Rural Community Health Centers Research Articles

A novel model in snakebite management from a rural community health centre of Assam, North East India: Impact on morbidity and mortality

A novel model in snakebite management from a rural community health centre of Assam, North East India: Impact on morbidity and mortality

163 Knowledge and Implementation of Tobacco Control Practices in Rural Louisiana Community Health Centers

OBJECTIVES/GOALS: Tobacco use remains a significant public health problem in rural America. Community health centers (CHCs) can help reduce the burden of tobacco use in rural areas, but we know little about their knowledge and implementation of best practices for tobacco control. This study assessed the knowledge and existence of tobacco control practices in rural CHCs. METHODS/STUDY POPULATION: Using a cross-sectional study design, we electronically surveyed health administrators and providers (n=64) in six rural CHCs in Louisiana between March 2021 and June 2023. The assessment measured 1) knowledge of the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use, 2) the priority given to smoking cessation programming, 3) the presence of best practices for tobacco control programming, such as having a tobacco control champion and team, 4) establishment of treatment and smoke-free campus policies, and 5) existence of referral procedure to external cessation services. We used descriptive statistics to characterize survey participants and responses. RESULTS/ANTICIPATED RESULTS: Most of the respondents were female (80%), White (61.8%), between 35 and 49 years of age (48.1%), and non-smokers (72.7%). Only half (51.6%) reported knowledge of the guideline for treating tobacco use among all respondents. Only a third (32.8%) said their health center gave smoking cessation high priority relative to other health priorities. Only a third (35.9%) reported having a tobacco champion; less than a fifth (18.8%) said they had a tobacco control team at their health center. Although all health centers had a smoke-free campus policy, about a quarter (23.4%) were unaware of the policy. Less than a quarter (23.4%) reported having a written policy for smoking cessation treatment at their health center, and less than half (46.7%) knew about cessation services to which they could refer patients. DISCUSSION/SIGNIFICANCE: Rural CHCs had limited knowledge of the guideline for tobacco use treatment. Smoking cessation lacked priority, and the prevalence of tobacco control best practices implementation was low. Rural CHCs must improve their implementation of guideline-recommend policies and clinical strategies to promote treatment and reduce the burden of tobacco use.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiencyin rural CHCs.

Experience of Establishment of a Community PAP Smear Lab at Rural Community Health Center in North India

Experience of Establishment of a Community PAP Smear Lab at Rural Community Health Center in North India

Improving CKD Screening in Spanish-Speaking Patients with Poorly Controlled Type 2 Diabetes at a Rural Community Health Center

Improving CKD Screening in Spanish-Speaking Patients with Poorly Controlled Type 2 Diabetes at a Rural Community Health Center

Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers

BackgroundAdoption of colorectal cancer (CRC) screening has lagged in community health center (CHC) populations in the USA. To address this implementation gap, we developed a multilevel intervention to improve screening in CHCs in our region. We used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide this effort. Here, we describe the use of implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) compilation in both the Exploration and Preparation phases of this project. During these two EPIS phases, we aimed to answer three primary questions: (1) What factors in the inner and outer contexts may support or hinder colorectal cancer screening in North Carolina CHCs?; (2) What evidence-based practices (EBPs) best fit the needs of North Carolina CHCs?; and (3) How can we best integrate the selected EBPs into North Carolina CHC systems?MethodsDuring the Exploration phase, we conducted local needs assessments, built a coalition, and conducted local consensus discussions. In the Preparation phase, we formed workgroups corresponding to the intervention’s core functional components. Workgroups used cyclical small tests of change and process mapping to identify implementation barriers and facilitators and to adapt intervention components to fit inner and outer contexts.ResultsExploration activities yielded a coalition of stakeholders, including two rural CHCs, who identified barriers and facilitators and reached consensus on two EBPs: mailed FIT and navigation to colonoscopy. Stakeholders further agreed that the delivery of those two EBPs should be centralized to an outreach center. During Preparation, workgroups developed and refined protocols for the following centrally-delivered intervention components: a registry to identify and track eligible patients, a centralized system for mailing at-home stool tests, and a process to navigate patients to colonoscopy after an abnormal stool test.ConclusionsThis description may be useful both to implementation scientists, who can draw lessons from applied implementation studies such as this to refine their implementation strategy typologies and frameworks, as well as to implementation practitioners seeking exemplars for operationalizing strategies in early phases of implementation in healthcare.

