Health Services In Remote Areas Research Articles

Reliability of Longshi scale with remote assessment of smartphone video calls for stroke patients' activities of daily living

ObjectivesThe impairment of activities of daily living (ADL) has brought a heavy burden to the life of patients after stroke. Timely and accurate assessment of patients' activities of daily living is very necessary, which determines the whole process of diagnosis, rehabilitation and prognosis of patients. However, the patients with limited mobility or transportation are difficulted to gain high quality assessment services. This study aimed to explore the reliability of remote Longshi Assessment Scale of Activities of Daily Life (Longshi Scale) with smartphone video calls by comparing the consistency of remote assessment and bedside assessment, as well as the test-retest reliability of the remote assessment. The evaluation duration of these two methods was recorded and the level of satisfaction of patients was investigated. MethodsIn this prospective study, a total of 129 stroke survivors were recruited and accepted a bedside face-to-face assessment and a remote assessment by video calls. The Longshi Scale was used for both bedside and remote assessment and conducted with the inquiry between patients and evaluators. A satisfaction questionnaire was also launched. ResultsThe result of disability level evaluated from the bedside and remote assessments was highly consistent. The intraclass correlation coefficient with weighted kappa (wK) value was 0.86 (95% confidence interval, 0.80∼0.92). And test-retest of the remote assessment indicated an excellent agreement beyond chance, and its correlation coefficient with wK value was 0.96 (95% confidence interval, 0.92∼1.00). It took 74.44±55.3 s to complete the bedside assessment and 90.86±63.30 s to complete the remote assessment of Longshi Scale. There was no statistical significance in the assessment duration between these two methods (P = 0.056). Satisfaction surveys showed more than 85% of participants were satisfied or very satisfied with remote Longshi scale assessment. ConclusionsThe remote assessment of Longshi Scale with smartphone video calls is reliable and has high acceptance. This method can be readily implemented to evaluate the ADL of stroke patients to improve the capacity of rehabilitation and health services in remote areas.

The role of the Mobile Mental Health Units in mental healthcare delivery in rural areas in Greece: current challenges and prospects.

The present paper aims to highlight the importance of Mobile Mental Health Units (MMHUs) in the delivery of mental health services in remote areas in rural Greece. Since the foundation of the first MMHUs in the eighties till nowadays, those services have expanded in many rural areas and there is some evidence that they are effective in the management of patients with severe mental disorders. The care of those patients seems to contribute to a significant reduction in voluntary and involuntary acute admissions and in length of hospital stay. Cost/effectiveness analysis studies have also shown favorable results. Besides their regular clinical work, MMHUs conduct research, such as epidemiologic surveys. Other research explores the care of elderly patients in rural areas and the care of immigrants that permanently reside in Greece. Other research involves the study of psychotic disorders in the rural context, such as the long-term outcome, the patients' functioning, and the long-term treatment with benzodiazepines. Current challenges for MMHUs involve staffing, particularly for those run by public hospitals, and the retainment of highly trained personnel. Other important challenges are related to the aging of the rural population and the refugee/migrant influx. The MMHUs of the islands that initially accept the refugee flow, have already faced an increased number of new referrals. Given the disparities in mental healthcare between rural and urban areas, further enhancement of the MMHUs' operation is required, as well as continuing training of their workforce. Research at the national level is needed and could be the basis for the design and staffing of new services. The establishment of valid and broadly accepted clinical indices to measure treatment outcomes would facilitate research and ensure the recording and evaluation of the MMHUs' work and their effectiveness as well; and would highlight their utility within the contemporary health system.

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities.

Female Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey. A cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews. Amongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6-28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8-70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch. With our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women's health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level.

