Rural Health Care Settings Research Articles

Drive-through Satellite Testing: An Efficient Precautionary Method of Screening Patients for SARS-CoV-2 in a Rural Healthcare Setting.

The first documented case of COVID-19 in the United States occurred on January 30th, 2020. Soon after, a global pandemic was declared in March 2020 with each state issuing stay at home orders based on population, risk for community transmission and current number of positive cases. A priority for each region was to develop efficient systems for testing large patient volumes in a safe manner to reduce the risk of community transmission. A community based United States health care system in the upper mid-west implemented a drive through testing site in an attempt to divert suspected cases of COVID-19 away from larger patient areas while protecting staff and patients. This commentary outlines the planning, work flow and challenges of implementing this drive through testing site in a rural community setting.

Depression prevalence, its psychosocial and clinical predictors, in diabetes mellitus patients attending two health institutions of north India catering rural population.

Background:Diabetes mellitus (DM) poses a greater risk of depression and a poor quality of life (QoL). There is a limited data regarding relationship of depression to QoL in patients from rural health care settings of North India.Aim:To know the prevalence and predictors of depression in patients of DM among various sociodemographic, clinical and QoL variables.Settings and Design:This cross-sectional study was conducted in two hospitals of North India mostly catering rural population from 2014 to 2018.Materials and Methods:Sociodemographic and clinical data of DM patients was collected. They were applied Hindi translation of QoL Instrument for Indian Diabetes Patients and Patient Health Questionnaire-9. Analyses were done by Statistical Package for Social Sciences (Version 17.0, USA).Results:Among 300 patients, 25.6% had clinical depression. Illiteracy, the affect on general, emotional/mental health and role limitation by diabetes predicted risk of depression.Conclusion:Education of patients regarding self-management in DM to assure good health should be emphasised.

Adolescent Mothers' Experiences With Community Health Assistants in Rural Zambia.

Adolescent health demands specific attention because adolescents have the lowest levels of health-care coverage of any age-group globally. The main objective as addressed in this article was to explore the lived experience of adolescent mothers and the services provided to them by community health assistants (CHAs) in rural Zambia. Because the number of adolescent mothers in rural Zambia is so high, it is even more critical to describe the lived experiences of health care among these young women with particular emphasis on primary health care as delivered by CHAs in rural Zambia. We used a mixed-methods design to address our research questions. Data were collected from nine focus groups, which were conducted with young mothers from four provinces and 10 districts (n = 60). To support our effort to better understand the delivery of maternal and child health care in rural Zambia, key informant interviews were conducted with adolescent mothers (n = 12). We also conducted surveys (n = 44) and one-on-one interviews (n = 22) with CHAs. To the best of our knowledge, this is the largest study focused on the intersection of adolescents, maternal child health, and CHA delivery of care in Zambia. The results of our study suggest opportunities for change to operational practices within the rural health-care setting and the need to develop structured and age-appropriate services that focus on adolescents. This work addresses the gap in research for adolescents in health care in rural Zambia and brings attention to the unique health-care needs of adolescent mothers within the rural health-care setting.

Impact of a Pharmacist-driven Methicillin-resistant Staphylococcus aureus Polymerase Chain Reaction Nasal Swab Protocol on the De-escalation of Empiric Vancomycin in Patients with Pneumonia in a Rural Healthcare Setting.

IntroductionPneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) carries a high rate of morbidity and mortality. Many clinicians empirically treat those at risk of developing MRSA pneumonia with vancomycin. Several studies have identified a high negative predictive value of the MRSA polymerase chain reaction (PCR) nasal swab test in lower respiratory tract infections, suggesting it can be used to guide the de-escalation of empiric anti-MRSA therapy.ObjectiveTo evaluate the impact of a pharmacist-driven MRSA PCR nasal swab protocol on the de-escalation of empiric vancomycin in patients with pneumonia in a rural healthcare setting. Secondarily, to assess the rate of hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality after pharmacist-driven de-escalation of empiric vancomycin in patients with pneumonia. MethodsA retrospective, single-center, pre-post cohort study was conducted in patients after the implementation of a pharmacist-driven protocol allowing pharmacists to obtain nasal swabs and PCR testing for MRSA in those on empiric vancomycin therapy for suspected MRSA pneumonia. Based on negative test results, pharmacists recommended a de-escalation of empiric vancomycin to the physician. Patients were included if they were adults at least 18 years of age, had a physician diagnosis of suspected or confirmed pneumonia, and initiated on at least one dose of intravenous vancomycin within 48 hours of admission.ResultsA total of 79 patients were identified for inclusion in the pre-protocol group (n=32) or post-protocol group (n= 47). The mean duration of vancomycin therapy in the pre-protocol group was 3.1 days as compared to 1.7 days in the post-protocol group for a 1.4 days reduction (p=0.044). There was no significant impact on the number of vancomycin cases de-escalated within 24 hours (p=0.14) but there was a significant reduction at 48 hours (p=0.01). Protocol implementation was associated with a reduction in the average length of hospitalization (8 versus 5.20 days, p=0.006). Neither group had a vancomycin-associated acute kidney injury or in-hospital mortality.ConclusionAmong patients with suspected MRSA pneumonia, a pharmacist-driven MRSA PCR nasal swab protocol resulted in a significant reduction of empiric vancomycin duration of therapy without an adverse impact on clinical outcomes in a rural healthcare setting.

Cultural, Social, Religious Beliefs and Practices During Postpartum Period Among Post Natal Women in Selected Rural and Urban Health Care Settings

Belief is the state of mind in which a person thinks something to be the case, with or without there being empirical evidence to prove that something is the case with factual certainty. In developing countries, over 60% of maternal deaths occur during the postpartum period. This period is also greatly influenced by different types of socio-cultural beliefs & practices that increases the risk for poor maternal and child health. A study was conducted to identify and analyse the cultural, social, religious beliefs and practices during postpartum period among postnatal women in Erashal BPHC & Medical College & Hospital of West Bengal. A comparative survey design was adopted in this study. A non probability purposive sampling technique was used to select 120 postnatal women from rural Erashal BPHC & 160 from urban Medical college & hospital as study subject. A valid & reliable Structured Interview schedule(r-0.85,0.90)was used to collect data from the postnatal women who were admitted for delivery and staying postnatal ward. The findings showed that the harmful beliefs regarding maternal, baby care, breast feeding & family planning aspect were present among women during postpartum period(R-75%,U-54%) Harm less beliefs regarding maternal care& breast feeding aspect were present in postpartum period(R-31% U-42 %). Beneficial beliefs regarding separation aspect were present in postpartum period(R-79%,U-90%).The practices were seen in post partum period(R-52%,U-21%).There was a significant difference in belief among rural & urban women as evidenced by ‘t’ test(t-11.38 at df 278 at p<0.05) . There was a significant difference in practice among rural& urban women (t-6.85 at df278 at 0.05 level).Significant relationship(r-0.35 , 0.28 at p<0.05) was seen between beliefs &practices during postpartum period in both area. There was a significant association (χ2-5.36, 10.56 at p<0.05) between religion with beliefs in both area. The significant association was seen between family type with beliefs in rural (χ2-4.41 at p<0.05) but not in urban. The study concluded that, a concerned matter of issue can be raised to prevent the practices contrary with harmful beliefs by counselling and evaluation of views of the mothers during reproductive period.
 
 Keywords: beliefs and practices, postpartum period, postnatal women, rural and urban settings

Implementation of a Dedicated Education Unit Model for ADN Students in a Rural Primary Care Setting

Dedicated education unit (DEU) clinical education models are an innovative, evidence-based approach to create effective learning environments for students. These models have been implemented primarily in acute care settings. The gap between nursing education and clinical practice in rural health care settings is a growing concern, compounded by a nursing faculty shortage and decreased availability of clinical sites. A descriptive study design was used to assess the outcomes of a DEU model of clinical practice with associate degree nursing students in a rural primary care clinic, using registered nurses (RNs) who were prepared as clinical nurse teachers. Associate degree nursing students experienced the RN role in primary care, worked with nurses who wanted to teach them, and improved their nursing skills. The DEU model is a positive clinical teaching pedagogy for students and staff nurses.

