Rural Catchment Area Research Articles

Prävalenz von spinalen Pathologien in einer konsekutiven Serie von CTs/MRIs in einem städtischen und ländlichen tansanianischen Krankenhaus – eine retrospektive neuroradiologische vergleichende Analyse

The prevalence of spinal pathologies in sub-saharan Africa has received little attention so far. The aim of the survey was to investigate and compare the prevalence pattern of spinal lesions in two different populations of Tanzania, one coming from the urban and semi-urban catchment area of Aga Khan Hospital in Dar es Salaam and the other coming from the rural catchment area of Haydom Lutheran Hospital in Mbulu, northern Tanzania. At the Aga Khan Hospital a total number of 1163 patients were included in the survey. In 50 cases (4.3%) no radiological findings were available and 150 patients (12.9%) showed no pathological abnormality. 90.4% (n = 1051) of screened population were classified in the category of extradural-extramedullary pathologies. Intradural-extramedullary lesions were observed in only three cases (0.3%). Intramedullary pathologies accounted for 2.1% (n = 24). Mean age of the screened population was 46.6 years, male-female ratio 1.08:1. At the Haydom Lutheran Hospital 105 cases were included into the study. Twenty-six patients (24.8%) showed no pathological abnormalities. Extradural-extramedullary pathologies occurred in 72.4% (n = 76) of overall cases. However, intradural-extramedullary pathologies were not seen in Haydom. Intramedullary pathologies were diagnosed in two patients (1.9%). Mean age was with 39.8 years clearly younger compared to urban areas, male-female ratio being 1.21:1, only non-significantly higher than in the Aga Khan Hospital's population. Beside this, one of the main goals of this study was to assess the frequency of infections to the spinal cord and vertebral column in rural and urban Tanzania. Surprisingly there were only few radiological findings at the Aga Khan Hospital, which suggested diagnoses consistent with tropical diseases, a striking difference from rural Haydom Lutheran Hospital, where nearly 30% of all patients showed changes on radiograph consistent with infections/infestations.

Imaging-based disease pattern in a consecutive series of cranial CTs and MRIs in a rural and an urban Tanzanian hospital: a comparative, retrospective, neuroradiological analysis

The prevalence of neurological diseases and cranial pathologies in sub-Saharan Africa remains a very little investigated field. This study aims at providing an imaging-based overview of cranial pathologies in two Tanzanian hospitals and at identifying possible differences in the spectrum of diseases between rural and urban African populations. At rural Haydom Lutheran Hospital (Manyara region) the data of 726 patients were included in a retrospective survey. At urban Aga Khan Hospital (Dar es Salaam) the data of 1975 patients who had undergone Computed Tomography (CT) and of 537 Magnetic Resonance Imaging (MRI) patients were obtained. All three surveys showed a clear male preponderance within the populations. The median age of the patients was higher in the city (urban CT 48 years; range 0-95/MRI 39 years; 0.1-89; rural CT 32 years; 0-102). In the urban series stroke, extracranial infections, cerebral atrophy and tumours formed the main groups of diagnoses. Amongst rural patients traumatic pathologies, followed by stroke and cerebral infections/infestations were the most common diagnoses. The most striking differences were noticed with cases compatible with cerebral infections/infestations and hydrocephalus being reported more frequently in the rural population. On the other hand stroke and cerebral atrophy were more frequent amongst urban patients. In the rural catchment area the data of 51 HIV-positive CT patients could be obtained, showing a clear female preponderance. Within the urban HIV-positive subgroup of CT patients (n = 57), the gender distribution was almost equal. Furthermore, in both HIV-positive populations the proportion "compatible with cerebral infections/infestations" was higher than amongst the overall study populations. In conclusion, cranial pathologies seem to differ widely in rural and urban areas of Tanzania in particular with respect to cerebral infections and vascular disease.