Rural Development Through Non-State Actors in Highlands of Pakistan

We explored the contribution and effectiveness of state and non-state institutions in rural development efforts in highlands (Khyber Pakhtunkhwa [KPK] province) of Pakistan. This study employed mixed-methods research design and data were collected from 300 household heads, randomly selected from six villages from two purposively selected districts Mansehra and Nowshehra. Findings showed people in KPK were deprived of due to conflicts, conspiracies and terrorism, poor governance, small landholdings and subsistence farming followed by sluggish marketing system, insufficient education and training for people, and inadequate employment opportunities. Regarding contribution, non-state institutions had more contribution as compared to state institutions. T-test analysis showed that the non-state institutions had an effective provision of agricultural extension and forestry advisory services, education, health services in remote areas, skill development, and provision of microcredit schemes. The results of F-test statistics showed highly significant difference among the perceived effectiveness of rural development activities of different types of non-state actors (localite, cosmopolite, and religious/faith-based) working in the research area. This study recommends state-owned rural development departments revisit their working mechanism and develop synergistic working relationship with the non-state institutions in discharging rural development efforts.

Expert system for heart disease based on electrocardiogram data using certainty factor with multiple rule

<span id="docs-internal-guid-b7163134-7fff-29de-9179-24e242f1239b"><span>Limited public health services in remote areas, where the lack of transportation infrastructure, facilities, communication facilities and minimal medical personnel, especially for areas with underdeveloped, foremost, and regular (3T) status. The limitation of medical personnel is one of the factors for the high mortality rate of heart disease. On the other hand, the development of information technology, especially in the field of computing, is very fast in the era of the industrial revolution 4.0, but not yet used optimally, especially in the health sector. This study aims to develop a system or software that can replace a doctor for the process of identifying heart defects based on an expert system. Expert system developed with the certainty factor with multiple rule approach. System testing is carried out from the results of the system validity with experts, so that the system test results produce a certainty factor value for a normal heart of 0.95 and an accuracy level of 95%, while the certainty factor (CF) value for an abnormal heart is 0.99 and produces an accuracy rate of 99%.</span></span><br /><div style="mso-element: comment-list;"><div style="mso-element: comment;"><div id="_com_1" class="msocomtxt"><!--[if !supportAnnotations]--></div><!--[endif]--></div></div>

Autonomy of patients in emergency services in the border area: A phenomenology study

Abstract The absence of hospitals is one of the problems that arise in health services in remote areas. To get further medical care, patients must be referred outside the island. The purpose of this study was to reveal the situation and experience of patients in emergency treatment in border and coastal areas in North Kalimantan. This study was designed with a qualitative method and a descriptive phenomenological approach was used. It involved 10 participants who lived on Sebatik island with the criteria of having experience with emergency cases and being referred out of the island. Data analysis was performed using a thematic analysis of Braun and Clarke (2006). Three themes emerged from this study: inappropriate emergency actions, patients’ choice of using the right to be referred, and assistance in challenging referrals. It was revealed that emergency management was not maximal due to the limitations of health workers and service facilities. Patients chose the right to be referred to as an effort to get better health services.

Regional government concerns in health services in remote areas: Case study on special capitation policies in North Bengkulu Regency

The Minister of Health Regulation No. 52 of 2016 states that the tariff for first-level health services in remote areas and islands is determined based on special capitation tariffs, which is greater than the usual capitation tariffs. In North Bengkulu there is a primary health care that does not include a special capitation even though the criteria are the same as the primary health care that received it. The perception of stakeholders involved is needed to see whether the determination of criteria for disadvantaged areas for recipients of special capitation funds is in accordance with existing regulations or not.The study was based on in-depth interviews with 6 respondents from 6 institutions (Local Government, Regional Secretary, Health Office, the BPJS health branch office, and two Primary health care). The local government does not help question that matter to BPJS or help in other ways so that health care that do not receive special capitation funds can still provide optimal services like other remote health care. This study found the lack of socialization about health services in remote areas to non-health officials in local governments is the causes of weak support by local governments. This research shows that the application of central policies without joint review and verification with local stakeholders can lead to unproductive situations. Local governments should also look for solutions so that health care in remote areas that do not receive special capitation funds continue to run optimally.