Trends in output of hypertension management and associated factors in primary care facilities: a latent trajectory analysis in China from 2009 to 2017

BackgroundThe prevalence of hypertension is high (25.2% in 2012) and there were a large number of patients with hypertension (more than 200 million) in China. Township health centres in rural areas and community health centres in urban areas are responsible for hypertension management. This study aims to identify trends in hypertension management output and related facility-level, geographical and economic factors in primary care facilities and to assess the effect of the national project of basic public health services in China from 2009 to 2017.MethodsA cross-sectional survey (2018) was combined with retrospective data collection (2009–2017) from 685 primary care facilities in six provinces in China. The hypertension management output was indicated by the number of patients with hypertension under management per 10,000 population. Latent class growth analysis and group-based trajectory models were applied to classify trajectories and determine associations with facility-level, geographic and economic characteristics.ResultsThe trend in the output increased rapidly from 2009 to 2012 with an average growth rate of 54.58% and slowed down from 2012 to 2017 (growth rate of 5.94%). Five trajectories of the output were identified and labelled according to baseline status and increase rates: low-gradually increasing (16.9%), middle-slightly increasing (16.2%), low-sharply increasing (7.9%), middle-sharply increasing (34.2%) and persistently high (24.9%). The time-stable characteristics, including region (eastern, central or western), district (urban or rural), landform, were associated with hypertension management output of the facilities. Number of public health physicians was a significant time-dependent characteristic influencing management output.ConclusionsFive latent trajectories of hypertension management output were identified. The output was still at a low level compared with the prevalence of hypertension. Hypertension screening in young people need to be emphasized. Facilities are recommended to establish good relationships with residents for better hypertension management outcomes especially in urban areas.

Managing patients with diabetes in rural underserved areas

Managing patients with diabetes in rural underserved areas Professor Richard J. Santen, MD from the University of Virginia, explains the need for retired endocrinologists returning to work to manage patients with diabetes in America’s rural underserved areas. Patients with diabetes living in rural, underserved areas frequently experience less than adequate health outcomes, often exacerbated by higher rates of poverty, lack of health insurance and insufficient primary care and specialist providers. While this is a shocking situation, it is also an opportunity. Many retired doctors are eager to offer their services and are looking for ways to reach out and help. Herein lies an opportunity to connect retired endocrinologists via telemedicine with patients attending these rural community health centers, Professor Santen says. He argues that the solution is telemedicine – for example, a doctor in Alabama would not have to leave home to help a person in an underserved rural community hundreds of miles away. Detailed reports of the findings and recommendations can take time, but, various digital dictation software programs are available, which are highly accurate and secure. Dr Santen comments that he knows of many specialists who have built highly successful careers and can now retire and enjoy the financial benefits of their hard work

Lessons From the Delta.

Lessons From the Delta.

Assessing the Feasibility of Rural Residency Training for Licensed Naturopathic Physicians in the Northwest: A Qualitative Study.

Naturopathic physicians (ND) are uniquely situated to address areas of unmet health care need as primary care providers (PCPs). In several states, NDs have a broad scope of practice and are licensed as independent practitioners regardless of residency training. However, with a larger role in the health care system, the need for post-graduate medical training becomes more important for clinical success and patient safety. Our study aimed at assessing the feasibility of developing residencies for licensed NDs in rural federally qualified health centers (FQHCs) of Oregon and Washington. We conducted interviews with leadership from a convenience sample of eight FQHCs. Six centers were rural, two of which already employed NDs. Two urban centers that employed NDs as PCPs were included for their valuable insights related to study design. Two investigators independently reviewed and coded site visit notes for prominent themes through inductive reasoning analysis. Consensus was met identifying the following themes: onboarding and mentorship; diversity of clinical training; financial structure; length of residency; and addressing health care needs in the community. We identified several opportunities for the development of primary care residencies for NDs, including the need for PCPs in rural communities, the ability of NDs to manage chronic pain with prescription drugs, and the prevention of morbidity from complex conditions such as diabetes and cardiovascular disease. Potential barriers to residency development include lack of Medicare reimbursement, mixed awareness of the ND scope of practice, and scarcity of dedicated mentors. These results may serve as guideposts for the future development of naturopathic residencies in rural community health centers.

