Rural Community Setting Research Articles

Volunteer Stroke Service (VSS) groups for patients with communication difficulties after stroke: a qualitative analysis of the value of groups to their users

Objectives: To identify the functions that Volunteer Stroke Service (VSS) groups fulfil for their members. Design: Qualitative focus group study. Setting: Mixed urban and rural community settings in Scotland. Participants: Seven focus groups comprising a total of 24 men and 14 women, with dysarthria or aphasia following stroke, who were members of VSS groups funded by Chest Heart and Stroke Scotland. Results: We identified eight main themes. VSS groups (1) include members in an interpersonal network, (2) provide members with the opportunity to develop interpersonal relations, (3) provide members with support, (4) provide opportunities for personal growth and development, (5) supply members with a purpose, structure and routine, (6) help members establish and confirm their identify, beliefs and values, (7) help members accomplish individual and shared goals, and (8) provide members with the opportunity to influence others and be influenced. Conclusion: VSS groups appear to provide a range of functions that meet members' personal, interpersonal and psychological needs.

Comparative study of four candidate strategies to detect cervical cancer in different health care settings

Considering the differing but potentially supplementary properties of visual inspection of the cervix with acetic acid (VIA) and the cytological examination (CYTO) of cervical smears for the screening of cervical cancers, we examined the performance of these two tests and their combinations for the screening of cervical cancer in different health care settings. In this cross-sectional diagnostic test performance evaluation study of 4235 female subjects in the reproductive age group, we assessed the screening performance of four strategies: VIA alone, CYTO alone, VIA and CYTO combined in a parallel fashion, and VIA and CYTO combined in tandem. Subjects were recruited from three settings: Hospital, Urban Community and Rural Community. Colposcopy was used as the reference standard. Screening performance was assessed using sensitivity, specificity, post-test probabilities and likelihood ratios (LR), diagnostic odds, area under receiver operating characteristic curve and LR chi(2). Both VIA and CYTO when used alone had a low sensitivity but high specificity, especially in the Rural Community setting. A combination of the results of VIA and CYTO improved the diagnostic accuracy but the strategy using a parallel combination of VIA and CYTO was the most accurate. In general, all screening strategies using VIA and CYTO showed a modest screening performance. In the settings of varying levels of health care and low resources, caution is needed for a generalized use of VIA for cervical cancer screening. Further evaluation of the cost-effective ways of combining VIA and CYTO is needed in these circumstances.

Community based medical education: a tool for developing countries

Providing undergraduate and professional medical training in rural community settings could greatly benefit the health of developing countries, as Yusuf Moradeyo and Kingsley Ukwaja report

Development and validation of a questionnaire for anxiety and depression in Pakistan

Currently clinicians and researchers in Pakistan have to use translated western instruments to screen for anxiety and depressive disorders. This study investigated the local idioms of emotional distress in Pakistan to develop a culturally valid and easy-to-use instrument to screen for common mental disorders in general clinical settings. A systematic survey was conducted of psychiatric case notes of patients attending clinics in Peshawar and Lahore, diagnosed with anxiety or depressive disorders, to identify the range of common idioms of psychological distress. A pilot version of the questionnaire was refined and validated among a composite sample of 330 patients in inpatient, outpatient and rural community settings. ICD-10 Diagnostic Criteria for Research were used to define cases and patients' relatives acted as normal controls. The pilot version of the questionnaire was reduced to 42 items based on odds ratios between cases and controls. Anxiety symptoms were generally reported by depressed patients, but not vice versa. Finally 30 items were selected, in two sub-scales. This final version achieved sensitivity, specificity, and positive and negative predicted values of over 90% when comparing cases and controls. This questionnaire was based on what patients tell doctors and may not capture the entire repertoire of local idioms of distress. The validation study was conducted only in an Urdu/Punjabi speaking population, in Lahore and surrounding areas. The Pakistan Anxiety and Depression Questionnaire consists of an anxiety/depression scale and a depression scale, each of 15 items. It demonstrates excellent validity as screening instrument for anxiety and depressive disorders in clinical settings in Pakistan.

