Rural Family Practice Research Articles

Exploring the use of tummy time guidelines to improve infant development in rural primary care

BackgroundTummy time enhances motor development, improves mobility, strength, and head clearance, reduces cranial asymmetry, and decreases the risk of childhood obesity. The American Academy of Pediatrics (AAP) advises all infants, beginning at birth, partake in supervised daily tummy time during awake periods. Since 1994, when the AAP initiated the “Back to Sleep” campaign, the number of infants participating in daily tummy time has significantly declined, leading to an increase in adverse outcomes. MethodsUsing a quasi-experimental design, tummy time guidelines were implemented in a rural family primary care practice to support infant development. This three-phase intervention included educating providers, developing a smart phrase, and posting visual reminders. A convenience sample of infants who presented for well-visits at a rural family practice in southwestern Washington were included in this project. The Survey of Wellbeing of Young Children measurement tool was used to collect infant developmental outcome data. FindingsFollowing the intervention, infant developmental outcomes improved. There was a 10% reduction at two months of age and a 7% reduction at four months of age in the number of infants with below average developmental scores. DiscussionThis project demonstrates that increased provider awareness and implementation of tummy time clinical practice guidelines can benefit infant development in primary care, especially in rural populations. Application to practiceViable strategies for incorporating clinical practice guidelines into primary care are presented.

Abdominal Ultrasonography Used for Abdominal Pain in the Rural Outpatient Setting of South Texas: Impact on Patient Outcomes.

Introduction Abdominal ultrasonography is a key diagnostic tool used in complaints of abdominal pain. The rationale for this study is to examine abdominal ultrasonography's impact on the conclusion of care of abdominal pain in a predominantly Hispanic/Latino patient population. Materials and methods A chart review of 350 patients with a new diagnosis of abdominal pain from a rural family practice clinic in Texas was performed. These patients' charts were reviewed for a new diagnosis of abdominal pain, medications prescribed for abdominal pain, whether abdominal ultrasonography was completed, and the number of visits regarding their complaint. The last visit for their abdominal pain was denoted as the conclusion of care of abdominal pain within the clinic. The primary analyses were logistic regressions with conclusion of pain care or number of visits as the outcome and abdominal ultrasound completion as the primary predictor. Results The sample size was 216 of the 350. Patients were excluded due to age under 18 and if the patient's pain was not coded as epigastric, generalized, or right upper quadrant pain. The patient age range was 18-88 years, and they were all of Hispanic/Latino origin. Abdominal ultrasound was completed on 59 of the patients, and 65 patients experienced conclusion of primary care for abdominal pain. Regarding the number of visits for abdominal pain, 69% had one visit, 25% had two visits, and 6% had three or more visits. Patients who had abdominal ultrasounds were more likely to have multiple visits (typically just two visits) but had markedly higher conclusions of care for abdominal pain. These relationships remained when adjusting for demographic and medical covariates such as age, abdominal pain (all types), and medical treatments used. Conclusion In the outpatient rural care of Hispanic/Latino patients residing in the Rio Grande Valley, patients who had a new complaint of abdominal pain were more likely to have conclusion of primary care for abdominal pain, with only a slight increase in primary care healthcare consumption, if abdominal ultrasonography was completed for abdominal pain.

Rural Family Physician Perspectives on Wellness and the Role of Training in Supporting Physician Wellness.

Research evaluating the well-being of rural family physicians is limited, resulting in minimal understanding of how to prepare family medicine residents to succeed in rural practice postresidency. Our study aimed to investigate factors associated with maintaining wellness within rural family medicine practices and highlight interventions that rural family physicians identify as important to promote wellness among those seeking future employment in rural settings postresidency. Forty-eight rural family physicians completed an online survey with qualitative and multiple-choice items including the Mini-Z about physician demographics, burnout, and wellness. We conducted data analysis using NVivo 12 software for qualitative analyses and R 3.6.1 software for descriptive statistics. The majority of participants reportedly maintained wellness in rural family practice (maintenance of wellness=79.17%; denied burnout=62.26%). Burnout rates were similar to the national burnout rates for family physicians (37.74% vs 46%). Participants identified multiple residency interventions that could be implemented to prepare rural family physicians to succeed. This study highlights factors that are associated with the maintenance of wellness among rural family physicians. This is the first study to investigate rural family physician perspectives on residency interventions that may have positive outcomes on wellness postresidency.