Use of Xpert MTB/RIF for the Identification of TB and Drug Resistance Among Smear-Negative and Re-Treatment Cases in Rural Areas of Ethiopia

Introduction: Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality worldwide. A key contributor to this burden is poor diagnosis as only 60% of new pulmonary tuberculosis (TB) cases in Africa are ever detected. Therefore, this study aimed to assess the feasibility of Xpert MTB/RIF test implementation in the region, and the performance of the assay to increase case detection on the selected rural health care setting. Objective: To assess the feasibility of Xpert MTB/RIF test implementation in the rural health care setting in Southern Ethiopia. Methods: Two Xpert MTB/RIF machines were brought in 2012 through TB REACH project. It was placed at Yirgalem hospital and at Aletawondo health centre. The instruments were installed after formal training was provided to laboratory technologists for three days. We collected sputum sample from participants who repeatedly had negative smear microscopy and those who had not responded to first-line anti-TB drugs. Result: Of the total participants tested, 1828 have valid result (MTB-, MTB+/RIF-, MTB+/RIF+, MTB+/RIF Indeterminate). From the participants with valid results, 217 (11.9%) were Xpert-positive of which were 165 (9.0%) RIF-negative, 6 (0.3%) RIF-indeterminate and 46 (2.5%) RIF-positive. Among TB suspects with previous treatment history and positive by Xpert, RIF resistance was detected in 10 (2.2%). From the new TB suspects with positive Xpert, RIF resistance was detected in 29 (2.7%). All cases identified were linked with TB/MDR-TB treatment centers. Conclusion: Xpert provides an additional tool for the diagnosis of TB and drug resistance, with almost 12% of new and retreatment cases obtaining information that is useful for clinical management. To enhance its efficient utilisation, operational challenges should be minimized particularly in relation to availing robust alternative power source.

Sensitivity and specificity of an electronic nose in diagnosing pulmonary tuberculosis among patients with suspected tuberculosis.

ObjectiveTo investigate the potency of a hand-held point-of-care electronic-nose to diagnose pulmonary tuberculosis (PTB) among those suspected of PTB.MethodsSetting: Lung clinics and Dr. Sardjito Hospital, Yogyakarta, Indonesia. Participants: patients with suspected PTB and healthy controls. Sampling: 5 minutes exhaled breath. Sputum-smear-microscopy, culture, chest-radiography, and follow-up for 1.5–2.5 years, were used to classify patients with suspected PTB as active PTB, probably active PTB, probably no PTB, and no PTB. After building a breath model based on active PTB, no PTB, and healthy controls (Calibration phase), we validated the model in all patients with suspected PTB (Validation phase). In each variable (sex, age, Body Mass Index, co-morbidities, smoking status, consumption of alcohol, use of antibiotics, flu symptoms, stress, food and drink intake), one stratum’s Receiver Operating Characteristic (ROC)-curve indicating sensitivity and specificity of the breath test was compared with another stratum’s ROC-curve. Differences between Area-under-the-Curve between strata (p<0.05) indicated an association between the variable and sensitivity—specificity of the breath test. Statistical analysis was performed using STATA/SE 15.ResultsOf 400 enrolled participants, 73 were excluded due to extra-pulmonary TB, incomplete data, previous TB, and cancer. Calibration phase involved 182 subjects, and the result was validated in 287 subjects. Sensitivity was 85% (95%CI: 75–92%) and 78% (95%CI: 70–85%), specificity was 55% (95%CI: 44–65%) and 42% (95%CI: 34–50%), in calibration and validation phases, respectively. Test sensitivity and specificity were lower in men.ConclusionThe electronic-nose showed modest sensitivity and low specificity among patients with suspected PTB. To improve the sensitivity, a larger calibration group needs to be involved. With its portable form, it could be used for TB screening in remote rural areas and health care settings.

Improving Detection of Trichomonas vaginalis Infection among Adult Females in a Resource-poor Setting in Ogoniland, Niger Delta, Nigeria