Utilisation of Supplementary Nutritional Services of ICDS by Paediatric Beneficiaries of Central Kerala, India: A Cross-sectional Study

Introduction: Integrated Child Development Scheme (ICDS) is a unique programme for childhood care and development. ICDS had expanded progressively over the past four decades, also the budget allotment for the programme has been increasing over the years. However, the expansion in coverage has not been translated into a proportionate increase in utilisation. Aim: To evaluate the utilisation of supplementary nutritional services of ICDS and also to assess the reasons for not utilising the same by paediatric beneficiaries. Materials and Methods: This community based cross-sectional study was conducted in the Department of Community Medicine, Government Medical College (selected Rural Community Health Centre), Thrissur district, Kerala, India, during January 2019 to August 2019. A total of 290 children, aged between six months to six years, were permanent residents were selected to participate in the study. Data were collected using pre-tested structured proforma by interviewing all the study subjects. Univariate analysis and logistic regression were used for statistical analysis to find the factors affecting the non utilisation of ICDS services. Results: Among the 290 participants, 141 (48.6%) were in the age group of six months to three years while 149 (51.4%) were in the age group 3-6 years, and 154 (53.1%) were boys and 136 (46.9%) were girls. The regular utilisation of supplementary nutrition was 67 (47.5%, 95% CI- 39.1, 56.1) in the age group six months to three years and 83 (55.7%) in 3-6 years. The main reasons for non utilisation were that children attended playschool and a lack of perceived benefits. Those who lived near Anganwadi Centres (AWC) had significantly higher utilisation. Utilisation among children between 3-6 years of age was significantly lower in those with higher maternal education (p-value<0.001), and who reach Anganwadi by vehicle (p-value<0.001). Conclusion: The study found that regular utilisation of supplementary nutrition was poor. Those who were staying away from Anganwadi and who had higher maternal education had lower utilisation of ICDS nutritional services. Public-private partnerships in providing hot cooked meals from Anganwadi in playschools can be explored to increase utilisation.

The preparedness of disaster among nurses in community health centers in rural areas during the COVID-19 pandemic in Malang City.

Positive COVID-19 cases in Malang City, Indonesia continue to increase. Until 04 August 2021, the COVID-19 update shows 3301 positive cases with 7754 cured and 832 deaths. This study aims to identify nurses preparedness in rural area community health centers during the COVID-19 pandemic in Malang for self-control to implement health protocol. This study intends to provide insights on controlling COVID-19 spread in Malang, Indonesia.This research is a quantitative study with correlative analytic observational design and a cross-sectional approach involving 120 nurses from 16 primary health centers. The results of the bivariate analysis using gamma correlation test are: knowledge factors (p = 0.005; r = 0.35), attitude (p = 0.000; r = 0.46), means of infrastructure (p = 0.000; r = 0.54), and self-control (p = 0.000; r = 0.52) for the quarantined COVID-19 patients. Knowledge, attitude, infrastructure, and safe house factors can influence self-control for COVID-19. In rural areas, health education—as education and empowerment for patient self-control—is an effort to encourage them to obey health protocol during the pandemic.Nurse readiness and preparedness during the pandemic is crucial for strengthening the assertive behavior commitment through self-control. This ensures the community's awareness of the importance of complying with health protocols for the common good. Mental nursing intervention needs to be added as a part of psychosocial therapy for the community's social problems, primarily in reducing the pressure due to the social distancing enforcement to control and prevent COVID-19 spread.

