Rural Community Setting Research Articles

P08-06 MOVEluencer: a project to promote physical activity during the COVID-19 pandemic in a rural community setting

BackgroundAn appropriate level of Physical Activity (PA) is important for both physical and mental health and has also been suggested as a protective element against COVID-19. However, even before the outbreak of the COVID-19 pandemic, there were already a high number of physically inactive people in Austria. Due to ongoing pandemic-related social restrictions, not only a further increase of inactivity is suspected, but also the promotion of PA is currently a major challenge. Therefore, the project “MOVEluencer” which has been running since July 2021, follows a multidimensional PA promotion approach that is less affected by the presence of any social restrictions.MethodsThe project was realized in six rural communities in Styria (a province of Austria), which were selected based on inequality factors related to health and PA. The target groups are physically inactive residents, particularly families and elderly. Overall, the project measures are based on a participatory approach and are implemented in three sections (phase 1 -3).ResultsPhase 1 (July - December 2021) represented an analysis phase in which a photo-challenge was conducted. The aim of the challenge was to identify resources and opportunities for improving active mobility and PA in the communities based on photos taken by residents. Sixty-seven people (43% female) participated in the challenge and submitted a total of 268 photos which were disseminated via the project-specific social media channels. Moreover, in phase 1 working groups represented by members from the project target groups were established. Phase 2 is currently being implemented (since January 2022). One measure is to recruit and train walking buddies to provide regular walks and simple strength exercises along the walking-way. A further measure represents outdoor-educational events, following an interactive learning approach to improve the populations awareness of active mobility and PA in general. During these events, simple tests that assess components of health-related fitness are also offered. Phase 3 will implement target group-specific PA programs currently being developed in the working groups.ConclusionPromotion of PA remains significant, especially during a pandemic and in rural communities, as awareness of the benefits of PA in this setting is still low.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

EHealth Tools That Assess and Track Health and Well-being in Children and Young People: Systematic Review.

BackgroundeHealth tools that assess and track health outcomes in children or young people are an emerging type of technology that has the potential to reform health service delivery and facilitate integrated, interdisciplinary care.ObjectiveThe aim of this review is to summarize eHealth tools that have assessed and tracked health in children or young people to provide greater clarity around the populations and settings in which they have been used, characteristics of digital devices (eg, health domains, respondents, presence of tracking, and connection to care), primary outcomes, and risks and challenges of implementation.MethodsA search was conducted in PsycINFO, PubMed or MEDLINE, and Embase in April 2020. Studies were included if they evaluated a digital device whose primary purpose was to assess and track health, focused on children or young people (birth to the age of 24 years), reported original research, and were published in peer-reviewed journals in English.ResultsA total of 39 papers were included in this review. The sample sizes ranged from 7 to 149,329 participants (median 163, mean 5155). More studies were conducted in urban (18/39, 46%) regions than in rural (3/39, 8%) regions or a combination of urban and rural areas (8/39, 21%). Devices were implemented in three main settings: outpatient health clinics (12/39, 31%), hospitals (14/39, 36%), community outreach (10/39, 26%), or a combination of these settings (3/39, 8%). Mental and general health were the most common health domains assessed, with a single study assessing multiple health domains. Just under half of the devices tracked children’s health over time (16/39, 41%), and two-thirds (25/39, 64%) connected children or young people to clinical care. It was more common for information to be collected from a single informant (ie, the child or young person, trained health worker, clinician, and parent or caregiver) than from multiple informants. The health of children or young people was assessed as a primary or secondary outcome in 36% (14/39) of studies; however, only 3% (1/39) of studies assessed whether using the digital tool improved the health of users. Most papers reported early phase research (formative or process evaluations), with fewer outcome evaluations and only 3 randomized controlled trials. Identified challenges or risks were related to accessibility, clinical utility and safety, uptake, data quality, user interface or design aspects of the device, language proficiency or literacy, sociocultural barriers, and privacy or confidentiality concerns; ways to address these barriers were not thoroughly explored.ConclusionseHealth tools that assess and track health in children or young people have the potential to enhance health service delivery; however, a strong evidence base validating the clinical utility, efficacy, and safety of tools is lacking, and more thorough investigation is needed to address the risks and challenges of using these emerging technologies in clinical care. At present, there is greater potential for the tools to facilitate multi-informant, multidomain assessments and longitudinally track health over time and room for further implementation in rural or remote regions and community settings around the world.