Aim: Trichomonas vaginalis infection is a neglected tropical parasitic infection affecting mostly women of child bearing age, especially those of low socio-economic status and those that have poor hygiene lifestyle. Unfortunately, the traditional wet mount microscopy routinely used in the rural health care settings, for the detection of this parasite from clinical specimen, hardly detect this parasite (false negative), thus making the diagnosis of trichomoniasis a huge challenge in the rural settings. The aim of this study was to determine the prevalence rate of Trichomonas vaginalis among adult females in Bori, a rural resource-poor setting in Ogoniland, Niger Delta, Nigeria using modified Parasite Concentration-Giemsa staining technique.&#x0D; Study Design: This was a randomized study of adult females attending Government Health Centers in the Ogoni areas of Rivers State, Nigeria between April and August, 2018.&#x0D; Methodology: A total of five hundred (500) women, grouped into married (128) and unmarried (372), were enrolled in this study. A structured questionnaire was also administered to the participants for demographic data. Using sterile specula, high vaginal swab samples were collected and analyzed using the wet mount preparation and 10% Giemsa staining of centrifuged specimens.&#x0D; Results: Results obtained showed that the prevalence rate was 1.8% (9 out of 500 subjects). The sensitivity of wet mount and Giemsa stain methods were 56.2% and 100% respectively while their specificity were 100% and 98.2% respectively. While wet mount detected 0.4%, Giemsa staining method detected 1.8%. Two (1.6%) out of 128 married women examined had T. vaginalis while 7 (1.9%) out of 372 unmarried women examined had T. vaginalis.&#x0D; Conclusion: Although study recorded a low prevalence, Trichomonas vaginalis infections, exists in rural areas of Rivers State and therefore a source of concern because of its attendant morbidities. Early detection using improved diagnostic methods and in this case, the relatively inexpensive Parasite Concentration-Giemsa staining method, will improve management within the rural setting. A meta screening of more rural communities is advocated.

Nurse Practitioner Role Transition and Identity Development in Rural Health Care Settings: A Scoping Review.

The purpose of this scoping review was to explore the literature regarding the nurse practitioner (NP) role transition and professional identity development at rural health care settings. Because of the shortage of primary care providers, NPs are meeting the demand for primary care in rural areas. Arksey and O'Malley's six-stage methodological framework for scoping reviews guided this systematic literature review, which resulted in selection of 145 sources. Three major themes emerged: NPs in rural clinical practice, defining NP professional identity, and role transition to an NP identity. Further research is needed to guide education program leaders on curriculum development. Rural health care facilities and nursing programs should partner in the orientation and continuing education needs of NPs to prepare and support their role transition and professional identity development. NPs will be instrumental in providing access to quality primary health care in rural communities.

Transition experiences of newly graduated Filipino nurses in a resource-scarce rural health care setting: A qualitative study.

Without a doubt, the transition to a professional nursing role is a challenging and stressful experience for many new nurses, regardless of where they are employed; yet, no study has been conducted to comprehend in detail the transition experiences of newly graduated nurses employed in a resource-scarce rural health care setting. This study describes the transition experiences of newly graduated Filipino nurses during their initial clinical placement process. A qualitative phenomenological approach using structured interviews with 15 newly graduated Filipino nurses were used along with the Coliazzi's methodological framework for data analysis. Four distinct themes emerged from the content analysis, as follows: experiencing transition shock, feeling pressured, learning excitement, and needing support. Similar to the findings of other international studies, newly graduated Filipino nurses described their transition experiences as a stressful and challenging journey. Both academic and nursing administration team members can play key roles in facilitating a smooth transition and the integration of new nurses into the nursing workforce through the employment of evidence-based educational and structured organizational strategies.

Yes, We Can and Did: Engaging and Empowering Nurses Through Shared Governance in a Rural Health Care Setting

The ever-increasing demands on health care systems to improve patient satisfaction, manage costs, improve the quality of care, and promote a healthy work environment known as the Triple Aim Plus One, has forced many organizations to reorganize, merge, affiliate, or close their doors entirely. At the center of any organization that hopes to be successful in achieving the Triple Aim Plus One, is an engaged nursing workforce.1 According to the Press Ganey employee engagement database, 15 of every 100 nurses are considered disengaged (thus lacking commitment and/or satisfaction with their work). Conservative estimates suggest that each disengaged nurse costs an organization $22,200 in lost revenue due to a lack in productivity.2 There have been many studies that have shown the impact nurses have on both patient satisfaction and quality of care outcomes.1,3 The challenges have been how to keep nurses in the rapid-fire, tumultuous health care environment from burning out and how to promote a high level of engagement. One method of achieving a high level of nurse engagement is the implementation of shared governance.4 The purpose of this article is to share the story of how one rural health care system ignited nurse engagement through the implementation of shared governance.

