Rural Community Health Centers Research Articles

Multimorbidity and its effect on perceived burden, capacity and the ability to self-manage in a low-income rural primary care population: A qualitative study.

Multimorbidity is increasing in prevalence, especially in low-income settings. Despite this, chronic conditions are often managed in isolation, potentially leading to burden-capacity imbalance and reduced treatment adherence. We aimed to explore, in a low-income population with common comorbidities, how the specific demands of multimorbidity affect burden and capacity as defined by the Cumulative Complexity Model. Qualitative interviews with thirteen rural community health centre patients in Victoria, Australia. Participants were aged between 47-72 years and reported 3-10 chronic conditions. We asked about perceived capacity and burden in managing health. The Theory of Patient Capacity was used to analyse capacity and Normalisation Process Theory to analyse burden. All data specifically associated with the experience of multimorbidity was extracted from each burden and capacity domain. The capacity domains of biography, resource mobilisation and work realisation were important in relation to multimorbidity. Conditions causing functional impairment (e.g. chronic pain, depression) interacted with physical, psychological and financial capacity, leading to biographical disruption and an inability to realise treatment and life work. Despite this, few people had a treatment plan for these conditions. Participants reported that multimorbidity affected all burden domains. Coherence and appraisal were especially challenging due to condition interactions, with clinicians providing little guidance. The capacity and burden deficits highlighted by participants were not associated with any specific diagnosis, but were due to condition interactions, coupled with the lack of health provider support to navigate interactions. Physical, psychological and financial capacities were inseparable, but rarely addressed or understood holistically. Understanding and managing condition and treatment interactions was a key burden task for patients but was often difficult, isolating and overwhelming. This suggests that clinicians should become more aware of linkages between conditions, and include generic, synergistic or cross-disciplinary approaches, to build capacity, reduce burden and encourage integrated chronic condition management.

Medical-Dental Integration in a Rural Community Health Center: A Qualitative Program Evaluation.

A community health center (CHC) implemented a medical-dental integration (MDI) program where children were seen at a pediatric medical clinic or women, infants, and children program location by medical and dental providers in the same visit. Our study aims were to elicit the perspectives and experiences of providers and administrators involved in the MDI program to assess the acceptability, feasibility, and success of a CHC integration strategy in Eastern Washington. This is a qualitative study where we conducted semistructured interviews over the phone over a period of 2 months with 12 medical and dental providers and clinical administrators who were involved with the MDI program. Questions addressed perspectives on workflow, patient identification and engagement, leadership support, and barriers and facilitators of the initiative. Qualitative data were analyzed, and emergent themes were identified. The emergent themes included (a) the MDI program is feasible and acceptable albeit with key considerations regarding the setting, including charting and service integration, progressive leadership and effective communication, and appropriate providers; (b) implementation included structural, systemic, and individual behavior barriers, (c) the program is seen as a benefit to the clinic and patients and a success to date as a way to increase access to quality care. Findings from this study helped identify facilitators, such as cultural relevancy and progressive office systems, as well as barriers, such as reimbursement, associated with integrating medical and dental care in a rural CHC setting, is acceptable by providers, and can inform future studies and implementation strategies for others wishing to integrate these services.

Relationship Between Polypharmacy and Medication Adherence in the Hypertensive Elderly Patients

Background: Proper adherence to the medication regimen in hypertensive elderly patients is important. This study aimed to investigate the relationship between polypharmacy with adherence to the medication regimen in hypertensive elderly patients. Materials and Methods: Using stratified random sampling method, the present descriptive-analytical study was performed on 384 hypertensive elderly patients in Gonabad, Iran in 2016. The study population included males and females aged over 60 years who were covered by Gonabad urban and rural community health centers. Data were collected using demographic questionnaire and the eight-item Morisky Medication Adherence Scale (MMAS-8). Results: The mean daily medications in participants was 6±2.43, and a high medication adherence was observed among 36.7% of the subjects. Chi-square test showed a significant relationship between polypharmacy and medication adherence (P = 0.006). Conclusion: Physicians and nurses can play an important role in preventing the risks of polypharmacy, as well as non-adherence to medication regimen by educating the hypertensive elderly patients or their caregivers.