Skilled birth attendance: What does it mean and how can it be measured? A clinical skills assessment of maternal and child health workers in Nepal

The presence of a skilled birth attendant at delivery is important in averting maternal and neonatal mortality and morbidity. It has now shown that even trained traditional birth attendants (TBAs) cannot, in most cases, save women's lives effectively because they are unable to treat complications, and are often unable to refer. Qualified midwives and doctors are often not available in the rural areas and community settings where most women in developing countries deliver. Defining the minimum competency level necessary to meet the definition of skilled birth attendant is important, particularly in countries such as Nepal with limited availability of facility-based emergency obstetric care. Maternal and child health workers are local women aged 18-35 who completed a 15-week course in maternal and child health. As the role of MCHWs has expanded to meet the country's needs for skilled attendance, a 6-week "refresher" course in midwifery skills is offered. The results of this clinical skills assessment of 104 randomly selected MCHWs from 15 districts across Nepal supports the premise that MCHWs with appropriate training have an acceptable level of knowledge and skill, demonstrated in a practice situation, to meet the definition of community level skilled birth attendants. Yet, competency alone will not necessarily improve the situation. To affect maternal mortality in Nepal, MCHWs must be widely available, they must be allowed to do what they are trained to do, and they must have logistical and policy support.

Facilitating interdisciplinary practice through mobile service provision to the rural older adult

Reaching the older adult in the rural communities in which they reside is desirable in an effort to support aging in place. The Idaho State University (ISU) Senior HealthMobile is an innovative, interdisciplinary rural health outreach effort designed to meet the needs of the older adult and support healthy aging. Health and wellness support services are provided through mobile interdisciplinary teams involving students and faculty in nursing, physical therapy, occupational therapy, pharmacy, and dietetics, among other disciplines. Students and supervising faculty provide services in the ISU Senior HealthMobile, in the rural senior centers, and in the home, providing a unique opportunity to be a part of the life of the older adult in the rural community setting. Partnerships and collaborative linkages within the community setting support the enhancement of existing services in collaboration with the ISU Senior HealthMobile.

Factors Associated with Chronic Illness among the Elderly in a Rural Community in Malaysia

Chronic illness is one of the major causes of mortality and morbidity among the elderly. To determine the prevalence and factors associated with chronic illness among the elderly in a rural community setting. A cross sectional study design was used. Stratified proportionate cluster sampling method was used to select respondents in Mukim Sepang, Sepang, Selangor, Malaysia. Out of 263 elderly residents (6.2% of the total population), 223 agreed to participate in the study giving a response rate of 84.8%. The prevalence of chronic illness among the elderly in Mukim Sepang was 60.1%. Out of 223 respondents, 134 were diagnosed as having chronic illness such as hypertension, diabetes mellitus, ischaemic heart disease, bronchial asthma or gout. Chronic illness was found to be significantly associated with functional dependence among the elderly (chi2=6.863, df=1, p<0.05). The prevalence of chronic illness among the elderly in the rural community is very high. Problems facing this age-group should be addressed comprehensively in order to formulate appropriate programmes for the health care of the elderly.

Two major hospitals can share level I status in a rural community setting.

Even though development of Level I trauma centers is thought to improve outcome of injury treatment, the political barriers in communities where two capable hospitals compete for designation can be formidable. This report documents the initial experience of a Level I trauma center developed in a two-hospital setting whereby each hospital hosted the trauma center on an alternating annual basis. Preliminary efforts began with a community-based report on trauma care to which both hospitals and their associated school of medicine contributed. In addition to confirming need, all parties agreed to develop a single Level I trauma center that would be verified by the appropriate state agency and would receive professional and financial support from all three institutions. The Southern Illinois Trauma Center began to function on July 1, 1999. Prehospital acceptance of the community agreement has resulted in appropriate triage to the designated hospital in 95% of the 1,000 cases seen annually. Integration of trauma care into the surgical residency program has been valuable both for function of the trauma center and as a teaching enhancement for trauma and critical care as reflected by significantly improved American Board of Surgery In-Training Examination scores. The trauma center is governed by a trauma committee with representation from the three institutions. The percentage of trauma transfers has increased over 3 years from 23% to 28%. Four annual institutional site changeovers have now occurred without incident or disruption of service. The trauma center finances are reviewed by the participants on a biannual basis and have been deemed favorable. The community medical resources are commonly polarized between two large hospitals but need not prevent centralized trauma center development if preagreed community support can be achieved. Annual site change is not an impediment and could be successfully used in other similar communities, provided they are receptive to the concept of sharing Level I trauma center site designation.