Utilizing Readers Theater for Health Promotion Education in a Rural Setting

Purpose: The aims of the study were to bring in healthy foods, such as fruits and vegetables, provide cardiac health promotion information, and build a community-based partnership with a rural community in West Alabama by soliciting members of the community to participate in and attend a play on cardiovascular health promotion. Sample: The sample population was mostly older African American community members from a non-incorporated, rural area along with individuals from surrounding communities in an Alabama Black Belt county. Through community collaboration, 67 persons were recruited to participate as actors via reading a script and (n =13) and all remaining persons were audience members for the community play (n = 54). Method: This study utilized a community-based participatory research approach with a qualitative, descriptive research design. The Farmers Theater Toolkit, which utilizes a readers theater technique was used to bring cardiovascular health promotion information to a rural community setting. Findings: The majority of audience participants either strongly or somewhat agreed that what they learned from the community play would help them make better food choices (96.3%). Conclusion: Utilizing the Farmers Theater Toolkit in a rural community was an innovative, fun way to share health promotion information. The citizens of this community were very welcoming to the researcher and were excited to partner with an academic institution. Health promotion education may reduce health risk behaviors such as unhealthy food choices. This type of intervention may serve as an impetus to making better food choices. Keywords: rural community, theater, health eating, health promotion DOI: https://doi.org/10.14574/ojrnhc.v22i1.696

Efficacy of a Virtual Education Program for Family Caregivers of Persons Living with Dementia.

Background:Family caregivers of people with dementia often experience negative impacts including stress and burden. Psychoeducational programs can reduce these negative outcomes.Objective:To evaluate whether this virtual caregiver education program changes caregiver confidence, self-efficacy, and burden relative to controls.Methods:This was a pre-post comparison of a five-week, synchronous, virtual caregiver education program delivered by a clinician and caregiver support specialist covering aspects of dementia, including changes in cognition, behavior, functional abilities, caregiver-care recipient roles, communication, and caregiver self-care. Caregivers (n = 90) were surveyed at baseline, at completion of intervention, and three months thereafter; controls (n = 44) were surveyed at two points six weeks apart. We compared validated measures of caregiver confidence, self-efficacy, and burden using generalized estimating equations.Results:Participants’ confidence and self-efficacy increased over follow-up compared with controls (p < 0.01 for intervention*time in regression models). There was no difference in burden. All participants (100%) reported perceived increased knowledge, 97% perceived increased confidence, and 95% perceived increased ability to manage dementia-related behaviors after the course.Conclusion:This virtual caregiver education program was effective in improving caregiver confidence and self-efficacy and participants’ self-reported impact was equivalent to those who had taken previous courses in person. Caregivers with greater confidence and self-efficacy have been shown to have better health outcomes and decreased stress and depressive symptoms. Health professionals, health care organizations, and public health agencies should consider using efficacious virtual caregiver education programs in rural and other community settings, during public health crises, or in standard practice as an alternative to in-person programs.

EVOLVE: Evaluating the Safety of De-escalated Head and Neck Irradiation in HPV Positive Oropharynx Cancer in Non/Minimal Smokers.

<h3>Purpose/Objective(s)</h3> HPV mediated oropharynx cancer in minimal smokers is a favorable disease entity but with high treatment related quality of life burden. Single institutional studies in large academic centers have favorable results with aggressive radiotherapy de-escalation after surgery or after complete response to induction chemotherapy. We hypothesize that radiotherapy can be safely de-escalated in the community cancer center setting. <h3>Materials/Methods</h3> Adults with HPV mediated squamous cell carcinoma of the oropharynx with ≤ 10 pack year smoking history T0-T3N0-N2M0 (AJCC8, including unknown primary p16+ minimal smokers) and with negative margins (if surgical arm) were enrolled on this prospective observational study. Initial surgical resection was performed if an R0 resection was anticipated AND if the surgeon would anticipate a good functional outcome post-operatively. Adjuvant radiotherapy was as per Ma <i>et al</i> JCO 2019. Induction chemotherapy with de-escalated radiotherapy to complete responders was undertaken when surgical resection was not deemed optimal. Platinum eligible induction chemotherapy was as per Marur <i>et al</i> JCO 2017. Platinum ineligible induction chemotherapy was as per Chen <i>et al</i> Lancet Oncology 2017. The primary endpoint was cumulative incidence of local/regional recurrence. Secondary endpoints included quality of life as determined by Head and Neck PRO (FACT-H&N, EORTC QLQ-C30 and H&N35), distant metastasis free survival and overall survival. Preliminary report includes 39 patients with at least 3 months follow-up. Planned accrual is 60 patients. <h3>Results</h3> Median follow-up was 18 months (3-45 months). 31/39 (80%) received initial surgery. 8/39 (20%) received initial induction chemotherapy. 1 withdrew during induction. 100% of patients receiving induction therapy had adequate response to qualify for de-escalation. Cumulative incidence of local/regional recurrence was 3% (1/39). Cumulative incidence of distant metastases was 3% (1/39). Both recurrences occurred in the surgical arm. Overall survival is 100%. No patient in the induction arm required salvage neck dissection or recurred. 1/11 (9%) of patients with extranodal extension (ENE) recurred locally/regionally. 1/11 (9%) patients with ENE recurred distantly. ENE status is unknown in the non-surgical arm. There were no recurrences in the 7 patients with N2 disease. No de-escalated patient required treatment related feeding tube placement. Patient reported quality of life was stable to improved at 12 month follow-up. <h3>Conclusion</h3> In a rural community setting, early results of aggressive de-escalation of radiotherapy demonstrate this approach to be both safe and effective with minimal change in patient reported quality of life. In this favorable disease entity, reported de-escalation results from large academic centers are readily translatable to daily community practice.