Knowledge, Attitudes, Practices and Blood Pressure Control of Hypertensive Patients at a South African Primary Health Care Centre

Hypertension is a serious global and South African public health problem. The high prevalence of uncontrolled hypertension is related to a patient’s lack of knowledge and healthy practices. The study aimed to assess the knowledge, attitudes and practices of hypertensive patients and their blood pressure control at a rural community health centre. This was a prospective cross-sectional study conducted on diagnosed cases of hypertension at the centre. Binary logistic regression analysis was conducted to determine the factors for the control of hypertension. Two hundred and ninety-seven known hypertensive patients were recruited, the majority of which were female. Eighty-eight percent were older than 45 years, and almost all had a monthly income of less than R3000 (USD 190). More than half controlled their blood pressure. It was found that 46% had poor knowledge, 64% had good attitudes and 60% were practising positively regarding the control of hypertension. Hypertensive patients attending the centre had poor knowledge but good attitudes and practices towards hypertension. The study revealed an urgent need for improved health promotion and educational efforts to increase the knowledge of hypertension in rural communities and to address poverty as a major obstacle to healthy lifestyle choices.

Evaluation of Warfarin Use in Patients With Mental Health Conditions in a Rural Community Health Center System.

Background: Mental health conditions (MHCs) may affect a patient's ability to comply with requirements necessary for safe warfarin use. Objective: To describe warfarin control, defined as time in therapeutic range (TTR), for patients with and without MHCs receiving care through a pharmacist-driven anticoagulation service within a rural community health center system. Methods: Retrospective cohort study of patients on warfarin between January 1, 2014, and December 31, 2017. The primary study endpoint was TTR. Secondary endpoints were the number of international normalized ratios (INRs) per 30 days, percentage of INRs within, above, and below target range, and warfarin-related adverse events. Results: A total of 79 patients were included-37 with and 42 without MHCs. Patients were mostly male (n = 47; 59.5%) and prescribed warfarin for atrial fibrillation (n = 45; 57.0%). There were no differences in overall TTR between those with (59.6%; interquartile range = 41.8-73.4) versus without (63.4%; interquartile range = 46.7-73.6) MHCs (P = .542). Secondary outcomes showed no differences in the frequency or percentage of INRs in, above, or below target range (all P > .05). However, there were about twice as many hemorrhagic complications in the group with MHCs (27% vs 11.9%; P = .149). Conclusion: Patients with MHCs experienced no difference in overall TTR as compared to patients without MHCs. However, there was a non-statistically significant reduction in TTR, which would be consistent with limited existing data and demonstrates possible reproducibility to a rural, underserved patient population. Future research is needed to validate these outcomes.

Psychiatric morbidity among patients attending a rural non-communicable disease clinic

Abstract Background The presence of psychiatric illness among patients with physical illnesses leads to poor treatment adherence, poor lifestyle, increased cost of treatment, poor quality of life, worsening of physical illness, work absenteeism, increased hospital visits, poor self-care and higher mortality. The study evaluated the prevalence of cognitive impairment and psychiatric morbidity in non-communicable disease patients. The study highlights that NCD patients should be provided information about the development of cognitive impairment in order to prevent it. Methods It was a cross-sectional study conducted among the patients attending the non-communicable disease clinic of a rural community health centre run in collaboration with the Postgraduate Institute Medical Education and Research (PGIMER), Chandigarh. We registered 124 patients after obtaining written informed consent. Instruments: Hindi Mental Status Examination (HMSE), Patient Health Questionnaire-9, Generalized anxiety disorder-7 (GAD-7) scale. Analysis of covariance was applied to see the relationship between the domain of the HMSE and NCDs. Results The mean age of the participants was 55.5 years (SD-11.9, Range-26-90). A little more than one third (N = 48, 38.7%) were diagnosed with hypertension only, one-sixth (N = 22; 17.7%) were diagnosed with diabetes mellitus only, and 54 (43.5%) patients were diagnosed with both hypertension and diabetes mellitus. A slightly more than one-third of the study participants were diagnosed with depressive disorder (N = 44, 35.5%), and 29% (N = 36) of the participants were diagnosed with an anxiety disorder. About one-fourth of patients with NCD have cognitive impairment and 39.51% have psychiatric morbidity. Conclusions The prevalence of cognitive impairment is higher among patients of NCD with psychiatric morbidity. Patients with NCDs should be routinely screened for cognitive functioning and provided information about the development of cognitive impairment. Key messages Because of high prevalence of cognitive impairment and psychiatric morbidity in NCD patients, patients should be provided information to prevent it. There is a need to screen NCD patients routinely for cognitive functioning, and provide them information to prevent cognitive impairment.

