pandemic is both highly threatening and poorly understood, typical of deeply distressing conditions. Stress associated with uncertain recommendations from authorities, fear of illness and contagion for oneself and one's loved ones, extended periods of isolation, moral conflicts, financial instability, perception of discrimination and/or stigma, and ongoing loss and grief imperil mental health and resilience among the general population and high-risk groups. Health care workers (HCWs) face additional challenges that increase their vulnerability to distress and burnout. Bolstering resilience among HCWs can allow them to continue working with the intensity and focus their jobs require, which in turn supports the overall functioning of the health care system. Given their training in understanding wellness, distress, and psychotherapeutic treatment, mental health clinicians are well positioned to respond to this need. By studying the lessons from past and present experiences with public health emergencies and by incorporating principles from psychotherapeutic literature and training, clinicians can help facilitate an informed and effective response. The goal of this article is to discuss the development of a resilience coaching model that is rooted in principles from psychotherapeutic literature and practice to support psychological well-being among hospital-based HCWs. This model, developed to support the authors' health care colleagues working in a Toronto hospital, is generalizable, can be adapted for use by any mental health clinician, and makes explicit how previous training in psychotherapy may be applied to coaching and supporting frontline HCWs.

Healthcare worker perceptions of the implementation context surrounding an infection prevention intervention in a Zambian neonatal intensive care unit

BackgroundInfants in the neonatal intensive care unit (NICU) are particularly susceptible to healthcare-associated infections (HAIs). NICUs in low- and middle income countries face additional challenges to HAI prevention. There is a need to better understand the role of the implementation context surrounding infection prevention interventions in low- and middle income countries.AimThe aim of this study was to identify NICU healthcare worker perceptions of an intervention to reduce bloodstream infections in a large Zambian NICU.MethodsSemi-structured interviews were conducted with NICU staff during a prospective cohort study examining the impact of an infection prevention bundle on bloodstream infections. Interviews were analyzed using an integrated approach, combining inductive theme generation with an application of the Consolidated Framework for Implementation Research (CFIR).ResultsInterviews were conducted with 17 NICU staff (5 physicians and 12 nurses). Respondents believed the bundle elements were easy to use, well-designed and facilitated improved performance. Four organizational characteristics that facilitated HAI transmission were identified – (1) lack of NICU admission protocols; (2) physical crowding; (3) understaffing; and (4) equipment shortages. Respondents suggested that NICU resource constraints reflected a societal ethos that devalued the medical care of infants. Despite the challenges, respondents were highly motivated to prevent HAIs and believed this was an achievable goal. They enthusiastically welcomed the bundle but expressed serious concern about sustainability following the study.ConclusionsBy eliciting healthcare worker perceptions about the context surrounding an infection prevention intervention, our study identified key organizational and societal factors to inform implementation strategies to achieve sustained improvement.

LGBTQ cultural competence for pharmacists

LGBTQ cultural competence for pharmacists

Building Partnerships to Provide Financial Opportunities for Minority Pharmacy Students

Abstract: The American Association of Colleges of Pharmacy (AACP) partnered with CVS Health to develop a Minority Scholarship for Pharmacy Students. The collaboration reflected an alignment of goals by the two organizations to promote diversity and support minority students and pharmacists who will care for an increasingly diverse population of patients. The scholarship was created with the recognition that minority students often face additional challenges associated with the cost of education and that diversity in the classroom can have a positive impact on educational and patient-care outcomes. The high number of applications received for a limited number of scholarships per year suggests that there is significant need in the minority community and more needs to be done.

Preventing mental health conditions in adolescents living with HIV: an urgent need for evidence.

IntroductionAs adolescents transition from childhood to adulthood, they experience major physical, social and psychological changes, and are at heightened risk for developing mental health conditions and engaging in health‐related risk behaviours. For adolescents living with HIV (ALHIV), these risks may be even more pronounced. Research shows that this population may face additional mental health challenges related to the biological impact of the disease and its treatment, the psychosocial burdens of living with HIV and HIV‐related social and environmental stressors.DiscussionPsychosocial interventions delivered to adolescents can promote positive mental health, prevent mental health problems and strengthen young people’s capacity to navigate challenges and protect themselves from risk. It is likely that these interventions can also benefit at‐risk populations, such as ALHIV, yet there is little research on this. There is an urgent need for more research evaluating the effects of interventions designed to improve the mental health of ALHIV. We highlight four priorities moving forward. These include: generating more evidence about preventive mental health interventions for ALHIV; including mental health outcomes in research on psychosocial interventions for ALHIV; conducting intervention research that is sensitive to differences among ALHIV populations and involving adolescents in intervention design and testing.ConclusionsMore robust research on promotive and preventive mental health interventions is needed for ALHIV. Programmes should be informed by adolescent priorities and preferences and responsive to the specific needs of these groups.