The actual scope of nursing practice in community health services in remote areas

Nurses can help improve access to health services and the quality of the care, provided that they fully engage in their field of practice. Conducted in Quebec in a remote region far from any major urban centers, this study aims to 1) measure the actual scope of nursing practice (ASCOP) in community health services and 2) determine the individual and work-based characteristics that influence it. This study uses a transversal description of work.Forty-four (44) nurses practicing in different types of community health services were invited to answer an online questionnaire. The results indicate a suboptimal ASCOP. Activities related to improving the quality and safety of care obtained the lowest scores. Activities with the highest scores were the assessment and planning of care, the education of individuals and their families, and updating and using knowledge. While no characteristics influenced the overall ASCOP, significant differences were found for gender, weekly working time, and sub-regions for certain dimensions of the ASCOP. The findings offer some insight into nursing practices in community health services in remote areas. This portrait helps to formulate recommendations adapted to these contexts.

Outpatient health-seeking behavior of residents in Zhejiang and Qinghai Province, China

BackgroundThe eastern and western regions of China are different in many ways such as socioeconomic characteristics and health resource distribution. This study aimed to explore the outpatient health-seeking behavior and compare the influencing factors of residents in Zhejiang and Qinghai Province, which represent the situation in eastern and western China. Thus, this research will provide evidence for health resource allocation and health reform.MethodsA cross-sectional study was conducted on a sample selected from 1600 households in Zhejiang and Qinghai province between 2016 to 2017 by the multi-stage stratified cluster random sampling method. Among the 4231 residents aged 15 years or older in the sample, 566 who reported ill-health were selected for data analysis. Two-week outpatient visits and choice of health institutions were used to measure residents’ outpatient health-seeking behavior and assessed using Chi-square tests. The binary logistic regression was adopted to demonstrate the association between explanatory variables and outpatient visits.ResultsThe study revealed that out of the people who reported ill-health, 58 individuals (50.97%) in Zhejiang and 106 (41.41%) in Qinghai went to health institutions to seek medical help (p < 0.05). The difference of residents’ choice of health institution between Zhejiang and Qinghai was not statistically significant (p > 0.05). Among these respondents, Self-report severity was the common and significant factor related to their outpatient visits and it had a greater impact on outpatient visits in Zhejiang (4.18, CI 2.23–7.83, p < 0.05). Other factors such as chronic disease, knowledge of medicine and doctors and distance to the nearest health institution were significant influencing factors in Zhejiang, while in Qinghai it was occupation.ConclusionsThe outpatient health-seeking behavior and its influencing factors among residents in Zhejiang and Qinghai province were different. The findings suggest the importance of having discrepant health policies in the two provinces. It’s necessary to improve health literacy of residents in both provinces, strengthen the accessibility of health services in remote areas of Zhejiang and pay more attention to people with low socioeconomic status in Qinghai.

The Comparison of Effectiveness between Static Clinic and Mobile Health Clinic in Remote Areas in Sabah

Background: The population of Malaysia is estimated in 2018 to be around 32.04 million and 23.5% of the population resides in rural areas. The Ministry of Health has provided healthcare services to the rural areas with the access of modern healthcare facilities based on the two-tier healthcare system. In remote areas, mobile health clinic is the extension of healthcare service by the nearest static health clinic. However, most of the remote areas only covered by a community clinic or Klinik Desa which is limited for mother and child healthcare. There is demand from the people in remote areas for static health clinic or Klinik Kesihatan. Objectives: This study is to evaluate and compare the effectiveness between two health services in remote areas applied in Sabah. This study also determines which type of health services that able to worth the service to people in remote areas. Methods: This is a descriptive study. Data was taken from HMIS report (Per PL 206) under Sabah State Health Department. The data analysed by using Microsoft Excel. Results: This study was conducted based from the data obtained in 2015 till 2017 for the number of patients attended to static health clinics and mobile health clinics on selected remote areas. For example, Jambongan Health Clinic only have an average of 10 – 15 patients per day while the Mobile Health Clinic team under Beluran Health District which covers the adjacent remote areas of Jambongan Island have more than 20 patients per day on a single visit. Another example is from Terian Health Clinic in Penampang, which only have an averageof 5 – 10 patients per day. However, on the mobile health team on a single visit to the village next to Terian which is Kg. Buayan, the average patients attended for the service is mo re than 20 patients. Conclusion: From the study, it was noted that people in remote areas prefer the mobile health service to visit their villages. This can be due to financial issue and limitation of transportation service to the nearest static clinic. The density of population and the development of the rural areas play important roles for the healthcare service to be effective in remote areas.&#x0D; Keywords: mobile health clinic, static clinic, effectiveness of healthcare, primary healthcare