The safety and efficacy of extracorporeal shock wave therapy in active, moderately active, and sedentary patients with chronic plantar fasciitis (SS-103)

Purpose: The purpose of this study was to examine the effects of extracorporeal shock wave therapy (ESWT) on patients with chronic plantar fasciitis treated by the same investigator in a rural, community setting, and to determine if there was a difference in outcome between active, moderately active, and sedentary individuals. Type of Study: Retrospective case series. Methods: The efficacy and safety of ESWT was investigated in active, moderately active, and sedentary patients with chronic plantar fasciitis unresponsive to six months of traditional nonoperative treatment. All procedures were performed by one investigator in a rural community setting. Fifty-three patients (60 heels) were treated with a single session of 3800 shock waves to the affected heel. Of these 53 patients, 16 (19 heels) were active, 21 (22 heels), were moderately active, and 16 (19 heels) were sedentary. A total of 1300 mJ/mm2 of energy was administered in each session. Outcome measures included visual analog, RAND-Physical Functioning, RAND-Pain, and Roles and Maudsley scores. Results: Twelve weeks post treatment, visual analog scores improved from 9.2 to 2.4 (P < .05), RAND-Physical Functioning score improved from 40.4 to 91.5 (P < .05), and RAND-Pain score improved from 33.3 to 90 (P < .05). Using the Roles and Maudsley scale, 50 heels (83.3%) were assigned an excellent or good result. There were no significant differences in VAS, RAND-Physical Functioning, or RAND-Pain scores among the subgroups. There were no significant complications. Conclusions: ESWT is an effective treatment for chronic plantar fasciitis nonresponsive to traditional measures, and can be performed safely in a rural, community setting. Active, moderately active, and sedentary patients appear to improve equally with this procedure.

Temporal settling of holidays and annual customs in villages at the foot of the Avala mountain

The life of rural population in villages at the foot of the Avala Mountain was marked by a constant shift of working days - when the local population had to ensure its existence - and idle days. Various holiday occasions altered the regularities of everyday life. During a holiday celebration the whole village community, as well as individuals, had to adopt a new way of behavior - i.e., to discontinue all work obligations that filled regular working days. In the past, these idle days were equally important for families and their members, and for the rural community in general. On the whole, the holidays appear in an annual cycle, discernible in a parallel mode: 1, Weekly and 2, Annual celebrations. The Weekly cycle is celebrated on Sundays, while the annual cycle celebrated various family' holidays or just days marked as During the celebration of holidays participants departed from their everyday existing conditions and attuned to the Holy time, generated during holidays. Various rituals and customs used to be performed that not only added to the holiday ambiance, but also ensured the well-being of the family and rural community, and protected in this way, against misfortune. This period was marked by profound changes in family and community organizations. The changes in rural areas are the result of the rural population mass relocation in search for work and the beginning of urbanization. The process of industrialization along with the influx of the authorities onto traditional folk culture have left permanent consequences in the rural community settings and inherited folk culture.

Prevalence of depression with chronic illness among the elderly in a rural community in Malaysia

Abstract Introduction: Depression is the most common psychiatric disorder among the elderly. The hallmark of depression in the elderly is its comorbidity with medical illness. Aim: To determine the prevalence of depression and its association with chronic illness among the elderly in a rural community setting. Methods: A cross sectional study design was used. A 30-item Geriatric Depression Scale questionnaire was used as a screening instrument. Results: The prevalence of depression was higher among elderly with chronic illness (9.0%) compared to elderly without chronic illness (5.6%). Depression among the elderly was significantly associated with ischemic heart disease. Conclusion: The prevalence of depression among the elderly with chronic illness in the community is high. Primary care providers need to be vigilant when treating elderly patients in their care as depression is commonly found in this group.

Incorporating Intergenerational Service-Learning into an Introductory Gerontology Course

Summary The service-learning approach in education, which integrates community service with academic classroom learning, is gaining national prominence. The goals of this project were to incorporate intergenerational service-learning into an undergraduate introductory gerontology course and to involve students and elders in meaningful in-teractions in a rural community setting. Thirteen of the 50 students in the class could be accommodated at nursing home and semi-independent living sites and were paired with elders for friendly visiting and oral history. Attitude scales (Pillemer & Albright, 1996) indicated that service-learning students showed more positive change at post-test in overall attitudes toward the elderly than did non service-learning students. Open-ended questions indicated that students valued the experience, felt it enhanced classroom learning, and gained knowledge about rural elders and communities. Follow-up interviews with elders were uniformly positive.

Recruitment and retention of physicians for primary care research.