Horizontal Integration and Financing Reform of Rural Primary Care in China: A Model for Low-Resource and Remote Settings.

Primary health care (PHC) systems are compromised by under-resourcing and inadequate governance, and fail to provide high-quality health care services in most low- and middle-income countries (LMICs). As a response to solve the problems of underfunding and understaffing, Pengshui County, an impoverished area in rural Chongqing, China, implemented a profound reform of its PHC delivery system in 2009, focusing on horizontal integration and financing mechanisms. This paper aims to present new evidence from the Pengshui model, and to assess the relevant changes over the past 10 years (2009–2018). An inductive approach was adopted, based on analysis of national and local policy documents and administrative data. From 2009 to 2018, the proportion of outpatients who sought first-contact care in rural community or township health centers increased from 29% (522,700 of 1,817,600) in 2009, to 40% (849,900 of 2,147,800) in 2018 (the national average in 2018 was 23%). Our findings suggest that many positive results have been achieved through the reform, and that innovations in financial governance and incentive mechanisms are the main driving forces behind the improvement. Pengshui County’s experience has proven to be a successful experiment, particularly in rural and low-income areas.

Blood pressure control in hypertensive patients attending a rural community health centre in Gauteng Province, South Africa: A cross-sectional study.

BackgroundHypertension is a major cause of morbidity and mortality and its control has important clinical and socio-economic benefits to the family and community. Unfortunately, the extent of blood pressure (BP) control and its potential predictors in hypertensive patients in many rural communities in low-resource settings are largely unknown. This study assessed the extent of uncontrolled BP and its predictors amongst hypertensive patients accessing primary health care in a rural community in South Africa.MethodsThis cross-sectional study included 422 randomly selected hypertensive patients. Demographic and clinical data were collected using structured face-to-face questionnaire supplemented by respondents’ clinical records.ResultsObesity plus overweight (n = 286, 67.8%) and diabetes (n = 228, 54.0%) were the most common comorbidities. Treatment adherence was achieved in only 36.3% and BP was controlled to target in 50.2% of the respondents. Significant predictors of uncontrolled BP were poor treatment adherence (odds ratio [OR] = 15.88, 95% confidence interval [CI] = 8.96, 28.14, p < 0.001), obesity compared with normal weight and overweight (OR = 3.75, 95% CI = 2.17, 6.46, p < 0.001) and being a diabetic (OR = 2.83, 95% CI = 1.74, 4.61, p < 0.001).ConclusionPoor adherence to treatment was the major predictor of uncontrolled BP. The increase in uncontrolled BP in the presence of diabetes and/or obesity as risk predictors, indicates the need for appropriate behaviour change/interventions and management of these conditions in line with the health belief model (HBM). We also propose the use of Community-Based Physical and Electronic Reminding and Tracking System (CB-PERTS) to address poor treatment adherence.

Medical Family Therapy in Rural Community Health: A Longitudinal "Peek" into Integrated Care Successes.

Integrated behavioral health care (IBHC) continues to grow as an evidence-based service delivery model adopted by healthcare systems all over the world to better care for the holistic needs of patients and their families. Medical family therapy (MedFT), as a field, has offered innovation to IBHC models by delivering biopsychosocial-spiritual (BPS-S), relational, and family-oriented care across a variety of healthcare contexts. This article details a longitudinal review of a program, spanning 16 years, that grew from no behavioral health services to one that is highly integrated, and embeds MedFTs in a number of rural community health centers. This model highlights the importance of interdisciplinary teams, including Peek’s clinical, operational, financial, and training worlds, as well as decision-making metrics for systems that predominately care for underserved and minoritized populations. The authors illustrate a framework for how the levels of primary care/behavioral healthcare collaboration relate to the work and practice of MedFTs as conceptualized through the MedFT Health Care Continuum and meet the BPS-S needs of diverse populations seeking pediatric, adult, and dental healthcare services. Also described are shifts made in the model over time based on (a) growth in cultural humility, (b) relationally-oriented practice, operations, finance, and training data, and (c) research informed decisions. Recommendations include ways MedFTs can facilitate provider and administrative buy-in, assess model fidelity, and strive for quality outcomes for patients.