The quality of primary care in community health centers: comparison among urban, suburban and rural users in Shanghai, China

ObjectiveFollowing World Health Organization’s initiatives to advance primary care, China put forth forceful policies including the Personal Family Doctor Contract to ensure that every family sign up with a qualified doctor in a community health center (CHC) ever since its 2009 New Health Reform. We used the Johns Hopkins-designed Primary Care Assessment Tool (PCAT) to assess primary care quality experienced by the contracted residents and compare this across different socioeconomic regions.MethodsUsing a multistage sampling method, four CHCs each were randomly selected from urban, suburban and rural districts of Shanghai, a metropolitan with 24 million residents. ANOVA and Multivariate analyses were used to assess the association between location of CHC and the quality of primary care experience.FindingsA total of 2404 CHC users completed our survey. Except for the domain of coordination (information systems), users from suburban CHCs reported best primary care experiences in all other domains, followed by users of rural CHCs. After controlling for covariates, suburban CHC users were more likely to report higher total PCAT scores (ß = 1.57, P < 0.001) compared with those from urban CHCs.ConclusionThat contracted residents from suburban CHCs reporting better primary care experience than those from urban CHCs demonstrates the unique value of CHCs in relatively medical-underserved areas. In particular, urban CHCs could further strengthen first contact (utilization), first contact (accessibility), coordination (referral system), comprehensiveness (available), and community orientation aspects of primary care performance. However, all CHCs could improve coordination (information system).

Implementation of a pharmacist-delivered Medicare counseling service in a rural community health center

ObjectiveTo describe a pharmacist-delivered Medicare counseling service in a rural community health center for providing patients and community members with information and resources to facilitate informed Medicare plan selection(s). SettingFederally-qualified health center. Practice innovationHealth center patients and community members met with a pharmacist for individual Medicare counseling. The appointments provided an opportunity to educate clients on Original Medicare and private plan options for supplemental medical and drug coverage, compare specific plans, and assess eligibility for financial assistance programs. EvaluationData were collected from client contact forms completed for individuals counseled between July 1, 2015 and June 30, 2018. Data were then summarized with descriptive statistics and analyzed with Fisher exact tests. ResultsA total of 47 appointments were completed with 31 unique clients. They were mostly women (n = 18, 58.1%) and aged 65 years or more (n = 17; 54.8%) but evenly divided between patients established with the health center (n = 15; 48.4%) and community members (n = 16; 51.6%). During appointments, the most common topic was an explanation of medical or drug benefits (n = 40; 85.1%) followed by comparison of specific plans (n = 25; 53.2%) and then screening individuals for Original Medicare or private plan eligibility (n = 27; 57.4%). There were no statistically significant differences when comparing topics discussed for current versus new Medicare beneficiaries. During follow-up visits, patients were less likely to be screened for Original Medicare or private plan eligibility (74.2% vs. 25%; P = 0.002), financial assistance programs (77.4% vs. 37.5%; P = 0.011), or have specific plans compared (71.0% vs. 37.5%; P = 0.034). ConclusionA pharmacist-provided Medicare counseling service in a rural community health center was used by both patients and community members. This may be an effective strategy to improve beneficiary understanding of Medicare benefits and enable the selection of better insurance plans in underserved populations. Further research is needed to assess individual-level outcomes and scalability to other settings.

Symptom burden among Northern Alberta radiotherapy patients with advanced cancer: mapping needs and gaps.