Real world utilization of Dalbavancin at a rural community emergency department

IntroductionAcute bacterial skin and skin structure infections (ABSSI) are frequently encountered in the emergency department and compromise more than 700,000 hospital admissions annually. Dalbavancin is a single dose long acting semi-synthetic lipogylcopepitde antibiotic with coverage against gram-positive organisms including methicillin resistant Staphylococcus aureus. Recent data from large tertiary care centers have shown a decrease in hospital admissions and repeat emergency department visits for ABSSI's but little data is available for those who practice in a rural community setting. The primary objective of this study was to describe the use of dalbavancin at a single rural emergency department. MethodsA retrospective cohort study of all adult patients who received dalbavancin between 2019 and 2021 while in the emergency department was completed. Abstracted data included patient demographics, infection location by body region, emergency department return visits, hospital admissions, and length of stay. Analysis was conducted using descriptive statistics, the Mann-Whitney test for continuous data, and the chi-squared analysis for nominal data. ResultsA total of 125 patients were included in the final analysis with 35.2% being female. The median age of those treated with dalbavancin was 54 years (42.0–64.0) and the most common infection site was the lower extremities. A total of 35 patients re-presented to the emergency department following treatment with dalbavancin within 30 days and 16 were admitted to the hospital. Of those who re-presented to the emergency department, the median age was 56 (40.0–66.0) and the median re-presentation was 9 days (3–17) after dalbavancin administration. A total of 16 patients (12.8%) were subsequently admitted to the hospital with a median length of stay of 5.5 days (3.0–8.0). 30-day readmission rates were 23.9% in those who had an abnormal WBC count at initial presentation, 26.1% for those with congestive heart failure, 20.3% for those with hypertension, and 26.0% in those who had diabetes mellitus. ConclusionFollowing the administration of dalbavancin for ABSSI at a rural emergency department, few patients are subsequently admitted within the following 30 days. To further decrease this number and alleviate the burden on emergency departments and hospitals, local treatment algorithms should be developed to minimize the risk of representation and hospitalization following administration.

The prevalence and burden of primary headache disorders among adults in rural villages of Bangalore District, South India: A community-based study

The prevalence of primary headache disorders (PHDs) and their burden has been seldom studied in the rural community setting of a developing country. To study the prevalence of primary headache disorders and their burden in the rural community A door to door survey was done in seven rural villages under Mugalur sub centre area, Sarjapura Primary Health Centre and Anekal taluk, Bangalore district, Karnataka State, south India, for finding the prevalence and burden of PHDs. During the study period of three months, a total of 1255 people were screened in the seven villages. 13.1% (165/1255) of people suffered from PHDs. The population prevalence of migraine without aura was 8.84% (111/1255), tension type headache was 2.86% (36/1255) and chronic migraine was 1.43%(18/1255). The mean number of headache days for all the PHDs was 4.26 (±1.64) days. 66.1% of persons with headache reported minimal or infrequent impact of headache. Among various demographic variables, headache was significantly associated with the female gender and marital status. PHDs are prevalent in the rural communities of developing countries and need urgent attention of primary care physicians, community health departments, governmental agencies and policy makers.