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve three-year adherence to colorectal cancer screening among patients cared for in rural community health centers

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender.Trial registration:Clinicaltrials.gov Identifier NCT04313114

Nurses’s knowledge and attitude in facing potential landslide disasters

Landslide is one of the natural disasters which cause not only infrastructure damage but also death. Nurses have a role in disaster management at the phase of mitigation to rehabilitation during landslide disasters. This study is aimed to analyze nurses' knowledge and attitudes in the face of future landslide disasters. A quantitative method with a descriptive design was used in the study. The respondents in this study were 20 nurses who work at one rural community health center in Malang. Data were collected using a questionnaire. From the current research, most respondents had been involved in disaster emergency response activities (85%), had good knowledge (75%), and all nurses (100%) had a positive attitude towards landslide disaster preparedness. From this current study, nurses' knowledge and attitudes towards preparedness for facing landslides might be essential to build more awareness among nurses in preparing the community in facing landslides; thus, the impact of the disaster could be decreased.

Self-efficacy in disadvantaged communities: Perspectives of healthcare providers and clients.

Most chronic disease self-management interventions emphasise the integral role of self-efficacy in achieving behaviour change. We explored the applicability of this model in a low-income setting, from the perspective of both patients and clinicians. Interviews with multimorbid patients and their health providers at two rural community health centres in Victoria, Australia. We used a phenomenological methodology, exploring themes of confidence to manage health, outcome expectations and goals. Many assumptions in which the self-efficacy model is grounded did not apply to this population. Past experiences and resource constraints, especially poverty and healthcare access, influenced confidence, expectations and the ability to achieve desired outcomes. The focus of traditional self-management support on individual behaviour change disadvantages rural low-income patients, who face barriers related to life experience and resource constraints. For this group, self-management support needs to return to its roots, moving away from a narrow conception of behaviour change and reinstating the role of 'support' into 'self-management support' interventions. Health providers working in rural low-income settings should recognise the limits inherent in self-efficacy focussed interventions and think broadly about engaging with their clients in whatever way supports them to find a life with meaning and purpose.

Onsite screening and enhanced EAP counseling improves overall health, depression, and work outcomes: Four-wave longitudinal pilot study at a community health center in Vermont

Over a 2-year period, patients at a rural community health center in Vermont were screened on-site for multiple behavioral health risk factors and, if found at risk, were offered no-cost counseling on-site at the health center. The treatment was delivered by two licensed employee assistance program (EAP) counselors highly proficient in an evidence-based motivational interviewing approach. Longitudinal data at four time points were examined: baseline; end of treatment (3 months); and 3 and 6 months post-treatment. Tests of paired data of baseline versus each later time point found significant improvement for global health (Patient-Reported Outcomes Measurement Information System [PROMIS]-10) in the total sample (N = 120); depression symptoms (Patient Health Questionnaire 9-item scale [PHQ-9]) among a subsample with depression as a clinical issue (n = 68); and work presenteeism and estimated hours of lost work time among the employed subsample (n = 46). Improvement in global health was significantly associated with improvement (reductions) in hours of lost work productivity at all later times (r = .33, .35, .50). Improvement in global health was moderated by level of household income (more improvement among patients with lower income levels), but not by clinical or demographic factors. Practical implications for behavioral health screening and intervention (BSI) in medical settings and onsite EAP counseling programs are discussed.

Accuracy and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among primary care patients (≥40 years) in China: a cross-sectional screening test accuracy study: findings from the Breathe Well group

ObjectivesTo examine the accuracy and cost-effectiveness of various chronic obstructive pulmonary disease (COPD) screening tests and combinations within a Chinese primary care population.DesignScreening test accuracy study.SettingUrban and rural community health...