Expanding Access to Social Support in Primary Care via Telemedicine: A Pilot Study.

The coronavirus pandemic quickly exposed the need for efficient and widespread implementation of telehealth services. Additionally, it further unveiled the impact of social and environmental barriers to healthcare in underserved, rural populations. This in-practice pilot study tested the utility of a geographically centralized social worker providing services between a patient and a primary care provider via telecommunication at two high volume rural outpatient family practice clinics. Outcome measures included patient and provider satisfaction. Twenty-two telehealth social work encounters occurred spanning both adult and pediatric patients. Data collected from patients, primary care providers, and social work staff revealed positive feedback. The data from our small pilot study demonstrated that social work triage delivered via a tablet was an acceptable and valued resource in busy primary care practices.

Systemic challenges and resiliency in rural family practice

The objective of our study was to understand how Canadian rural family physicians (RFPs) define and use resilience strategies to maintain their roles as generalists and resist burnout, while also understanding how organisational supports and systems may play a role. This was a qualitative study of RFPs with at least 1 year of experience working in rural Canada. Data were collected via semi-structured, in-depth interviews using a grounded theory approach. The participant recruitment process involved purposive and theoretical sampling, and was stopped when theoretical saturation was reached. RFPs identified the following five themes related to resilience: (1) powerlessness, (2) strained work/life balance, (3) colleagues as supportive or straining, (4) living under the microscope and (5) compassion fatigue or empathy. Strategies to enhance resilience were identified at personal, community and organisational levels by participants. Enhancing RFPs' awareness of the specific individual and organisational strategies, as well as system-oriented solutions to maintain resilience, is of benefit to RFPs and rural and remote communities across Canada.

Association of anxiety-depressive disorders with irritable bowel syndrome among patients attending a rural family practice center: a comparative cross-sectional study

BackgroundComorbidity of irritable bowel syndrome (IBS) and psychiatric disorders is common, and the prevalence of at least one psychiatric disorder has been reported as high as 80% among patients with...

Screening and Education for Postpartum Depression

The purpose of this doctor of nursing practice (DNP) student quality-improvement project was to implement the use of a routine screening tool and increase patient education within a rural family practice setting, where women and neonates are treated and monitored after birth. After a review of current evidence-based practice in postpartum depression screening, a screening and education process was designed and implemented using the Edinburgh Postnatal Depression Scale (EPDS) tool, an educational brochure, and community-specific resource and referral information.

Family Medicine Physicians' Perspectives Regarding Rural Behavioral Health Care: Informing Ideas for Increasing Access to High-Quality Services.

Primary care settings often function as the front lines for behavioral health services in rural areas. The lack of formal behavioral health care in rural areas is also well documented. Rural family practice physicians were interviewed regarding the state of behavioral health care in their communities and their ideas for increasing access to quality care. Thirteen family practice physicians in rural locations participated in in-depth semi-structured interviews. Interviews were transcribed, coded, and analyzed following a phenomenological design. Physicians described a lack of quality behavioral health services and challenges for integrating and collaborating with those that do exist. Participants also described the changing role of stigma, service delivery strategies that are currently working, and the unique role primary care plays in rural behavioral health care. Several ideas for increasing access to and efficacy of services are discussed; these ideas are informative for future research and interventions.