Cost-effectiveness Analysis of a Rural Telemedicine Collaborative Care Intervention for Depression

Collaborative care interventions for depression in primary care settings are clinically beneficial and cost-effective. Most prior studies were conducted in urban settings. To examine the cost-effectiveness of a rural telemedicine-based collaborative care depression intervention. Randomized controlled trial of intervention vs usual care. Seven small (serving 1000 to 5000 veterans) Veterans Health Administration community-based outpatient clinics serving rural catchment areas in 3 mid-South states. Each site had interactive televideo dedicated to mental health but no psychiatrist or psychologist on site. Patients Among 18 306 primary care patients who were screened, 1260 (6.9%) screened positive for depression; 395 met eligibility criteria and were enrolled from April 2003 to September 2004. Of those enrolled, 360 (91.1%) completed a 6-month follow-up and 335 (84.8%) completed a 12-month follow-up. Intervention A stepped-care model for depression treatment was used by an off-site depression care team to make treatment recommendations via electronic medical record. The team included a nurse depression care manager, clinical pharmacist, and psychiatrist. The depression care manager communicated with patients via telephone and was supported by computerized decision support software. The base case cost analysis included outpatient, pharmacy, and intervention expenditures. The effectiveness outcomes were depression-free days and quality-adjusted life years (QALYs) calculated using the 12-Item Short Form Health Survey standard gamble conversion formula. The incremental depression-free days outcome was not significant (P = .10); therefore, further cost-effectiveness analyses were not done. The incremental QALY outcome was significant (P = .04) and the mean base case incremental cost-effectiveness ratio was $85 634/QALY. Results adding inpatient costs were $111 999/QALY to $132 175/QALY. In rural settings, a telemedicine-based collaborative care intervention for depression is effective and expensive. The mean base case result was $85 634/QALY, which is greater than cost per QALY ratios reported for other, mostly urban, depression collaborative care interventions.

Schizophrenia and the city: A review of literature and prospective study of psychosis and urbanicity in Ireland

Urbanicity has been repeatedly associated with increased incidence of schizophrenia. This article (a) presents results of a prospective study of urbanicity and schizophrenia in Ireland and (b) reviews the literature relating to urbanicity and schizophrenia. We prospectively compared incidence of schizophrenia and other psychoses in urban and rural catchment areas (over 4 years and 7 years, respectively) using face-to-face, DSM-III-R diagnostic interviews. Incidence of schizophrenia in males was higher in urban compared to rural areas, with an age-adjusted incidence rate ratio (IRR) of 1.92 (1.52–2.44) for males and 1.34 (1.00–1.80) for females. Incidence of affective psychosis was lower in urban compared to rural areas for males (IRR 0.48; 0.34–0.67) and females (IRR 0.60; 0.43–0.83). These findings are consistent with the literature, which provides persuasive evidence that risk for schizophrenia increases with urban birth and/or upbringing, especially among males. Register-based studies support this conclusion more consistently than studies using face-to-face diagnostic interviews, the difference being related to power. The mechanism of association is unclear but may relate to biological or social/environmental factors or both, acting considerably before psychotic symptoms manifest. There is a diversity of potential candidates, including air pollution, cannabis and social exclusion. Urbanicity may have a synergistic effect with genetic vulnerability. Future research is likely to focus on the relationship between urbanicity and neural maldevelopment, the possibility of rural protective factors (e.g. social capital, low social fragmentation), urbanicity in developing countries, cultural variables and geographical location, and associations between urbanicity and other disorders (e.g. affective psychosis).

A spatially distributed hydroeconomic model to assess the effects of drought on land use, farm profits, and agricultural employment

In this paper a high‐resolution linked hydroeconomic model is demonstrated for drought conditions in a Brazilian river basin. The economic model of agriculture includes 13 decision variables that can be optimized to maximize farmers' yearly net revenues. The economic model uses a multi‐input multioutput nonlinear constant elasticity of substitution (CES) production function simulating agricultural production. The hydrologic component is a detailed physics‐based three‐dimensional hydrodynamic model that simulates changes in the hydrologic system derived from agricultural activity while in turn providing biophysical constraints to the economic system. The linked models capture the effects of the interactions between the hydrologic and the economic systems at high spatial and temporal resolutions, ensuring that the model converges to an optimal economic scenario that takes into account the spatial and temporal distribution of the water resources. The operation and usefulness of the models are demonstrated in a rural catchment area of about 10 km2 within the São Francisco River Basin in Brazil. Two droughts of increasing intensity are simulated to investigate how farmers behave under rain shortfalls of different severity. The results show that farmers react to rainfall shortages to minimize their effects on farm profits, and that the impact on farmers depends, among other things, on their location in the watershed and on their access to groundwater.