Increasing use of mental health services in remote areas using mobile technology: a pre-post evaluation of the SMART Mental Health project in rural India.

BackgroundAbout 25% of the Indian population experience common mental disorders (CMD) but only 15–25% of them receive any mental health care. Stigma, lack of adequate mental health professionals and mental health services account for this treatment gap, which is worse in rural areas. Our project evaluated task shifting and mobile–technology based electronic decision support systems to enhance the ability of primary care health workers to provide evidence–based mental health care for stress, depression, and suicidal risk in 30 remote villages in the state of Andhra Pradesh, India.MethodsThe Systematic Medical Appraisal Referral and Treatment (SMART) Mental Health project between May 2014 and April 2016 trained lay village health workers (Accredited Social Health Activists – ASHAs) and primary care doctors to screen, diagnose and manage individuals with common mental disorders using an electronic decision support system. An anti–stigma campaign using multi–media approaches was conducted across the villages at the outset of the project. A pre–post evaluation using mixed methods assessed the change in mental health service utilization by screen positive individuals. This paper reports on the quantitative aspects of that evaluation.ResultsTraining was imparted to 21 ASHAs and 2 primary care doctors. 5007 of 5167 eligible individuals were screened, and 238 were identified as being positive for common mental disorders and referred to the primary care doctors for further management. Out of them, 2 (0.8%) had previously utilized mental health services. During the intervention period, 30 (12.6%) visited the primary care doctor for further diagnosis and treatment, as advised. There was a significant reduction in the depression and anxiety scores between start and end of the intervention among those who had screened positive at the beginning. Stigma and mental health awareness in the broader community improved during the project.ConclusionsThe intervention led to individuals being screened for common mental disorders by village health workers and increase in mental health service use by those referred to the primary care doctor. The model was deemed feasible and acceptable. The effectiveness of the intervention needs to be demonstrated using more robust randomized controlled trials, while addressing the issues identified that will facilitate scale up.

The Influence of National Factors on Transferring and Adopting Telemedicine Technology

Telemedicine has drawn increasing attention as a beneficial healthcare delivery medium, especially in developing countries that struggle with physician and health professional shortages, through providing health services in remote areas. This paper presents the findings of a survey conducted to investigate the national factors influencing the adoption of telemedicine technology in Iran, as a less developed country. Designing a self-administered questionnaire the data were collected from the Chief Information Officers (CIOs) of Iranian healthcare system. The findings indicate that political factors such as Information and Communication Technology (ICT) policies, national data security policies, national e-health policies, national ICT infrastructures and rational decision-making, along with organizational factors such as organizational readiness and implementation effectiveness, are positively associated with telemedicine capability in Iran. However, no evidence was found to support the direct impact of cultural factors on transferring telemedicine technology in the country.

Genetic services and testing in the Philippines.