Pharmacist‐led phone call initiative targeting hemoglobin A1c levels in patients with uncontrolled diabetes

AbstractPurposePharmacist‐led telemedicine initiatives have been shown to lower hemoglobin A1c (HbA1c) levels compared with usual care, but few studies have targeted patients with uncontrolled diabetes in the rural setting. The purpose of this study was to evaluate the impact of a pharmacist‐led diabetes telemedicine initiative on HbA1c in patients with uncontrolled diabetes at a family medicine clinic in rural North Carolina.MethodsPharmacists implemented a telemedicine initiative to help manage patients with uncontrolled diabetes at a large, rural family medicine clinic. Adult patients with uncontrolled diabetes were identified through a generated report or by provider referrals. Pharmacy residents called each patient and documented type of interventions, demographic information, and HbA1c results. Patients were followed within a time period of 18 months (September 2018‐March 2020).ResultsA total of 64 patients were successfully contacted by the telemedicine program. The patients were primarily non‐Hispanic, white patients (50% female) with type 2 diabetes on insulin. The most common interventions that patients received included general education (68.8%), scheduling labs (51.6%), insulin titration (51.6%), and facilitating medication access (50.0%). For patients who had been in the telemedicine program long enough to have had an HbA1c lab completed post‐contact (n = 46), there was a significant reduction of 1.15 in mean HbA1c (t = −3.5, P < .01) compared with their initial HbA1c prior to receiving phone calls.ConclusionA pharmacist‐led diabetes telemedicine program was associated with a reduction in HbA1c for patients with uncontrolled diabetes in a rural family practice.

Covid 19: última evidencia

Esta actualización forma parte de la serie de actualizaciones clínicas, publicadas en los dos números anteriores de la Revista Practica Familiar Rural, el objetivo, es poner a la disposición de profesionales en salud la evidencia actualizada alrededor de la epidemiologia, la transmisión comunitaria, el riesgo de infección de personal de salud la fisiopatología y las manifestaciones clínicas extra-pulmonares, tomado en cuenta que en la primera etapa de la pandemia se puso mucho enfoque sobre el aparato respiratorio.Finalmente trascribimos las guías sobre el apoyo ventilatorio en pacientes que pueden requerir Cuidados Intensivos y las nuevas recomendaciones sobre el tratamiento farmacológico.

Covid 19 evidencia

Ante la gran expectativa mundial por la nueva epidemia de coronavirus, la revista Practica Familiar Rural pone a disposición de estudiantes y profesionales de la salud, y de la sociedad en general, una lectura crítica de la evidencia actualizada sobre la nueva epidemia, realizada por nuestros compañeros Diego Herrera y David Gaus.

Adverse childhood experiences: Assessing the impact on physical and psychosocial health in adulthood and the mitigating role of resilience

BackgroundMore than 2000 studies demonstrate adverse childhood experiences ACEs are universal and that experiencing multiple ACEs increases risk for developing physical and psychosocial health problems in adulthood. A challenge faced by clinicians is identifying those most at risk. Recent evidence suggests socio-ecological resilience may mitigate the consequences ACEs. We hypothesize that integrated assessment of ACEs and resilience might improve identification of those at highest risk. ObjectivesWe examined ACEs among adults attending a rural family practice clinic and explored associations between ACE, socio-ecological resilience and health. MethodsA cross-sectional survey measured ACEs, resilience, and health in adult patients attending a collaborative family health care centre in Lunenburg, Nova Scotia, Canada. Correlation analyses were used to determine associations between the measures. The impact of socio-economic status, level of education and gender was considered. ResultsTwo hundred and twenty-six persons participated in this study.Approximately 73 % of participants had experienced at least one ACEs and 31 % experienced 4 or more. Overall with increasing numbers of ACEs prevalence of health problems increased. However, individuals with high resilience scores had lower prevalence of health problems. Regression analyses indicated that the number of ACEs were slightly more important predictor of health issues than level of resilience, though both were important. Social economic status, education level and gender were not significant predictors of the impact of ACEs on person's health. Conclusion: The results suggest integrated assessment for resilience and ACEs may facilitate identification of those at higher risk and in need of preventative intervention.

My Fourth Child.

My Fourth Child.

Exploring the experiences of people in Ontario, Canada who have trouble affording medicines: a qualitative concept mapping study

ObjectivesThe experiences of people who report cost-related medicine non-adherence are not well documented. We aimed to present experiences relating to accessing medicines reported by the participants in a randomised controlled...