Chronic Urogenital Schistosomiasis among In-School Adolescents in Sokoto, North-Western Nigeria

Aims: To assess the prevalence, intensity, associated factors and predictors of chronic urogenital schistosomiasis among in-school adolescents in Sokoto.&#x0D; Study Design: Descriptive cross-sectional survey.&#x0D; Place and Duration of Study: Secondary Schools in Sokoto metropolis, Sokoto State, Nigeria, between January and April 2018.&#x0D; Methodology: A total of 590 apparently healthy secondary school students aged between 10 and 19 years in Sokoto metropolis were selected using multi-stage random sampling technique. Designed pretested semi-structured questionnaire was used to obtain relevant socio-demographic and clinical information. Urine specimen was obtained and subjected to urine analysis and microscopy for ova of Schistosoma haematobium. Data was analyzed using IBM-SPSS version 25.0.&#x0D; Results: Mean age of subjects was 15.1 ±2.6 years. There were 334 (56.6%) males and 256 (43.4%) females. Majority 371 (62.9%) attended public secondary schools, most 264 (44.7%) were of middle socio-economic family status, and 300 (50.8%) were from rural community setting. The commonest source of water for domestic use was pipe-borne 203 (34.4%), and swimming was the predominant 55(9.3%) recreational water- related activity. The overall prevalence of chronic urogenital schistosomiasis was 22.9%, significantly (p&lt;0.001) higher among males, with age group category 15-17 years mostly 59 (29.6%) affected. All 135 (100%) of the infected subjects had microscopic haematuria, 119 (88.2%) had proteinuria, and 108(80.0%) had leucocyturia. Age group category 15-17 years (p=0.027), male gender (p&lt;0.001), low and middle social classes (p&lt;0.001) respectively, and residence in rural community setting were independent predictors of chronic urogenital schistosomiasis infection. Majority 81(60.0%) of the infected respondents had light infection. Male gender was the only predictor (p=0.003) of intensity of infection.&#x0D; Conclusions: Chronic urogenital schistosomiasis is prevalent among the subjects. Middle adolescence, male gender, swimming, rural community setting and low-middle socio-economic classes were independent predictors of infection.

Personal Agency and Community Resilience: Narratives of Women Navigating Health Care With Chronic Lyme Disease.

Chronic Lyme disease can manifest as a debilitating illness with symptoms that change over time. With its varied presentation, timeline variation, diagnostic difficulty, and lack of definitive treatment, clinical recognition of chronic Lyme disease remains controversial. At the same time, patients face challenges in finding a provider who is supportive and knowledgeable about diagnosing and treating Lyme. We examined the ways the medical system may have affected the lived experiences of chronic Lyme patients. In this article, we communicate the personal, health care, and community illness experiences of 14 women navigating the medical system with chronic Lyme disease through a qualitative community-based participatory research study using interviews and narrative reflection in a rural community setting. The women were interviewed by a researcher living with chronic Lyme disease and the transcripts were analyzed for themes. All participants described navigating multiple allopathic and nonallopathic care modalities to find satisfactory care. They struggled with physical and emotional burdens of chronic, nonlinear illness, as well as disbelief and discrimination by medical providers. Their lives followed patterns of illness and wellness, trust and mistrust of medical treatment, and community connection and disengagement. They learned to become their own advocates to seek affirmative care. They are aware of the controversial nature of their illness, and many have channeled their frustrations into caring for one another through their Lyme community. Women living with controversial diagnoses like chronic Lyme disease experience increased challenges navigating the medical system to find satisfactory care and thus create communities with each other for mutual aid and support. In understanding these challenges, the medical community can improve care for people living with contested chronic illnesses.

P61.09 Feasibility of Lung Cancer Screening With Low-Dose Computed Tomography in a Rural Community Setting; An 8-Year Experience

Low-dose computed tomography (LDCT) screening guidelines per the United States Preventive Services Task Force (USPSTF) represent the most effective method to detect lung cancer at an early stage. Despite this, adoption of this practice has been mostly urban-centered and established protocols for screening in rural communities remains limited. To date, there is no published literature suggesting feasibility of an effective LDCT screening program at the rural level. Our data set contradicts this notion.

An Evaluation of Cognitive Behaviour Therapy with Mindfulness (CBTm) Classes and Telepsychology Utility in Rural Community Settings

An Evaluation of Cognitive Behaviour Therapy with Mindfulness (CBTm) Classes and Telepsychology Utility in Rural Community Settings

What is the Unemployment Situation of Nurses and Midwives in Nigeria?