Chronic disease prevalence and care among the elderly in urban and rural Beijing, China - a 10/66 Dementia Research Group cross-sectional survey.

BackgroundDemographic ageing is occurring at an unprecedented rate in China. Chronic diseases and their disabling consequences will become much more common. Public policy has a strong urban bias, and older people living in rural areas may be especially vulnerable due to limited access to good quality healthcare, and low pension coverage. We aim to compare the sociodemographic and health characteristics, health service utilization, needs for care and informal care arrangements of representative samples of older people in two Beijing communities, urban Xicheng and rural Daxing.MethodsA one-phase cross-sectional survey of all those aged 65 years and over was conducted in urban and rural catchment areas in Beijing, China. Assessments included questionnaires, a clinical interview, physical examination, and an informant interview. Prevalence of chronic diseases, self-reported impairments and risk behaviours was calculated adjusting for household clustering. Poisson working models were used to estimate the independent effect of rural versus urban residence, and to explore the predictors of health services utilization.ResultsWe interviewed 1002 participants in rural Daxing, and 1160 in urban Xicheng. Those in Daxing were more likely to be younger, widowed, less educated, not receiving a pension, and reliant on family transfers. Chronic diseases were more common in Xicheng, when based on self-report rather than clinical assessment. Risk exposures were more common in Daxing. Rural older people were much less likely to access health services, controlling for age and health. Community health services were ineffective, particularly in Daxing, where fewer than 3% of those with hypertension were adequately controlled. In Daxing, care was provided by family, who had often given up work to do so. In Xicheng, 45% of those needing care were supported by paid caregivers. Caregiver strain was higher in Xicheng. Dementia was strongly associated with care needs and caregiver strain, but not with medical helpseeking.ConclusionApparent better health in Daxing might be explained by under-diagnosis, under-reporting or selective mortality. Far-reaching structural reforms may be needed to improve access and strengthen rural healthcare. The impact of social and economic change is already apparent in Xicheng, with important implications for future long-term care.

Service innovation: a virtual informal network of care to support a ‘lean’ therapeutic community in a new rural personality disorder service

This article presents a brief overview of service user-led informal networks of care in therapeutic community practice before discussing the design and evolution of a new kind of network in one of the pilot services of the Department of Health National Programme for the Development of Services for People with Personality Disorder (National Institute for Mental Health in England, 2003a). This network employs well-established internet messaging and chat room facilities uniquely structured and moderated to encompass therapeutic community principles and provide equality of access across a huge mixed urban and rural catchment area. Both hardware and software are inexpensive, easily transferable to similar services and could be modified to suit other applications. The success of this system in allowing challenging work to proceed in a much reduced therapeutic community programme may offer the prospect of many more community-based therapeutic communities at the heart of new personality disorder services.

Teaching science in school…: and I still have a blackboard!

Sarah Darkins teaches science at Langtree, a school in South Oxfordshire with 550 pupils, which has just attained Performing Arts status. The school has a comparatively rural catchment area and has no sixth form. I put some fairly probing questions to Sarah on the subject of being a science teacher. Her responses were considered, frank, some surprisingly upbeat and some critical of today's teaching environment.

SEAM - improving the quality of palliative care in regional Toowoomba, Australia: lessons learned