Barriers to sexual recovery in men with prostate, bladder and colorectal cancer.

Survivors of prostate, bladder, and colorectal cancer endure many sexual side-effects of treatment that negatively impact their relationships and diminish their quality of life. Multiple barriers exist in addressing men's sexual concerns in oncological care. To describe barriers of sexual recovery in men with prostate, bladder, and colorectal cancer. We searched PubMed for peer-reviewed, English-language articles published from 1999 to 2019 using the following search terms: "prostate cancer," or "bladder cancer," or "colorectal cancer," and "male," and "sexual function," or "sexual barrier" or "sexual dysfunction." Criteria for inclusion consisted of peer-reviewed articles (review, cross-sectional, longitudinal, interventional, or pilot studies) addressing sexual issues in men with a history of prostate, bladder, or colorectal cancer. Barriers to sexual recovery in men with prostate, bladder, and colorectal cancer include psychosocial barriers such as the feeling of loss, grief, depression and anxiety, the poor utilization, and excessive cost of pro-erectile aids, a diminished sense of masculinity and reluctance to seek help for sexual problems, as well as poor couple coping. Barriers in healthcare also exist, as healthcare providers often do not effectively address sexual issues due to poor communication, lack of comfort in discussing sexual issues, time constraints, and patients' hesitation to initiate discussions on sexual dysfunction. Patients with stomas and gay, bisexual, and queer men face additional challenges in their recovery of sexual intimacy. Barriers to sexual recovery are present in men during all stages of cancer and all modalities of treatment including surgery, radiation, or androgen deprivation therapy. There are multiple overlapping psychosocial and healthcare system barriers to sexual recovery after prostate, bladder, and colorectal cancer treatment. Oncological providers must be cognizant of these complex barriers so they can facilitate patients' access to resources needed for successful sexual recovery after genitourinary cancer treatment. Evidence based interventions, such as couple psychosexual counseling and peer support should be implemented via multidisciplinary care.

The Current State of HIV and Aging: Findings Presented at the 10th International Workshop on HIV and Aging.

With increasing effectiveness of antiretroviral therapy, people with HIV (PWH) are living longer and the prevalence of older PWH continues to increase. Accordingly, PWH are experiencing an increased burden of age-related comorbidities. With this shifting demographics, clinicians and researchers face additional challenges in how to identify, address, and manage the complex intersections of HIV- and aging-related conditions. Established in 2009, the International Workshop on HIV and Aging brings together clinicians and researchers in cross-disciplinary fields along with community advocates and PWH to address the multidisciplinary nature of HIV and aging. This article summarizes plenary talks from the 10th Annual International Workshop on HIV and Aging, which took place in New York City on October 10 and 11, 2019. Presentation topics included the following: the burdens of HIV-associated comorbidities, aging phenotypes, community engagement, and loneliness; these issues are especially important for older PWH, considering the current COVID-19 pandemic. We also discuss broad questions and potential directions for future research necessary to better understand the interaction between HIV and aging.

Identifying, Replicating, and Spreading Health care Innovations across a Nation‐Wide Health care System: VHA Diffusion of Excellence