Background: The quacking controversy that trailed the Nursing &amp; Midwifery Council of Nigeria’s (N&amp;MCN) release of a “License Community Nurse (LCN)” circular (Ref No. N&amp;MCN/SG/RO/CIR/24/VOL.4/152 dated March 3, 2020) which conveyed the intention of the council to lower the existing standard of nursing education for the LCN programme that will take secondary school leavers at least a credit in English and Biology to be admitted into and two years to complete, and inter alia blamed the crude situation and abysmal performance of the Nigerian Primary Healthcare (PHC) system in the community settings on mass migration of Nurses &amp; Midwives to urban areas and to other countries prompted UGONSA to initiate this survey to empirically determine whether there are indeed a shortage of Nurses &amp; Midwives to fill the manpower need of the Nigerian PHC system in the community settings or not, or whether the shortage is as a result of the deliberate age-long policy of attrition and displacement of Nurses &amp; Midwives from the PHC system in the community settings and their replacement with Community Health Extension Workers (CHEWs) [who do not have nursing education, training, skills or the ethical leaning to be responsible and accountable for nursing &amp; midwifery services] by the National Primary Healthcare Development Agency (NPHCDA). Objective: The main aim of the study was to determine if there is a shortage of nurses that could fill the nursing needs of the PHC system in the community settings. The study also sought to compile the list of unemployed and underemployed Nurses &amp; Midwives and to find out if unemployed Nurses &amp; Midwives are willing to work in the community settings if the opportunity to serve the PHC system in the community setting is offered to them by the NPHCDA. The study further sought to determine the ratio of unemployed Nurses &amp; Midwives in relation to the possible number of graduates that can be licensed by the N&amp;MCN in a session. Methods: Using Google forms an online compilation was carried out from March 7 to April 08, 2020, in a descriptive survey of unemployed Nurses &amp; Midwives that could be reached online within the timeline. Names, Phone numbers, State of Residence, Year of Graduation, Qualification(s), and how long they have remained unemployed after graduation were compiled. In addition, two questions were asked about the objective of the study. Analysis of data was done via Google forms statistical tools. Results: A total of 3317 unemployed Nurses &amp; Midwives responded to the survey. Among these unemployed Nurses &amp; Midwives – 38% holds RN only, 19% holds both RN &amp; RM, 15.4% holds RM only, while 27.6% holds BNSc plus another qualification. For the year they have remained unemployed after graduation 57.1% have spent 0–2 years, 29.9% have been unemployed for 3–5 years, 7% have been unemployed for 6 – 8 years and 6.1% have been unemployed for more than 8 years. To the question, “Do you think there is a shortage of Nurses and Midwives in Nigeria?” – 47.5% said yes, 43.5% said no whereas 9% were undecided (said maybe). Furthermore, the result showed that while 95% of the unemployed Nurses &amp; Midwives are willing to work in the rural community settings, 1% was not willing to work in the rural community settings and 4% were undecided (.i.e. said maybe) on whether they will work in the rural community settings or not. The result also revealed that the 3317 unemployed Nurses &amp; Midwives captured in the survey represents graduates of 66 Nursing &amp; Midwifery schools per session out of a total of 162 schools that are currently accredited by the N&amp;MCN. This represents 41% of the possible number of graduates that can be turned out of the accredited Nursing &amp; Midwifery Schools (excluding Post-basic schools) in a session. Conclusion: Despite the reported migration of Nurses to urban areas and other countries, at least 41% of Nigerian Nurses &amp; Midwives produced in a session remain unemployed and 95% of them are willing to work in the rural community settings if given the opportunity. These unemployed Nurses &amp; Midwives can bridge the Nursing &amp; Midwifery manpower needs in the Primary Healthcare System should the NPHCDA engage their services with a commensurate or higher payment to what their employed counterparts receive in Federal Government-owned establishments and hospitals. There is no current shortage of Nurses that necessitates the lowering of the existing standard of nursing education. Nurses &amp; Midwives are not responsible for the design, implementation, and delivery of healthcare services at the PHC level and therefore are not culpable for the deplorable condition and abysmal performance of the Nigerian PHC System.

Efficacy of Bamlanivimab in Reducing Hospitalization and Mortality Rates in COVID-19 Patients in a Rural Community.