Teaching Medical Students in the Rural Setting Long Term: Physicians' Attitudes and Perceptions.

The University of Alabama School of Medicine Tuscaloosa Regional Campus conducted a 2-month block in rural family practice, but committed to expanding to an 8-month longitudinal rural curriculum. We wanted to explore how rural physicians feel about teaching students in a prolonged rural preceptorship. We brainstormed with colleagues, reviewed the literature, and conducted two focus groups supplemented by five interviews with rural physicians. The focus groups explored satisfaction and dissatisfaction in teaching, medical school and community support, evaluation of preceptors, and the sharing of information between students and preceptors. The analysis sought common themes among study participants and colleagues. Twenty-one study participants included 19 family physicians, 15 in private practice. Eleven had taught medical students. Our key finding, combining four themes, was that a satisfactory context within which to teach medical students long term in rural sites depends on the optimization of the roles of preceptors, students, communities, and educational institutions. There were comments addressing each of these roles. This finding cannot be generalized beyond the study group because of the qualitative methodology using a convenience sample. These physicians' concerns foment hypotheses about engaging rural physicians in their own unique local networks involving preceptors, students, community, and educational institutions to conduct satisfactory long-term medical education in rural sites. We recommend investigations to substantiate a prevalence among rural physicians of concern about the four roles and to describe various contexts in which these roles produce satisfactory long-term preceptorships, perhaps as best practices in different settings.

The regional medical campus model and rural family medicine practice in British Columbia: a retrospective longitudinal cohort study.

Regional medical campuses have been implemented across North America to address gaps in the physician workforce. We report findings from a study that examined the association between a combined model of regional medical campuses and students' decision to enter rural family medicine practice. In 2004, the University of British Columbia added 2 regional medical campuses, 1 in a large population centre in a rural and coastal context and 1 in a medium-sized population centre in an isolated northern and rural context. Data were extracted from the University of British Columbia's Medical Education Database. Multivariable logistic regression examined the relationship of age, sex, rural background and campus location to students' choice of rural family medicine practice. There was an association between campus location and choice of family medicine versus other specialties. A rural background (odds ratio [OR] 2.59, 95% confidence interval [CI] 1.08-6.21) and training at either of the 2 regional medical campuses (OR 3.24, 95% CI 1.19-8.83 and OR 5.38, 95% CI 2.24-12.91) predicted rural family practice. Choosing to practise family medicine in a rural location was associated with having a rural background and having trained at a regional medical campus. These early results suggest that a combined regional campus model in medical education contributes to the rural family practice workforce.

Standardized Follow-Ups Lower HbA1c in Adults With Type 2 Diabetes Living in a Rural Community: A Pilot Study.

To implement and evaluate the use of a standardized process, which includes the teach-back method for follow-up among patients with type 2 diabetes in rural health care settings in order to reduce glycosylated hemoglobin A1c (HbA1c) in adults with diabetes. It remains unclear whether or not controlled patient follow-up among patients with type 2 diabetes between office visits (at 3-month intervals) is effective in reducing their HbA1c. This study recruited 12 participants from a rural health family practice in Northern Illinois to participate in a pretest-posttest study to evaluate if close patient follow-up with reinforced education was effective in helping patients reduce their HbA1c. The preintervention for HbA1c and postintervention HbA1c mean difference was found to be statistically significant. The HbA1c level decreased from preintervention to postintervention (p < .05). Further, the mean and standard deviation from the preintervention for HbA1c and postintervention HbA1c were used to calculate an effect size using Cohen's d found that there was a medium to large effect size d = .67. The change in HbA1c levels was of clinical significance as well as statistical significance. The use of a standardized process for patient follow-up as part of routine management of type 2 diabetes appears to have had a clinically as well as statistically significant impact in reducing HbA1c levels.