Patients with advanced cancer often experience symptoms including pain, nausea, anorexia, fatigue, and depression. High symptom burden can be alleviated by multidisciplinary palliative care (PC) teams practicing symptom-directed management. Patients who are unable to access such services may be at higher risk of increased symptoms and poor outcomes. A sequential exploratory mixed methods study was performed to explore the burden of symptoms experienced by Northern Alberta patients with advanced cancer. The symptom burden among patients from rural and remote communities was characterized in a retrospective review capturing basic demographic and clinicopathologic information, in addition to patient-reported outcomes. Symptom prevalence was evaluated against the nature and range of supportive care services available. Service accessibility was assessed at community level by surveying health care providers (HCPs) and performing thematic analysis on their responses. From January 1 to December 31, 2017, 607 outpatients were seen in consultation in an integrated palliative radiotherapy clinic in Edmonton, Alberta. A total of 166 (27.3%) patients resided in Alberta communities designated as rural or remote. Patient-reported symptom prevalence and intensity of scores did not differ significantly between rural/remote and urban populations. Unmet practical needs were flagged significantly more often by patients from rural communities (p = 0.05). HCPs from rural community health centers in Northern Alberta were knowledgeable regarding PC services availability and referral processes within their communities. Although the symptom burden experienced by patients living with advanced cancer in rural and remote areas of Northern Alberta does not differ significantly from their urban counterparts, and community HCPs are knowledgeable regarding PC services, unmet needs within these communities remain. Continuing support for PC services in rural communities, as well as establishing care pathways for patients from rural populations traveling to urban centers to receive treatment, will help to minimize the unmet needs these patients experience.

Can Mobile Health Improve Depression Treatment Access and Adherence Among Rural Indian Women? A Qualitative Study.

Major Depressive Disorder (MDD) is associated with low rates of treatment and medication non-adherence, more so in low- and middle-income countries (LMICs). Mobile mental health (mHealth) interventions offer promise as a tool to address these problems. However, the feasibility and acceptability of mHealth interventions among rural women in LMICs is unknown. We examined barriers to accessing mental health treatment, reasons for non-adherence, and attitudes towards mHealth solutions among women with MDD in rural south India. Six focus groups were conducted among women with MDD (n = 69) who had been in treatment at a rural community health center. The discussion was transcribed and analyzed using a modified grounded-theory approach. Women perceived limited autonomy within their family structure, and experienced financial and systemic barriers as contributing to poor treatment access and non-adherence. Illiteracy, limited personal access to mobile phones, and preference for in-person clinical consultation were identified as barriers to use of mHealth. This is the first qualitative study, to our knowledge, that examines attitude towards mHealth among women with MDD in a rural setting in India. The study identified contextual barriers that will be important to address before implementing mHealth interventions.

Enhancing Staffing In Rural Community Health Centers Can Help Improve Behavioral Health Care.

Community health centers are a vital part of the primary and behavioral health care systems in rural areas. We compared behavioral health care staffing and services in rural and urban centers. In the period 2013-17 the overall staff-to-patient ratio in behavioral health rose by 66percent in rural centers, faster than growth in urban centers (49percent). Growth in both settings was mostly driven by clinical social workers and other licensed mental health providers; staffing by psychiatrists and psychologists changed only slightly. In rural centers the average adjusted increase in annual visits per additional behavioral health staff member was 411 for substance use disorders, slightly higher than at urban centers. Additional annual visits per additional staff member in rural centers were 539 for depression, 466 for anxiety, and 300 for other mental disorders, similar to the numbers in urban centers. Behavioral health staff currently participating in the National Health Service Corps (NHSC) contributed more to visits for depression and anxiety in rural centers, compared to both their urban counterparts and non-NHSC staff in rural centers. Enhancing behavioral health staffing in rural community health centers could help reduce the urban-rural gap in the availability of behavioral health services, but still more could be done.

Horizontal integration and financial reform of a primary care delivery system in Pengshui County, China: a case study