ObjectiveIn this study, we aimed to evaluate the association between the monoclonal antibody infusion, bamlanivimab, and a reduction in 30-day hospitalization and mortality rates in patients with coronavirus disease 2019 (COVID-19) in a rural community setting with various comorbidities.MethodologyA retrospective data analysis was conducted over a 60-day period for patients who visited the Emergency Department of a community hospital. A group of COVID-19-positive patients who received bamlanivimab was compared with another group of COVID-19 patients with similar characteristics, demographics, and disease severity who did not receive the infusion. Data for 30-day hospitalization rates were analyzed using odds ratio for various individual comorbidities. Fisher’s exact test was used to analyze chronic kidney disease (CKD) and mortality. Logistic regression analysis and subsequent odds ratio estimates were used to adjust for demographics and comorbidities and evaluate for the association of bamlanivimab infusion with 30-day hospitalization rates.ResultsA total of 144 patients were included in the bamlanivimab group and 140 patients in the non-bamlanivimab group of COVID-19 patients. When analyzed by comorbidity using odds ratio analysis, 10.3% of diabetic patients, 6.1% of obese patients, 8% of hypertensive patients, and none of the patients with CKD required hospitalization at 30 days from the initial visit in the bamlanivimab group in contrast to 35.2% of diabetic patients, 38.1% of obese patients, 33.9% of hypertensive patients, and 63.6% of patients with CKD in the non-bamlanivimab group. Logistic regression analysis with odds ratio estimates showed that when adjusted for demographics and various comorbidities, bamlanivimab infusion was associated with decreased hospitalization (p < 0.001; confidence interval [CI] = 0.017-0.135). However, using logistic regression and taking all variables into account, among the evaluated comorbidities, only hypertension was found to be individually associated with decreased hospitalization (p = 0.0174; CI = 0.140-0.827) along with younger age (p = 0.0023; CI = 1.017-1.080) and female gender (p = 0.0077; CI = 0.212-0.789). We could not establish mortality benefit in the subgroups.ConclusionsBased on the results of this study, there is an association between bamlanivimab use and reduced hospitalization rates in COVID-19 patients.

Diagnosis of advanced prostate cancer at the community level in Rwanda.

Prostate cancer is the second most common cancer in men and sixth leading cause of mortality. If not recognized early, patients with advanced prostate cancer can experience debilitating complications which can otherwise be prevented by early androgen deprivation therapy. This research intends to define clear diagnostic tools that will guide practitioners in the rural community setting toward early management of advanced prostate cancer. We conducted a cross-sectional observational study at three referral hospitals in Kigali, Rwanda on patients who presented with clinical suspicion of advanced prostate cancer over a period of 6months. All patients underwent prostate biopsy as well as metastatic work up (CT or MRI), for those who were eligible. Statistical analysis was done using STATA 14.2. 114 patients were included in the study. The median age was 70years (interquartile range: 65-79years). In total 14 (12.3%) patients were found to have benign disease, while 100 (87.7%) patients were found to have cancer. Among those who had cancer, 85 (85%) had advanced prostate cancer. 110/114 (96.5%) were symptomatic at presentation. Common presenting symptoms were lower urinary tract symptoms (80.7%), back pain (54.4%), and urinary retention (36.8%). Abnormal digital rectal examination (DRE) was a strong risk factor for both cancer and advanced disease. Prostate cancer was found in 92.2% of those with abnormal DRE compared to 41.7% in those with normal DRE (p = 0.001). Also, cancer was found in 96.1% of those with multinodular prostate on DRE (p = 0.02) and had high odds (OR 14.6; CI 3.41-62.25) of having advanced prostate cancer (p < 0.001). The mean (± SD) PSA was 643.3 ± 1829.8ng/ml and the median (range) was 100ng/ml (9.05-10,000ng/ml) for the whole study population. All patients with prostatic-specific antigen (PSA) of 100ng/ml or above had advanced prostate cancer. The results show that there is a significant correlation between clinical findings and advanced prostate cancer. All patients with abnormal DRE and PSA above 100ng/ml had advanced prostate cancer. Diagnosis of advanced prostate cancer is possible at the community level if PSA testing is utilized and practitioners are well trained.

Overall Survival Disparities in Metro/Urban/Rural Diffuse Large B-Cell Lymphoma (DLBCL) Patients