Research ObjectiveLarge health care systems and organizations face the challenge of identifying, replicating, and spreading evidence‐based innovation across health care system locations. The Diffusion of Excellence (DoE) program aims to incentivize implementing and spreading innovations across the nationwide Veterans Health Administration (VHA). VHA frontline staff submit successfully implemented innovations/practices to a “Shark Tank” competition, in which VHA facility directors place bids to support further implementation. DoE designates the best submission as Gold Status Practices (GSPs), and “winning” bidders receive 6‐months of external facilitation to implement their GSP. DoE then provides national support for diffusing successful GSPs across the VHA. We present results from a mixed‐methods evaluation focused on motivations for program participation, adopting innovations, predictors of implementation, and innovation maintenance/sustainability.Study DesignThe evaluation utilizes the Consolidated Framework for Implementation Research (CFIR). Data sources include: (a) metrics on innovation adoptions linked to VHA facility characteristics; (b) tracking of project specific metrics for practices receiving intensive support for national spread (e.g., potential costs averted, individuals served); (c) 2 focus groups with bidders; (d) observations of 7 DoE events; (e) 143 participants in semi‐structured interview of facility leaders, innovation developers, teams implementing Shark Tank innovations, and implementation facilitators; and (f) 4 surveys of DoE stakeholders. Results are summarized based on the RE‐AIM (Reach‐Effectiveness‐Adoption‐Implementation‐Maintenance) evaluation framework.Population StudiedInnovations aimed at 146 VHA facilities/individual health care systems.Principal FindingsREACH—In the first four Shark Tank rounds, 1676 promising innovations/practices were submitted, with 47 designated as GSPs. EFFECTIVENESS—The impact of specific practices varied. However, impacts have been associated with greater use of evidence‐based services and improved administrative functioning. ADOPTION—Motivations for participating in the DoE process varied among individuals with key roles. Innovations frequently arose from “passion” projects to address identified issues. VA facility/medical center leaders often focus on “big picture” quality metrics and getting middle manager support. Front‐line staff varied in their motivation to implement new projects, potentially leading to a mismatch in stakeholder motivation. IMPLEMENTATION success—approximately half of facilitated‐implementation efforts were fully successful. CFIR themes of Engaging Key Stakeholders and Available Resources received ratings that varied based on level of successful implementation (i.e., fully, partially, or not successful). While sites reported some degree of concern with External Policies and Incentives (e.g., challenges quickly hiring staff), all tried to overcome these challenges with the assistance of External Change Agents (e.g., facilitators and practice developers). MAINTENANCE—At the facility‐level, 74% of facilities originating or receiving facilitated‐implementation support have maintained the practice, including facilities that may have taken longer than 6 months for initial implementation. VHA‐wide, 834 decisions to adopt GSPs have been documented.ConclusionsDoE’s innovative Shark Tank approach identified a large number of candidate practices, successfully promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across VHA.Implications for Policy or PracticeAs health systems grow in size and complexity, they face additional challenges in identifying, prioritizing, replicating, and spreading best practices. DoE offers a potential model for other health systems and can be a key strategy to move toward being a learning health system.Primary Funding SourceDepartment of Veterans Affairs.

Delays in Death Reports and their Implications for Tracking the Evolution of COVID-19

Understanding the determinants and implications of delays in reporting COVID-19 deaths is important for managing the epidemic. Contrasting England and Mexico, we document that reporting delays in Mexico are larger on average, exhibit higher geographic heterogeneity, and are more responsive to the total number of occurred deaths in a given location-date. We then estimate simple SIR models for each country to illustrate the implications of not accounting for reporting delays. Our results highlight the fact that low and middle-income countries are likely to face additional challenges during the pandemic due to lower quality of real-time information.

Impact of Perceived Health Competence on the Quality of Life of Emerging Adults With Chronic Health Conditions

Emerging adults with chronic health conditions (CHCs) face additional challenges compared to their peers during this transitional period, which can exacerbate their symptoms and negatively impact their quality of life (QoL). This study assessed the impact of CHC status and the potential protective factor of perceived health competence (PHC) on QoL. Nine hundred twenty-nine emerging adults, aged 18–25 years ( M age = 22.19, SD = 1.95; 55% female), participated in the current study as part of a larger online survey. Results showed that those with a CHC reported significantly lower QoL than those without a CHC. Additionally, higher PHC was associated with higher QoL for both groups of emerging adults. Although the current study identified some factors that may differentially impact this positive association, the results consistently suggest that promotion of emerging adults’ PHC may play a key role in improving their QoL during this transitional period, regardless of CHC status.