BackgroundThe major obstacles to strengthening the primary care system in China are shortages of finance and workforce, especially in rural and low-income areas. To address these barriers, in 2009, Pengshui County (Chongqing, China), implemented a reform on its primary care delivery system, with a focus on horizontal integration and financing mechanisms. We aimed to analyse the horizontal integrated-care model and evaluate the effect of the reform in the past 10 years. MethodsWe analysed the reform to the primary care delivery system in Pengshui County, focusing on the design and implementation of the horizontal integrated-care model, as well as its financial mechanisms. A descriptive, explanatory, evaluative case study was conducted based on analysis of national and local policy documents, in-depth interviews with local policy makers and institution managers in March, 2019, and analysis of pre-reform and post-reform administrative data from provincial and local health administrative departments. FindingsImplementation of the reform was characterised by establishment of a commission of primary care and a policy-coordinating board, which was charged with managing all horizontally integrated primary care providers and strengthening strategic planning and management of Pengshui County's primary care system. Additionally, a primary care funding pool was developed to support facility purchasing, professional development, and financial incentives. The reform was also characterised by performance assessments, with equal emphasis on public health care and basic medical services, and an enhanced compensation system to encourage uptake of grassroots medical posts by the primary care workforce. From 2009 to 2018, the number of primary care health professionals increased by 125% (from 1113 to 2510). The proportion of outpatients who sought first-contact care in rural community health centres or township health centres 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%). From 2009 to 2018, the proportion of inpatients in primary medical institutions decreased slightly from 67% (30 528 of 45 450) to 60% (93 273 of 156 166), marking a decline rate that was 6 percentage points lower than the national average (the national average decreased from 31% to 17%). However, numbers of inpatients tripled in the same period. The mean annual payment to primary care staff was ¥120 800 (SD 25 615) in 2018, which was five times higher than in 2009. InterpretationOur study suggests that a high priority of Pengshui County's reform strategy was the mobilisation of enough resources to finance efficient and equitable provision of primary care. The horizontal integrated-care model established a clear division of responsibilities and governance structure. The policy of fundraising and mutual aid-sharing of compulsory payment improved the financing and compensation mechanism and made up for the problem of insufficient investment. Many positive results have been achieved through the reform, including advanced medical facilities, more qualified medical professionals, better capability of primary health care, and improved patients' trust of public health and primary medical services. Pengshui County's experience represents a successful experiment in the development of integrated-care reform, especially for rural and low-income regions. FundingWorld Bank China and Science and Technology Department of Chongqing.

Virologic and immunologic responses of patients on highly active antiretroviral therapy in a rural community health centre in Limpopo, South Africa: A retrospective study.

BackgroundSouth Africa has a high HIV burden. Despite increased uptake of persons living with HIV into the South African national antiretroviral therapy programme, the incidence of HIV increased between 2013 and 2016. Studies suggest that increased community viral suppression results in reduced HIV incidence in that community ‘independent of unsafe sexual behaviours and sharing used syringes’.ObjectiveThe aim of this study was to investigate the viral and immunologic responses of patients, in a rural community health centre in South Africa, to combination antiretroviral therapy (cART) between January 2004 and July 2016.MethodsThis was a retrospective medical record review conducted in Thohoyandou Community Health Centre. Data analysis was done using SPSS 24.0 and Microsoft Excel. The estimates used were 95% confidence intervals, and a p-value < 0.05 was considered to be statistically significant.ResultsAnalysis was done using 1247 individuals, with 76% of the cohort being female and 98% first-line cART. The proportion of patients with a suppressed viral load (VL) at 6 months post-treatment was 64%, and 72% at 60 months. Fifty-nine per cent had consistent viral suppression over a 6-month period and 14% over at least 54 months. The mean CD4+ cell count at baseline was 227 cells/µL, and 538 cells/µL at 60 months. Multivariate regression analysis revealed that males had poorer immunologic and virologic responses.ConclusionsViral suppression in the study population was inferior to the UNAIDS target of 90%. The sustainability of viral suppression, once attained, was also low. These may have a negative impact on HIV transmission.

Virologic and immunologic responses of patients on highly active antiretroviral therapy in a rural community health centre in Limpopo, South Africa: A retrospective study