The proliferation of professional palliative care services in recent years has increased access for people with palliative care needs; however, gaps in services continue to exist, particularly in rural and remote areas of Australia. In order to address one gap in rural health service delivery, the Support, Education, Assessment, and Monitoring (SEAM) Service for regional and rural people in Toowoomba, Queensland, Australia, was introduced. This new model of service delivery aimed to provide palliative services to patients and their families who live in the regional city of Toowoomba and its rural catchment area. It also aimed to facilitate education, support and networking among health-care professionals, particularly general practitioners and nurses employed in general practice (practice nurses). The evaluation involved twenty face-to-face interviews with a variety of health professionals who had contact with the SEAM service from June 2003 to June 2004. Qualitative data analysis of the transcribed interviews provided the basis for the evaluation. The emergent themes regarding the SEAM service included: satisfaction and benefit of the SEAM service; knowledge of and contact with the SEAM service; the SEAM role; and expansion of the role. The data indicate that the majority of health professionals who had contact with the SEAM service were satisfied with the service and found it to be of benefit to them and their clients. Participants commented on the extensive networking and support work established by the SEAM nurse with other health service providers. Difficulties experienced with the SEAM service included poor utilisation by GPs and, therefore, clients in need of palliative support. This was predominately due to lack of knowledge of the service as well as limited understanding of the SEAM nurse role. The SEAM service has resulted in increased links between health professionals providing palliative care to rural clients. The most successful strategy was the use of multidisciplinary case conferencing which not only built links among health professionals caring for individual clients, but also resulted in improved care for those clients. As a result of better integration and communication, palliative care services to rural people have been improved. However, with regard to the delivery of direct patient care, or in the support of GPs for the management of palliative care patients, it was apparent that the service did not meet its objectives. The lack of use by GPs and patients appears to be related to a lack of awareness of the existence of the service. A positive outcome of this poor utilisation is, however, that the model has allowed the identification of factors that work as barriers to GPs and client/family utilisation of rural palliative care services.

Attitudes Toward Antipsychotic Medication

Nonadherence to antipsychotic medication is a major cause of psychotic relapse and is strongly influenced by attitudes toward treatment. Although patient variables such as insight and symptoms that contribute toward attitudes have been identified, the contributions of relationship and service factors have not been adequately studied. To determine relations between clinical and service variables and attitudes toward medication in people with a diagnosis of schizophrenia and schizoaffective disorder. Consecutively admitted patients were approached to take part; 23 refused. Measures included symptoms, insight, drug adverse effects, self-reported adherence, attitudes toward treatment, perceived relationship with the prescriber, ward atmosphere, and admission experience. Data were analyzed by a proportional odds model and structural equation modeling to test predicted paths between experience of admission, relationship variables, attitudes toward treatment, and self-reported adherence to medication. Twenty-eight inpatient wards at 8 hospitals in North Wales and the Northwest of England. Sites included hospitals with inner-city and rural catchment areas. Patients Two hundred twenty-eight patients meeting DSM-IV criteria for schizophrenia or schizoaffective disorder, assessed during acute admission. Attitudes toward treatment and self-reported adherence to medication. The data fit a model in which attitudes toward treatment were predicted by insight, relationship with staff (especially the physician-prescriber), and the patient's admission experience (maximum likelihood chi(2)(49) = 89.3, P<.001). A poor relationship with the prescriber, experience of coercion during admission, and low insight predicted a negative attitude toward treatment. The quality of relationships with clinicians during acute admission appears to be an important determinant of patients' attitudes toward treatment and adherence to medication. Enhancing such relationships may yield important clinical benefits.

Non-collision injuries in public buses: a national survey of a neglected problem

Objectives: This prospective, nationally representative, multi-centre study was undertaken to assess non-collision injuries sustained by public bus passengers in Israel. Methods: The emergency departments (EDs) of six medical centres, which...

Older people with schizophrenia: a community study in a rural catchment area

An increasing number of older people with schizophrenia are living in the community but we still have little data on their clinical presentation, service use and functioning. All patients over the age of 60 years with a primary diagnosis of a non-affective psychotic disorder who were known to health services were identified in a rural area of East England. Subjects were interviewed with the Present State Examination and other standardised interview instruments. Seventy-two subjects fulfilled study inclusion criteria. Forty-six of these had first become ill before the age of 60 years and 26 after (the very late onset group (VLO)). Eighty per cent were women and 26% had never married. Eighty-seven per cent lived in their own homes and 51% alone. In the preceding month, 41% of the sample had experienced psychotic symptoms and 15% depressive symptoms. Twenty-seven per cent of the sample were cognitively impaired. The earlier onset group had significantly higher rates of tardive dyskinesia and negative symptoms of schizophrenia and were treated with higher doses of neuroleptics. The VLO group had higher rates of hearing impairment (54% vs 15% p = 0.001) and of partial or no insight (93% vs 55% p = 0.004). Despite significant differences in presentation, elderly patients with schizophrenia and very late onset schizophrenia-like psychosis have much in common. Both groups are vulnerable with high levels of psychopathology, poor insight, sensory impairment and social isolation. The needs of older people with schizophrenia must be taken into account when services for older adults are planned.