EFFECTIVE WAYS TO INCREASE THE SECURITY OF STORING INFORMATION IN A DATABASE

In the era of rapid technological development, the issue of information security is very relevant. The article discusses issues related to information security in computer systems due to the simple and quick copying of information through communication channels. The problem of information security covers a wide range of issues, from the legislature to a specific technical device. Program developers suggest the need for technical means of protection that provide a high level of information security. Experience has shown that software cannot guarantee information security. Therefore, any software must be supplemented by organizational measures that determine the rules for access and storage of information. In practice, software users face additional challenges when using security tools. This article presents a classification of guarantees and methods of self-defense, as well as methods of protection by requesting additional information.

Adaptation and evaluation of a nutrition and physical activity program for early childhood education settings in Aboriginal and Torres Strait Islander communities in remote Far North Queensland.

Good nutrition, physical activity and adequate sleep are essential for the healthy growth and development of young children. Due to complex cultural, historical, social factors, Aboriginal and Torres Strait Islander children face additional challenges to optimal health, particularly in remote areas of Australia. 'Learning, Eating, Active Play and Sleep' (LEAPS) was a Queensland-wide professional development program designed to support early childhood education and care (ECEC) educators to implement and reinforce healthy nutrition and physical activity in their services. This article describes the adaptation, implementation and evaluation of LEAPS for remote ECEC settings in Cape York. An Aboriginal and Torres Strait Islander Reference Group was commissioned to provide advice about the appropriateness of the existing program for Aboriginal and Torres Strait Islander ECEC settings. Based on the advice of the Reference Group, the program was adapted for use in Cape York and was evaluated using the RE-AIM framework and a combination of data sources. Quantitative data provided information about changes to participant knowledge and confidence regarding nutrition and physical activity and in-depth interviews allowed further insights into enablers and challenges for successful program implementation. A tailored LEAPS program increased participants' knowledge and confidence regarding nutrition and physical activity in ECEC settings. The importance of community consultation, building relationships and face-to-face delivery of training were highlighted as key enablers. The evaluation identified a number of challenges relating to competing priorities, limited support for ongoing implementation and adoption of improved practices. SO WHAT?: Poor nutrition and growth in children in remote Aboriginal and Torres Strait Islander communities indicates the need for the ongoing commitment to and investment in nutrition and physical activity across a range of community settings. To achieve success, this requires a dedicated preventative health workforce supporting evidence-informed, coordinated programs driven by community priorities and developed via community development approaches.

A Qualitative Assessment of the Impact of the Rural Setting on Healthcare Professionals’ Work Experiences

There is no question that rural patients face a number of healthcare-related obstacles; however, rural healthcare challenges may also place a significant burden on healthcare professionals who treat these patients. Cancer care is already complex and challenging, but oncology professionals in rural settings may face additional challenges as a result of unique issues their patients face. Very little research has specifically assessed how distinct characteristics of the rural setting and patient population may impact rural oncology professionals’ work experience. The purpose of this study was to better understand the impact of the rural setting on oncology professionals’ work experience in hopes to identify future areas to target for recruitment and retention purposes. We utilized a qualitative case study design. Multiple healthcare professionals, including oncologists, nurses, social workers, and administrators, were interviewed, and a number of challenges and benefits to providing rural healthcare were identified. Overall, we provide a holistic, interdisciplinary approach to understanding positive and negative work experiences associated with providing rural care. We also provide a foundation for future research to better understand direct connections between rural healthcare, and challenges and benefits faced as part of oncology professionals’ work experience.

CD11d is a novel antigen on chicken leukocytes

In life sciences, antibodies are among the most commonly used tools for identifying, tracking, quantifying and isolating molecules, mainly proteins. However, it has recently become clear that antibodies often fall short with respect to specificity and selectivity and in many cases target proteins are not even known. When commercial availability of antibodies is scarce, e.g. for targeting proteins from farm animals, researchers face additional challenges: they often have to rely on cross-reactive antibodies, which are poorly characterized for their exact target, their actual cross-reactivity and the desired application.In this study, we aimed at identifying the true target of mouse monoclonal antibody 8F2, which was generated against chicken PBMC and used for decades in research, while it's actual target molecule remained unknown. We used 8F2 antibody for immunoprecipitation in chicken PBMC and subsequently identified its true target as CD11d, which was never described in chicken lymphocytes before, by quantitative LC-MSMS. The most abundant interactor of CD11d was identified as integrin beta 2.The existence of this alpha integrin was therefore clearly proven on protein level and provides a first basis to further assess the role of CD11d in chickens in future studies.Data are available via ProteomeXchange with identifier PXD017248. SignificanceOur studies determined CD11d as the true target of a previously uncharacterized mouse monoclonal antibody 8F2, generated against chicken peripheral blood derived mononuclear cells (PBMC). This is therefore now first member of alpha integrins in chickens, that existence was now clearly identified on protein level. The additional identification of CD11d interactors provides information on integrin-dependent regulation of signaling networks, allowing further functional studies.