Background: South Africa has a high HIV burden. Despite increased uptake of persons living with HIV into the South African national antiretroviral therapy programme, the incidence of HIV increased between 2013 and 2016. Studies suggest that increased community viral suppression results in reduced HIV incidence in that community ‘independent of unsafe sexual behaviours and sharing used syringes’. Objective: The aim of this study was to investigate the viral and immunologic responses of patients, in a rural community health centre in South Africa, to combination antiretroviral therapy (cART) between January 2004 and July 2016. Methods: This was a retrospective medical record review conducted in Thohoyandou Community Health Centre. Data analysis was done using SPSS 24.0 and Microsoft Excel. The estimates used were 95% confidence intervals, and a p -value &lt; 0.05 was considered to be statistically significant. Results: Analysis was done using 1247 individuals, with 76% of the cohort being female and 98% first-line cART. The proportion of patients with a suppressed viral load (VL) at 6 months post-treatment was 64%, and 72% at 60 months. Fifty-nine per cent had consistent viral suppression over a 6-month period and 14% over at least 54 months. The mean CD4+ cell count at baseline was 227 cells/µL, and 538 cells/µL at 60 months. Multivariate regression analysis revealed that males had poorer immunologic and virologic responses. Conclusions: Viral suppression in the study population was inferior to the UNAIDS target of 90%. The sustainability of viral suppression, once attained, was also low. These may have a negative impact on HIV transmission.

Qualitative Study of Barriers to Adherence to Antihypertensive Medication among Rural Women in India.

Objective There is poor adherence to antihypertensive therapies among women in India. To determine its socioeconomic barriers we performed a qualitative study on Indian rural women with hypertension. Methods In-depth interviews with women having hypertension and presenting to outpatient department at a teaching hospital were performed in 30 women aged 35-65 years, using a questionnaire focused on reasons for nonadherence and poor lifestyle modification. Low to medium adherence was observed in two-thirds of women. Results Majority of women were from low socioeconomic status and were illiterate. Awareness of hypertension and its complications was poor. Knowledge and practices of cessation of smoking and tobacco use and salt restriction in hypertension were low. Efforts to increase physical activity and decrease dietary fat and sugar intake were largely absent. Local follow-up at rural community health centres was not practiced due to physician nonavailability and about half used alternative systems of medicine. None had health insurance or access to free medicines. All the women had to pay out-of-pocket for medicines and were concerned with cost of therapy as well as pill burden. Half of the women borrowed money from relatives or friends to reach the hospital and pay for medicines. Conclusions Socioeconomic barriers for low adherence to antihypertensive medication in women in India are low awareness of hypertension and complications, poor access to care, out-of-pocket payments, borrowing money, lack of insurance, and cost of medicines.

Home Environment-Focused Intervention Improves Dietary Quality: A Secondary Analysis From the Healthy Homes/Healthy Families Randomized Trial

ObjectiveEstimate Healthy Homes/Healthy Families (HHHF) intervention efficacy for improving dietary quality. MethodsLow-income overweight and obese women (n = 349) recruited from rural community health centers were randomized to receive HHHF, a 16-week home environment–focused coaching intervention or health education materials by mail. Healthy Eating Index–2010 scores were calculated from 2 24-hour dietary recalls collected at baseline and 6- and 12-month follow-up. ResultsHHHF participants reported greater improvements in Healthy Eating Index–2010 total scores at 6-month follow-up (+3.41 ± 13.43 intervention vs +2.02 ± 12.26 control; P =.009). Subcomponent analysis indicated greater consumption of total vegetables (P = .02) and greens and beans (P = .001), whole grains (P = .02) and reduced consumption of empty calories (P = .03). Standardized intervention effect sizes were 0.16 at 6 months and 0.13 at 12 months of follow-up. Conclusions and ImplicationsThe HHHF resulted in short-term improvements in dietary quality, although more research is needed to interpret the clinical significance of effect sizes of this magnitude.

Health‐personnel recruitment and retention target policy for health care providers in the rural communities: A retrospective investigation at Pudong New Area of Shanghai in China

To tackle the shortage of health personnel in the rural areas of Pudong New Area of Shanghai, the local government issued an incentive policy as one of the medical reforms. The current investigation focused on the relevant incentive measures and their corresponding effects and problems with a view to providing referential and useful experiences for those who are engaged in addressing the same problem at home and abroad. The details of the incentive policy were derived from the government document, and the related data about the flow of the rural community health care providers, from the institutional investigation. As indicated by the current investigation, the incentive policy produced some positive effect in attracting health care providers to work in the rural community health centers, especially general practitioners, nurses, MS/MD degree holders, and intermediate professional title holders to be employed in the farther ones. However, it was turned out that the population of high quality health care providers was still not sufficient enough to cover the whole rural areas, which suggested that it was still hard to draw such qualified medical individuals. To conclude in the current investigation, we made three recommendations for the policymakers to take into account in terms of policy maintenance, benefits for health personnel, and guarantee of their lawful rights and interests.