How the Pediatric Autopsy Yields Valuable Information in a Vertically Integrated Health Care System

Although autopsy rates have declined significantly in recent decades, studies continue to validate the autopsy as an important source of clinically relevant information, a teaching tool, and a quality assurance measure. A recent review of autopsy series showed a decline in the number of serious errors likely to have affected clinical outcome detected at autopsy during the past 46 years, with a current major error rate of 8.4% to 24.4%. Our hypothesis was that the pediatric autopsy would uncover a significant number of major unexpected findings at the high end of the spectrum predicted by a recent review. This study assesses the unexpected findings at a pediatric hospital whose autopsy service handles both in-house (tertiary care) and referral (mostly perinatal) cases for a vertically integrated health care system. Data were analyzed from an autopsy effectiveness report completed for all autopsies performed in 2000. The data from this series include concordance of premortem and postmortem diagnoses, with the autopsy considered the criterion standard. The autopsy effectiveness report also provided logistic information, such as problems with consents, medical records, specimen identification, and prosection. Pediatric autopsies were performed by members of the Pediatric Pathology Division in a freestanding children's hospital in the Intermountain West of the United States with a large rural catchment area. This hospital is part of a large health maintenance organization serving the surrounding urban and rural areas. A sample of all in-house and referral autopsies for the year 2000 was examined. The percentage of cases with a major or minor diagnostic discrepancy or unexpected pathologic finding using the autopsy as the criterion standard. The overall autopsy rate was 40% (39 hospital autopsies and 15 forensic autopsies per 135 total deaths) and was 32% excluding forensic cases. Twenty-two additional referral autopsies from outside institutions were performed. Of 61 autopsies, 12 (20%) revealed a major diagnostic discrepancy or unexpected pathologic finding, 17 (28%) had a minor unexpected finding or additional diagnosis, 41 (67%) clarified the differential diagnosis, 46 (75%) confirmed or verified a major diagnosis, and 21 (34%) provided information regarding treatment effects. Additionally, 3 (5%) had problems with identification, and 12 (20%) had problems with consent, all of which were resolved prior to initiation of the autopsy. These data confirm the value of the pediatric autopsy in a children's hospital and a vertically integrated health care system. It is an important medical and quality assurance procedure for assessing the accuracy of diagnoses, clarifying differential diagnoses, yielding unexpected findings, and providing feedback regarding therapeutic outcomes.

Costs of deinstitutionalization in a rural catchment area in The Netherlands.

In contrast to many other countries, The Netherlands left the initiative in deinstitutionalizing mental health care to the traditional providers of mental health services. The goal of this study is to determine the effect of this policy on the allocation of mental health care resources to services. All 20- to 64-year old users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Service utilization was combined with the direct unit costs of these services for the 1999 price level. Changes in the population as to size and age were taken into account. In 1999 the direct costs of mental health care were Euro 268 per adult inhabitant of the register area, which is 9% higher than in 1990. Costs increased most in the early 1990s before deinstitutionalization policy took effect. From 1993 and onwards the reduced length of stay in the hospital was the main cause for the decreased costs of in-patient care. These savings equalled the increased expenditures for day-treatment, sheltered residences and home-treatment, even though the unit costs of these types of community care are much lower than the unit costs of admissions. This was not caused by an increasing number of new clients, but was a result of longer periods of care during a larger number of years. These findings are in accordance with Dutch mental health care policy, which aims at prolonged care and aftercare outside the hospital whenever possible.