Background:Numerous studies have shown that rural patients have poorer overall survival (OS) compared to metropolitan patients across several cancers including lymphoma. Using a Nebraska regional dataset of all-type lymphoma patients treated from 1982-2006, Loberiza et al discovered that patients treated in rural community settings had worse mortality than their counterparts treated in academic or metropolitan institutions1. Our study expands on this using a nationwide retrospective cohort of DLBCL patients to determine if 5-year OS rates differ between rural, urban, and metro populations and to identify factors that may contribute to OS differences.Methods:We used the National Cancer Database (NCDB), a nationwide database sponsored by the American College of Surgeons and the American Cancer Society. We compared outcomes in HIV-negative DLBCL patients treated from 2004-2014 who were classified according to the USDA Office of Management and Budget as rural (county population less than 2,500), urban (county population more than 2,500 but outside metropolitan areas), or metro (at least 50,000 urbanized population in county). Patients missing information on metro/urban/rural area or outcomes were excluded. Data on patient demographics (age, gender, race, insurance status, census region), socioeconomic status (SES measured by household income for the region), prognostic factors, and initial treatment information (regimen, treatment facility type) were examined using Chi-square tests to compare clinical variables for metro/urban/rural areas. Logistic regression was performed to assess the impact of degree of urbanization on clinical prognostic factors, controlling for sociodemographic features. Kaplan-Meier (KM) survival curves with log-rank tests compared survival for metro/urban/rural groups. Univariate and multivariable Cox regression models (controlling for treatment facility type (academic/community), sociodemographic factors, and clinical features) were generated to determine unadjusted and adjusted hazard ratios (HR) and 95% confidence intervals (CI) for metro, urban, and rural populations.Results:Among 83,108 patients with DLBCL, 85.2%, 13.1%, and 1.7% were classified as metro, urban, and rural, respectively. We found rural and urban populations were more likely to have lower SES, increased Medicaid, advanced stage at diagnosis, and more comorbidities than metro populations. KM curve showed moderately decreased 5-year OS in rural/urban populations (See Figure). The univariate Cox model showed rural/urban populations to have worse 5-year OS (HR 1.16, CI 1.08-1.25; HR 1.10, CI 1.07-1.13, respectively). Logistic regression showed no difference in diagnosis stage, B-symptoms, or comorbidities between rural and metro. Urban patients were more likely than metro patients to have B-symptoms present (OR 1.06, CI 1.01-1.11) and less likely to have comorbidities (OR 0.94, CI 0.89-0.99). Urban and rural populations were less likely to have treatment delayed more than 14 days after diagnosis (OR 0.93, CI 0.89-0.98; and OR 0.81, CI 0.72-0.91). A multivariable Cox model, adjusting for age, race, gender, and clinical factors, found rural (HR 1.09, CI 1-1.19) and urban (HR 1.08, CI 1.04-1.11) populations to be at higher risk of death than metro populations. These effects were no longer observed after controlling for treatment facility type, SES, or insurance status.Discussion:Rural DLBCL patients displayed a moderate decrease in expected OS compared to metro DLBCL patients, but this risk was attenuated by SES, insurance status, and treatment facility type. Because of this, decreased SES and underinsurance must be addressed along with distance to quality care when developing strategies for rural/urban patients with this curable cancer. Further studies should be conducted with urban/rural DLBCL patients to better understand the barriers to care for ongoing treatment as well as exploration of what methods of care best deliver treatment to urban/rural DLBCL patients.

Usefulness of the English version of the Stress Overload Scale in a sample of employed South Africans

Amidst reports of high levels of stress in South Africa, it remained difficult to quantify psychological stress in the absence of locally validated measures. This study explored the English version of the Stress Overload Scale (SOS) in a South African sample. The first aim was to replicate the basic psychometric analysis of the original English version used in American samples, as well as the Setswana version used in a South African rural community setting. The second aim was to investigate criterion validity to determine its appropriateness for use in South Africa. A total of 2136 employed South Africans with at least 9 years of schooling participated in this study. Participants completed a range of mental health and well-being measures, both clinical and dispositional. Responses were analysed to examine both scale characteristics and validity indices related to the SOS. Little sociodemographic influence (age, gender and first language) was found, with analyses supporting validity across most indices. Furthermore, good predictive ability for mental (ill-) health was observed. This study, for the most part, replicated previous validation findings of the SOS. Validity was further confirmed by correlating the scale with measures of clinical mental health and dispositional well-being. Given the positive support to its validity, when used amongst employed South Africans with at least 9 years of education, the scale holds promise for application in local health-related research, for triage in primary healthcare contexts and for measuring outcomes of mental health interventions in therapeutic settings.

The pattern and socio-cultural determinants of intimate partner violence in a Nigerian rural community.

BackgroundIntimate partner violence (IPV) refers to a violation of women’s reproductive rights as it impacts on their sexual and reproductive health autonomy.AimIn this study, we aimed at assessing the pattern of IPV and the socio-cultural determinants and predictors of partner violence in a rural community setting where the bulk of the abuse prevails.SettingThis study was conducted in a rural community in Southern Nigeria.MethodsThis study employed a mixed method comprising seven focus group discussions (FGDs) and quantitative components. The cross-sectional survey was conducted amongst 209 ever married or cohabited females in 2018 using the World Health Organization (WHO) multi-country survey questionnaire adapted to the study objectives. Data analysis was conducted by using IBM SPSS v21.0. The level of significance was set at p < 0.05.ResultsThe overall IPV prevalence was 79.4%. The prevalence of partner’s controlling behaviour, emotional IPV, physical IPV and sexual IPV was 62.6%, 55.98%, 49.3% and 2.6%, respectively. Membership of an interest group was protective against IPV (OR = 0.430, 95% CI = 0.193–0.957) whilst the belief that a good wife obeys her partner even if she disagrees (OR = 9.201, 95% CI = 1.299–65.194) and the belief that it is the wife’s obligation to have sex with the husband even if she doesn’t feel like (OR = 2.356, 95% CI = 1.049–5.288) were risk factors.ConclusionThe burden of IPV in the studied rural community is enormous. There should be public enlightenment to desensitise people regarding the erroneous views that encourage partner violence. We encourage women to become a part of social groups that can enhance their education and empowerment.