Experience of sexual and gender minority youth when accessing health care in Turkey.

Lesbian, gay, bisexual, transgender and questioning (LGBTQ) patients report alarming rates of identity-based discrimination in healthcare settings. Despite the health risks and challenges impacting LGBTQ young adults, little is known about their healthcare experience, especially in Turkey. This study aimed to increase the knowledge base on LGBTQ young individuals' experiences when accessing health care in an attempt to address the myriad of health disparities they might face. Participants were recruited from the division of Adolescent Medicine at Hacettepe University, and also from an LGBTQ support group. Participants' responded to open-ended items asking about their experiences in the healthcare setting, in particular to any case of discrimination and reasons for non-disclosure of gender identity/orientation. A total of 24 LGBTQ youth completed the interview, mean age 21.1 years. Overall participants reported alarming rates of identity-discrimination and non-disclosure when accessing health care. Additionally, participants reported high rates of postponing care as they felt they would be subjected to LGBTQ-based discrimination. Furthermore results suggest that transgender individuals face additional healthcare challenges compared with their LGB and cisgender counterparts. To the best of our knowledge this is the first study in Turkey to evaluate the experiences of LGBTQ youth accessing medical care. This study shows that similar to barriers observed in previous studies on LGBTQ individuals, discrimination when accessing healthcare is a serious problem. Increasing knowledge concerning the discrimination LGBTQ people face when accessing healthcare is essential to decreasing healthcare disparities.

COVID-19 Preparedness in US Home Health Care Agencies

ObjectivesIn the United States, home health agencies (HHAs) provide essential services for patients recovering from post-acute care and older adults who are aging in place. During the COVID-19 pandemic, HHAs may face additional challenges caring for these vulnerable patients. Our objective was to explore COVID-19 preparedness of US HHAs and compare results by urban/rural location. DesignCross-sectional study. Setting/ParticipantsUsing a stratified random sample of 978 HHAs, we conducted a 22-item online survey from April 10 to 17, 2020. MethodsSummary statistics were computed; open-ended narrative responses were synthesized using qualitative methods. ResultsSimilar to national data, most responding HHAs (n = 121, 12% response rate) were for-profit and located in the South. Most HHAs had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with COVID-19 education and training (97%). More urban HHAs had cared for confirmed and recovered COVID-19 patients than rural HHAs, but urban HHAs had less capacity to test for COVID-19 than rural HHAs (9% vs 21%).Most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. Rural agencies were affected less than urban agencies. HHAs have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (PPE). Many HHAs reported accessing supplemental PPE from state/local resources, donations, and do-it-yourself efforts; more rural HHAs had accessed these additional resources compared with urban HHAs. Conclusions/ImplicationsThis survey reveals challenges that HHAs are having in responding to the COVID-19 pandemic, particularly among urban agencies. Of greatest concern are the declines in patient census, which drastically affect agency revenue, and the shortages of PPE and disinfectants. Without proper protection, HHA clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members.

Understanding risk in accountable care organisations

The US healthcare system is in the midst of a transition from reimbursement based on the volume of services to that based on the value and quality of services provided to patients. Accountable care organisations (ACOs), or groups of providers that come together to meet certain financial and care quality goals, are illustrative of this movement. This paper presents two prerequisites for a successful Medicare ACO, which serves aged and disabled beneficiaries. First, an ACO makes strategic use of population health techniques, including advanced primary care and nurse-led services such as annual wellness visits (AWV) and data-driven chronic care management (CCM). Second, an ACO must achieve significant scale to avoid unexplained swings in year-to-year savings and losses. The paper demonstrates that, in spite of early success, rural ACOs face additional challenges, including a strong aversion to risk in light of their economic fragility and community-based governance and random pricing inaccuracies created by cost-based reimbursement.