Trihalomethane Formation Potential of Small River Water of Rural Agricultural Catchment Area

Trihalomethane Formation Potential of Small River Water of Rural Agricultural Catchment Area

Stroke management in a stroke unit with rural catchment area

The experiences of a rural stroke unit since 1997 are reported. A special referral concept was developed with the emergency services and hospitals of the region. As a result, 35% of patients arrived in the stroke unit within 3 hours after onset of stroke symptoms. This corresponds with the data from larger cities. The major peculiarity of the Günzburg Stroke Unit is that, after emergency diagnostic and therapeutic procedures, 41% of the patients with mainly internistic problems were transferred to another regional hospital and only 40% were admitted to the inpatient stroke unit. Moreover, among these were an above-average proportion of patients with intracerebral hemorrhage (24% of the inpatients in 1998), and complete acute treatment and rehabilitation were carried out in the same hospital according to an integrative treatment concept. Since 1997, the average hospitalization duration decreased from 11.4 days to 5.9 days and the number of patients per month increased to an average of 22.3. The total hospitalization duration--including inpatient rehabilitation--was 33.9 days. All in all, a comparably good stroke treatment thus is possible outside urban regions.

What do general practitioners and paediatricians want from discharge letters?

ABSTRACTObjectives To ascertain the relative importance ascribed by general practitioners and hospital paediatricians to items of information given in paediatric final discharge letters, and determine general practitioner preference for the format of such letters.Design A questionnaire was sent to 158 local general practitioners and 24 hospital‐based paediatricians.Setting A district general hospital serving both a large industrialized urban area and a rural catchment area in Northern England.Results One hundred and twenty‐eight (81.0%) general practitioners and 23 (95.8%) hospital paediatricians responded. There was consensus on which items of information were essential. These included correct diagnosis; correct drug dosage, frequency and duration; dates of admission; investigations performed; admission ward; case history, and admitting/responsible consultant. There were differences as to the essential nature of which doctor wrote the letter; why the child was admitted; parental information given.Conclusions Many features of paediatric inpatient discharge letters are regarded with the same priority by general practitioners and hospital paediatricians. However, there are some important differences in preferences between these groups of doctors.

Adolescent participation in the U.K. National Lottery Games

This study investigated illegal participation in the two U.K. National Lottery games (on-line game and scratchcards) by children under the age of 16 years. The sample consisted of 256 children aged between 13 and 15 years from four mixed-sex comprehensive schools/colleges, which serve city, town, rural and coastal catchment areas in the county of Devon, U.K. Pupils completed a questionnaire in a controlled environment at their respective schools/colleges. The findings indicated that 56% of the sample had participated in the National Lottery on-line game and 54% in the National LotteryInstants scratchcards. Regression analysis revealed that the best predictors of participation in the on-line game were income, household participation, whether the TV show was watched and whether a retailer had ever refused to sell a child a lottery ticket. The same variables (minus watching of the TV show) were also the best predictors of buying scratchcards.

Small area variation in rate of schizophrenia vs bipolar disorder by place at birth vs place at onset within an Irish rural catchment area population

In order to assess the accuracy of schizophrenia diagnoses for genetic studies, we identified all schizophrenia patients (n = 492) in an isolated community with a diagnosis of schizophrenia in the Finnish Hospital Discharge Register (HDR) between 1969–1991. For the accuracy study we identified a sample of 73 patients from registers with Diagnostic and Statistical Manual (DSM)-III-R for schizophrenia (codes 295.10, 295.30, 295.60, 295.90) (n = 62) or “schizophrenia spectrum” diagnoses (295.40, 295.70, 297.10, 301.20, 301.22) (n = 11). When the operational criteria (DSM-III-R) were applied by two senior researchers using information from the original mental hospital records, 93% (68/73) of the cases fulfilled criteria for schizophrenia or schizophrenia spectrum. The results demonstrate that the schizophrenia diagnoses of the registers are accurate when a broad concept of schizophrenia is applied. When using operational DSM-III-R schizophrenia criteria, eight false positive cases were found among the 62 mental hospital schizophrenia diagnoses. Consequently, there may be a need to reassess schizophrenia diagnoses depending on the purpose of the study. We also found good agreement between DSM-III-R (kappa 0.93) and operational criteria (OPCRIT) diagnostic system (kappa 0.89) diagnoses, made by one researcher, compared with operational diagnoses. This indicates the possibility for the reliable use of one of these methods alone for diagnostic reassessment. The information in the HDR on primary diagnoses and on the dates of admission and discharge was accurately transferred from the hospital records.

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department