The Effect of Education on the Attitude and Child Abuse Behaviors of Mothers with 3-6 Year Old Children: A Randomized Controlled Trial Study.

Child abuse is a kind of domestic violence of children under the age of 18 which potentially or actually damages all aspects of their health. This study was conducted to determine the effect of education based on growth and development with home-visiting follow up on the mothers' attitude and child abuse with 3-6-year-old children. This controlled trial study was carried out in two rural community health centers in Khorasan Razavi province in Iran, during April 2016 to Jun 2017 on 64 abusive mothers of 3-6-year-old children. The data collection tools included the 32-item adult adolescent parenting inventory (AAPI) and the questionnaire of child abuse. By using multi-stage random sampling, the mothers referring to two health centers were assigned to the experimental (N=32) and control groups (N=32). The intervention group received parenting educational interventions based on child growth and development and after being followed up for eight weeks through home-visits. The data were analyzed in SPSS-16, using descriptive statistics, analytical tests including the Chi-square, independent t-test, and Mc Nemars test. After the intervention, the overall score of parenting attitudes was found to be significantly increased (P<0.001), and the prevalence of most abusive behaviors towards children was significantly reduced (P<0.05) in the intervention group compared to the control group. According to the results, this educational program was found to be significantly more effective in improving parenting attitudes and preventing child abuse compared to routine childcare programs in health centers. Trial Registration Number: IRCT2016052628094N1.

Influences on Exclusive Breastfeeding Among Rural HIV-Infected South African Women: A Cluster Randomized Control Trial.

South African guidelines for prevention-of-mother-to-child-transmission (PMTCT) of HIV emphasize exclusive breastfeeding (EBF). This study examined the impact of a PMTCT intervention and male involvement on EBF. In a two-phase cluster-randomized trial, rural South African community health centers were randomized to offer HIV-infected pregnant women PMTCT standard of care plus either: a behavioral PMTCT intervention, or a time-equivalent attention-control condition. Phase 1 women had non-participating male partners; Phase 2 women had participating partners. Pregnant women (n = 1398) were assessed on HIV stigma, disclosure of HIV status to partner, male involvement, and family planning knowledge. Feeding practices were assessed 6 weeks postpartum (56% retained). Reduced depressive symptomatology predicted EBF 6weeks postpartum, adjusting for attrition (AOR = 0.954, p = 0.001). Neither male involvement in antenatal care, phase, HIV stigma, disclosure, nor family planning knowledge predicted EBF. Future studies and perinatal care should address depression, which has important implications for infant health.

Screening for developmental dysplasia of the hip in a rural health district: An analysis of practice.

To describe hip dysplasia screening practices in a local rural health district. Cross-sectional study of hospital birth records, local physiotherapy records, public community health electronic medical record (Community Health Information Management Enterprise database) and a survey of local clinicians who work with infants and children. Three rural public hospitals and community health centres in a New South Wales health district. Birth records (n=196) from March 2012 to May 2012; attendance at child and family nurse checks (n=788) May 2013-April 2014; 13 cases of managed developmental dysplasia of the hip (DDH) 2012 and local clinicians (n=49). At birth, the majority of infants (91%, 179/196) had documented hip screening. Community health records show this dropped to 75% (587/788) at 1-4weeks and 29% (227/788) at 6-8weeks. A survey of local clinicians (54% response rate; 49/91) revealed most (78%) screen for DDH and less than half (43%) use guidelines. Almost all (97%) clinicians reported screening for DDH at 6-8weeks of age. Only 51% of clinicians reported having specific training for DDH screening and 76% would like further training. The rate of late DDH requiring management in 2012 was 0.87% (7/806) and the rate of late DDH requiring surgery was 0.25% (2/806). DDH screening practices are well established at birth in the rural health district. There is variability in DDH screening practices beyond 8weeks of age. Clinicians report variations in their knowledge and training. Training in DDH screening and hip screening prompts added to the personal health record might improve rates of DDH screening beyond 8weeks of age.