Opioid Prescribing in Rural Family Practices: A Qualitative Study

ABSTRACTBackground: Rural Tennessee, especially rural East Tennessee has seen a dramatic increase in rates of controlled drug prescriptions and controlled drug overdose deaths in recent years. However, little is known about the individual decisions to prescribe or continue prescriptions with relation to addiction concerns. Objectives: The purpose of this study was to learn more about what factors lead to physicians’ prescribing control drugs for non-cancer pain through the use of focus groups. Methods: A qualitative study, using focus groups, in five family medicine clinics in East Tennessee and Southwest Virginia. The investigators used a semi-structured interview guide designed to facilitate group discussions about prescription drug abuse and misuse. Results: There were four main themes identified by the focus groups: (1) prescribers’ changing prescribing patterns over time; (2) factors that influence controlled drug prescribing; (3) use and barriers to using state prescription drug monitoring programs (PDMPs); (4) prescribing controlled drugs to women of childbearing age. Each theme had several subthemes. Conclusions: The balance between treating the patient's symptoms and causing potential harm is a challenge. The patient's pain cannot be ignored, but the potential harm of opioid therapy is not taken lightly. As the public health concern of prescription drug abuse in rural Appalachia continues to spread, prescribers are aware of their connection to the problem, and ultimately the solution.

Development of a Rural Family Practice Rotation in an Athletic Training Residency Program

Context: Postprofessional residency (PPR) programs continue to gain popularity as athletic training education prepares for a paradigm shift. The Commission on Accreditation of Athletic Training Education has established didactic and clinical infrastructure for PPRs seeking accreditation. Accredited programs provide athletic trainers (ATs) with an advanced level of knowledge in a focused area of clinical practice. Objective: A case study report to introduce a novel PPR general medical rotation to illustrate the skills and knowledge of ATs, evaluate the impact of the athletic training residents in the rural family practice (FP) setting, and to discuss how employing an AT in this setting aligns with the triple aim of the Affordable Care Act (ACA). Background: Currently, there is very little literature regarding PPRs. Additionally, very little research exists describing how ATs function within the ACA model of health care delivery. Description: The PPR developed a rotation for a rural FP outpatient clinic. Athletic training residents completed 3-week rotations in this setting working with multiple providers. Learning objectives were created to emphasize the evaluation, diagnosis, and management of general medical conditions. Objectives were assessed at the conclusion of the rotation. Finally, data were collected to evaluate the impact of athletic training residents in the ACA model of health care delivery. Clinical Advantage(s): The athletic training residents improved their clinical evaluation and diagnosis skills in a FP clinic through this educational opportunity. This rotation cultivated and fostered interdisciplinary education and interprofessional collaboration. Finally, the observational findings of this rotation revealed the impact of ATs appear to align with the objectives of the ACA health care model, supporting the use of ATs in this role. Conclusion(s): This rotation highlights an area of clinical practice future ATs could pursue. Accredited PPR programs must consider the evolution in health care delivery and the shift in athletic training education standards to develop strong PP programs.

Using the Consolidated Framework for Implementation Research to Increase Provider Screening for Intimate Partner Violence in Rural Health Clinics

PurposeTo demonstrate the utility of the Consolidated Framework for Implementation Research as a tool for conceptualizing and overcoming obstacles to the implementation of universal screening practices for intimate partner violence (IPV), with a particular focus on rural family practice settings. This article uses data from a 2014 statewide survey of rural primary care providers to identify potential leverage points for policy and practice changes. MethodsThe Physician Readiness to Manage Intimate Partner Violence was administered to 134 physicians and nurses at rural health clinics in a Midwestern state. Six scales measuring knowledge, attitudes, and behaviors were computed and analyzed with bivariate and logistic regression models to ascertain links between knowledge/attitudes and screening/response behaviors. FindingsKnowledge and attitudes did not predict screening; rather, the number of hours of previous training on abuse and the organizational protocols of the clinics where providers were employed significantly increased the likelihood of frequent IPV screening. ConclusionsGuided by Consolidated Framework for Implementation Research principles, the author concludes that external factors, that is, state or national policies mandating IPV screening in clinics, may be an effective way to increase provider identification of a major public health problem affecting women. Rural women may benefit especially from IPV screening during health care encounters, because there are few other supportive services for abuse survivors in rural areas.