The Philippines is a developing middle-income country in Southeast Asia and is regarded as one of the fastest growing economies in the region. It became a Spanish colony for more than three centuries (16th to 19th century), after which the Americans took over until the Japanese came in the 1940s during World War II. With the help of the Americans, the Filipinos regained their freedom. The country became a republic and achieved sovereignty in 1946. With a very long history of colonizations and intermarriages, the Filipinos are said to be a mixture of different races, including Malay, Chinese, Spanish, Negrito and American. Most of the people in the country are Tagalog, and the rest belong to other ethnic groups such as Cebuano, Ilocano, Bisaya, Hiligaynon Ilonggo, Bikolano and Waray. Majority of Filipinos are Catholics, but Muslims and other Christian and non-Christian sects also play important roles in the society. The official languages used in the country are Filipino (Tagalog) and English (World Factbook 2011; Dolan 1991). In general, health indices in the country show an improving trend due to the programs of the Department of Health (DOH) and local government units (LGUs). However, despite this progress, issues of poverty and compromised access to health services in remote areas continue as pressing concerns. Additionally, the country’s health expenditure per capita remains on the low side compared to other countries in the region (UNDP 2009; UNESCO 2009). Delivery of medical genetic services remains to be a challenge in both private and public sectors. Since infectious diseases are still in the top ten causes of infant mortality and morbility, limited attention is given to congenital anomalies and other genetic diseases, despite the fact that congenital anomalies are included in the top ten causes of infant mortality (DOH 2006). This is aggravated by the lack of geneticists and genetic counsellors to serve the patients that are spread out in numerous islands.

Telepsiquiatría: innovación de la atención en salud mental. Una perspectiva general

IntroductionDevelopment and growth of the technological era require the exploration of new opportunities in health services. Telepsychiatry is a clear example of technology implemented in the solution of a specific problem, such as the provision of specialized mental health services in remote areas. ObjectiveTo describe strengths and barriers related to new technologies, focusing on the applications of telepsychiatry on mental healthcare, and possible opportunities for implementation and application in our scenario. MethodsReview of the medical literature in Medline, The Cochrane Library Controlled Trial Registry databases, Lilacs y Scielo (until January 2011), using the term “telepsychiatry”. A total of 244 articles were identified. Articles were selected manually by title and availability if they discussed the advantages and disadvantages of telepsychiatry specifically, or technology in general. Development and ConclusionsPublished data indicate that telepsychiatry and face to face treatments have comparable outcomes on different levels. Additionally, positive outcomes were found regarding costs and access in isolated places. In Colombia, there are legal and logistic opportunities to develop programs in this field.

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AUSTRALIA — Malaria Breakthrough in Australia. AUSTRALIA — Advances in Early Alzheimer's Diagnosis. AUSTRALIA — Genetic Test for Epilepsy Sufferers Developed By Victoria, Australia Scientists. AUSTRALIA — New R &amp; D Facility Leads Way for Australian Biotech Sector. AUSTRALIA — Australia Launches New Center to Focus on HIV Prevention, Treatment Research. CHINA — Genomics Center Researchers Identify Key Mechanism in DNA Damage Response. CHINA — Hemophiliacs in Guangdong Suffer From Lack of Treatment. CHINA — Microbix to Build Flu Vaccine Plant in China. CHINA — Applied Biosystems, 454 Life Sciences and Illumina Join 1000 Genomes Project. INDIA — Indian Scientists Develop GM Mice Through Transgenic Sperm. JAPAN — Experts Identify Genes for Bird Flu Replication. JAPAN — Boosting Survival of Insulin-cell Transplants For Type 1 Diabetes. JAPAN — Medtronic Launches First Insertable Cardiac Monitor in Japan. JAPAN — Sewing DNA Thread with Lasers, Hooks and Microbobbins. KOREA — CSD Korea launches its Patient Longitudinal Database. NEW ZEALAND — NZ Signs Science Agreement with EU. SINGAPORE — Singapore Researchers Identify Viral Factor That Induces Deadly Fungal Infection. SINGAPORE — Singapore, Indonesia Enhance Collaboration to Fight Bird Flu. SINGAPORE — Singapore Scientists Beat More Than 140 Teams to Claim Top Award at 46th American Society of Neuroradiology 2008 Meeting. TAIWAN — Government Plans Development of Five Bio-Agricultural Parks. TAIWAN — Local Researchers Cast New Light on Genetic Mutations. TAIWAN — Enterovirus Cases Hit Record High. VIETNAM — New Cholera Outbreaks in Vietnam. VIETNAM — Vietnam, WB Join Hands to Improve Health Services in Remote Areas.