The primary objective of this report is to examine factors associated with recruitment of physicians in community-based primary care research. Reported results are based on an observational study of physician recruitment efforts undertaken in a randomized controlled trial designed to improve primary care physicians' cancer screening and counseling activities. The Partners for Prevention project was a statewide randomized controlled trial of primary care physicians selected from the state of Colorado. Two-hundred and ten eligible internal medicine and family medicine practices in both rural and urban community settings of the state of Colorado were selected into this study and a sentinel physician was chosen to represent each practice. Only 6% (13/210) of recruited practices initially declined to participate in the study, but the total refusal rate had reached 30% (59/210) by the time the intervention was implemented five months later. Study participants (n = 136) were younger (mean age 45.7 vs. 50.0, p = 0.008) and more often located in a rural area (46% vs. 31%, p = 0.04) than decliners (n = 59), but there was no association with gender of the physician (87% for females vs. 95% for males, p = 0.13). Participants were more often family practice physicians by training rather than internists (75% vs. 56%, p = 0.008), whereas there was no difference in participation rates by practice type (solo versus group, 60% vs. 64%, p = 0.52). Differences in demographic, geographic, and training characteristics between trial participants and decliners suggest the potential for better targeting of recruitment efforts. Viable strategies for recruiting community-based primary care practices to research studies are proposed.

Homebound status in a community-dwelling elderly population in Japan.

The present study investigated the association between sociodemoraphic profiles, health condition and functional disabilities of subjects with a homebound status in a rural community setting. The subjects were residents aged 65 years or over in a mountain village of Japan. A comprehensive questionnaire was used to obtain their data. Among the 1,002 residents, the information of 866 residents (85%), who voluntarily completed the entire survey, was obtained for this study. All the subjects were native Japanese. Of the 866 subjects investigated, 301 (34.8%) were homebound as defined by the parameters of this study. Univariate analysis revealed age, female gender, functional impairment (vision, hearing and memory), all the ADL impairments, and the use of a portable toilet were associated with homebound status. Multivariate analysis revealed that older age, female gender, visual and two ADL impairments (moving inside the home and bathing) and use of a portable toilet remained significantly related to homebound status. Homebound elderly people have more functional limitation and disability related factor than their nonhomebound counterparts. Functional impairment, particularly in the mobility domain and sensory disturbances, was associated with homebound status. These data indicate the importance of assessment in the provision of home care for elderly people.

Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain

Although chronic pain is a frequent cause of suffering and disability and is costly to society, there continues to be limited access to specialty pain clinic services. Hence, there is a need for cost-effective, accessible interventions that will help people find ways to better manage this difficult problem. This randomized controlled trial examined the effect of a low-cost, community-based, nurse-delivered, group psychoeducation program entitled the Chronic Pain Self-Management Program (CPSMP). It has a standard protocol that was modified from the successful Arthritis Self-Management Program (ASMP). One hundred and ten individuals with mixed idiopathic chronic pain conditions were enrolled in the study (75% female; mean age 40 years; mean chronicity 6 years) and were randomly assigned to one of two conditions: the 12-h (CPSMP) intervention group, or the 3-month wait-list control group. Self-report measures of pain-related and other quality of life variables as well as two hypothesized mediating variables were collected pre-treatment and 3 months later by assessors blind to group allocation. One hundred and two subjects completed the study. Results of intention-to-treat analysis indicated that the treatment group made significant short-term improvements in pain, dependency, vitality, aspects of role functioning, life satisfaction and in self-efficacy and resourcefulness as compared to the wait-list control group. Because it has a standard protocol, this intervention has the potential to be reliably delivered at low cost in varied urban and rural community settings and hence be more widely accessible to a greater number of people suffering from chronic pain than is currently the case with more specialized pain clinic services. Based on the results of this study, further research evaluating the long-term impact and potential cost savings to the individual and to the health care system is warranted.

A family systems approach to case management in a rural community setting

Case management has proven to be an effective mechanism in assisting clients to seek and receive health care in the most appropriate setting. A family systems approach has been added to the case management program in a Midwestern rural community to encourage greater client and family participation in developing solutions to health care problems. Clients and families become more autonomous decision-makers and authors of change.

Training internal medicine residents in the community: the Minnesota experience.

The University of Minnesota Internal Medicine Residency Program has developed ambulatory general medicine rotations in rural community settings and urban managed care settings in Minnesota. Based on what had been learned from community focus groups, from discussions with residents about what they perceived to be training holes in the traditional curriculum, and from resident evaluations of pilot rotations, an educational framework for the rotations was established. The authors describe the process of developing these rotations, their educational rationale and objectives, the structure of the rotations, teaching strategies, faculty development, and the evaluation system, and outline the important elements of the successful implementation of these new rotations. The community practice setting has offered a unique, important, and previously untapped resource for residency training, and the community rotations have been highly valued both by housestaff and by community preceptors. As residency programs begin to offer more community-based ambulatory care opportunities for their trainees, the impact of this trend on quality of training, residents' career choices, and patient outcomes will need to be evaluated.

The cost of problem-based vs traditional medical education.

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.