The best today for a better tomorrow: a standard of practice to both recognise and develop infectious diseases pharmacy

Infectious disease is a multidisciplinary specialty involving infectious diseases physicians, clinical microbiologists, nurses and pharmacists among other specialities. Given that so much of infectious diseases involves antimicrobial drugs, it is obvious that pharmacists are an integral part of the care of patients with infections. Infectious diseases pharmacy has developed as its own specialty over the last 10–15 years with the development of antimicrobial stewardship programs, which are now a requirement of hospital accreditation. For those of us that have the privilege of working with specialist ID pharmacists, there are few days that we would not call upon their expertise for difficult areas – HIV drug interactions, dosing in organ failure and critically ill patients, the more unusual antibiotic interactions, and hospital in the home programs, for example. Australian pharmacists have also contributed immensely to areas outside of direct clinical care. In research, The Australian newspaper named Prof Jason Roberts as the leading national researcher in the fields of both critical care and communicable diseases in 2019.1 Many other examples of the impact of pharmacists are provided in this document. Pharmacists have led the ongoing development of Australian national treatment guidelines, Therapeutic Guidelines, while providing key insights into quality and safety programs at state and national levels, as well as contributing to the National COVID-19 Evidence Task Force, among many other contributions. The SHPA Standard of Practice in Infectious Diseases for Pharmacy Services, published in this issue, crystallises the skills and scope that pharmacists have in the management of infectious diseases, particularly in providing clinical care but also into broader governance systems. These include ensuring the quality use of antimicrobials (through education, antimicrobial stewardship programs, developing and reviewing policies and procedures) and ensuring access through formulary policies. The immediate impact of the Standard is to form the basis for a curriculum for junior pharmacists intending to specialise in this area, or for general pharmacists who may require skills in this area in other settings, such as rural hospitals or community settings. Advanced training for physicians has evolved from an “apprenticeship” model to a more structured educational model. While most currently available post-graduate courses are international, a standardised curriculum should facilitate local training and education initiatives, analogous to accreditation developed for infection prevention and control nurses by the Australasian College of Infection Prevention and Control. Collaborative guidance such as this Standard will help future ID pharmacists to build on existing roles and extend into emerging areas of practice. It should be noted that like the scope of practice of pharmacists more generally, this will continue to evolve and expand over time. The infectious diseases community welcomes this major step in recognising the expertise of infectious diseases pharmacists and their contribution to clinical care and the systems that support healthcare. The author has no conflicts of interest to declare.

Association of the FRAIL Scale with Geriatric Syndromes and Health-Related Outcomes in Korean Older Adults.

BackgroundOwing to the growing older population, appropriate tools are needed for frailty screening in community-dwelling older people. We investigated the association between geriatric conditions and health-related outcomes using the five-item Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight (FRAIL) scale in a Korean rural community setting. MethodsWe performed comprehensive geriatric assessments, including the FRAIL scale, in 1,292 community-dwelling people (mean age, 74.6 years) in the Aging Study of Pyeongchang Rural Area. These populations were prospectively followed up for 3 years to analyze the outcomes of death, institutionalization, disability, and quality of life. We investigated the association between frailty status and outcomes using the FRAIL scale. ResultsAccording to the FRAIL scale, 524 (36.5%) participants were prefrail and 297 (23.0%) were frail. According to the adjusted model, the degree of frailty status was significantly associated with concurrent geriatric syndromes and 3-year incidences of mortality, institutionalization, and disability; Kaplan–Meier analysis showed significant differences in 3-year survival based on frailty status (92.6% for robust, 85.7% for prefrail, and 74.2% for frail; log-rank p<0.001). ConclusionThe five-item FRAIL scale can be used to screen for accompanying geriatric syndromes and is associated with the 3-year health-related outcomes in community-dwelling Korean older adults. From the public health perspective, this simple screening tool for frailty assessment might be applicable to older populations in Korea.