Doctors and nurses in outback Australia: living with bush initiatives

This qualitative in-depth study investigates the work and life experiences of 18 female doctors and nurses in remote Australia. The study begins to unravel some of the events and relationships in the women's lives that keep them working and living in remote areas. The study also examines social and working conditions that cause the women to leave, and concludes that action must be taken at both government and local levels to support female health professionals who work in remote locations. This may be achieved by the means of a health promotion action model to underpin such initiatives as the 1999 Commonwealth Government 'fly-in-fly-out' initiative, in which sessional female doctors provide women's health services in remote areas.

The Ottawa telehealth project.

To examine the telehealth system as a means of improving access to cardiac consultations and specialized health services in remote areas of Ontario. The University of Ottawa Heart Institute has set up a telehealth test program, Healthcare and Education Access for Remote Residents by Telecommunications (HEARRT), in collaboration with industry and the provincial and federal government, as well as several remote clinical test sites. The program makes off-site cardiology consultations possible. History taking and physical examinations are conducted by video and electronic stethoscope. Laboratory results and echocardiograms are transmitted by document camera and VCR. The technology is being tested in both stable outpatient and emergency situations. Various telecommunications bandwidths and encoding systems are being evaluated, including satellite and terrestrial-based asynchronous transfer-mode circuits. Patient satisfaction and cost-effectiveness are also being assessed. Bandwidths from as low as 384 kbps using H.320 encoders to 40 Mbps using digital transport of NTSC video signals have been evaluated. Although lower bandwidths are sufficient for sending echocardiographic and electrocardiogram data, bandwidths with transport speeds of 4 to 6 Mbps appear necessary to capture the nuances of the cardiac physical examination. A preliminary satisfaction survey of 19 patients noted that all felt that they could communicate effectively with the cardiologist by video, and each had confidence in the advice offered. None reported that he or she would rather have traveled to the doctor in person. Initial and projected examination of the costs suggested that telehealth will effectively reduce overall health care spending while decreasing travel expenses for rural patients. Telehealth technology is sufficiently sophisticated to allow off-site cardiology assessments. Preliminary results suggest there is a sound business case for the implementation of telehealth technology to meet the needs of remote residents in northern Ontario. Working closely with government and industry, we will develop a marketing and commercialization plan to support the use of this technology throughout Ontario and expand application to patient education and continuing medical education.

Child health and pediatric nursing in the Kingdom of Lesotho

Lesotho's health policy is based on primary health care (PHC), which consists of safe water supplies, basic sanitation, and adequate food supply for nutritional needs. PHC also entails the prevention of endemic diseases via immunization, maternal and child health care, family planning, and treatment of common injuries. Since the 1979 adoption of this PHC strategy, 19 Health Service Areas (HSA) have covered the whole country. The Flying Doctor service provides health services in remote areas. Health care centers and clinics providing PHC are staffed by nurse clinicians and nurses, with a medical doctor visiting on scheduled days. The severely ill are referred to the HSA hospital by the nurse clinician. 80% of Basotho children have access to a health center by local transport within an hour, although in inclement weather access can be difficult. Free maternal care and care for children under 5 are testimony to the commitment of the government about the improvement of child health. PHC for children has focused on: 1) care of mothers and children, 2) immunization against communicable diseases, and 3) the treatment of chronic diseases. Mothers employed by the government and by nongovernmental organizations are given 60 days of maternity leave after delivery. Six weeks after delivery a complete physical examination is done at clinics; and preschool children pay visits to clinics one to four times a year. School- age children are seen by a nurse at least once a year. Despite these improvements, acute respiratory infection (ARI) still accounted for 46% of outpatient visits in 1988, and 22% of deaths were attributed to it in 1987. Pneumonia is responsible for 25% of child deaths, and in 1986 an estimated 600,000 cases of diarrhea occurred in children under 5. Oral rehydration therapy has become prevalent in hospitals and full immunization is improving. The training of nurses consists of a 3-year general program and a 1-year midwifery program, and has produced 900 registered nurses.