Constructing a value-based healthcare system for hypertensive patients through changing payment mode: evidence from a comparative study in rural China

Objective: To construct a value-based healthcare system for rural Chinese hypertensive patients through an increasing outpatient care reimbursement ratio.Methods: This comparative study sampled two similar counties, Dangyang County and Zhijiang County, in Hubei Province of China, as the intervention group and the control group, respectively. The Social Health Insurance Fund of the intervention group budgeted 600 yuan per capita per year to insured patients with third stage hypertension to cover their outpatient expenditures, while the outpatient expenditures of the control group were not covered by its Social Health Insurance Fund. The inpatient expenditure reimbursement policies in both groups were not adjusted during the study. Value improvement in this study was defined as reduction in medical costs and improvement in health outcomes within the pilot healthcare system. A propensity score matching model combined with a difference-in-differences model was used to estimate the changes in medical costs and health outcomes.Results: In total, 1,673 pairs of patients were enrolled into statistical analysis after the propensity score matching. The intervention increased per capita annual outpatient expenditure by 81.2 (+31.8%) yuan (p > .05), but decreased the per capita annual inpatient expenditure and total medical expenditure by 475.4 (–40.7%) yuan and 394.2 (–27.7%) yuan, respectively (p < .05). Accordingly, the per capita annual total medical expenditure reimbursement decreased by 192.3 (–28.5%) yuan (p < .05), and the per capita annual total out-of-pocket expenditure by 201.9 (–29.9%) yuan (p < .05). The diastolic blood pressure of the intervention group decreased significantly by 2.9 mmHg (p < .05), but no significant change was found in systolic blood pressure and prevalence of hypertension complications (p > .05).Conclusion: Increasing the outpatient expenditures, the reimbursement ratio was beneficial to the value of the healthcare system for hypertensive patients. Outpatient care for patients with chronic diseases should be prioritized for rural China and healthcare settings with inadequate health insurance funds.

Challenges with Healthcare in the Rural and Prairie Environment.

This symposium includes thirteen personal narratives from individuals who have learned, first-hand, what it means to provide healthcare services in rural or frontier communities in the United States. This meaning is uncovered as the authors describe an array of personal and professional challenges and rewards-the careful balancing of one's soul, psyche, family, and profession-with the constraints that accompany care in less populated areas. This symposium also includes three commentaries by authors who have expertise in the areas of bioethics, patient advocacy, health policy, and healthcare decision making. We hope that readers of these stories will gain greater understanding and respect for the work entailed in providing healthcare in rural settings and for some of the more unique issues that can accompany healthcare delivery in places where resources and expertise may be limited, where relationships among patients and families may be more continuous and intertwined, and where medicine becomes a job and a lifestyle.

Development of a nurse-led tranexamic acid administration protocol for trauma patients in rural South Africa.

IntroductionAdministration of tranexamic acid (TXA) has been shown to effectively reduce all-cause mortality in trauma patients when given within three hours of injury. We found that many trauma patients in our hospital were not receiving TXA. This was due to a variety of factors, including late presentation to hospital, lack of staff awareness, short staffing, and unavailable drugs or equipment. Our aim was to develop a protocol for safe, nurse-led administration of TXA in the emergency centre in order to increase the number of eligible patients treated.MethodsWe developed a protocol based on the inclusion criteria of the CRASH-2 study, opting to use physiological observations along with criteria from the South African Triage Scale to allow nursing staff to identify patients with, or at risk of, significant haemorrhage. We tailored the protocol to the equipment and training available in our poorly resourced rural healthcare setting.ResultsIn a two-month period, 14 patients were given TXA by nurses before the arrival of a doctor. 13/14 (92.9%) were deemed appropriate, with 1/14 (7.1%) deemed inappropriate due to the time since injury. 12/13 (92.3%) patients received the correct infusion dose, with 1/13 (7.7%) only receiving the infusion once the doctor arrived. No adverse events were reported.ConclusionsNursing staff in resource poor rural settings can use a protocol based on the South African Triage Scale and the CRASH-2 study to safely administer TXA to trauma patients. We believe this to be the first published literature on nurse-led administration of TXA. Mortality from trauma may be reduced in rural settings by the timely administration of TXA in the prehospital and rural primary healthcare settings.

Glioblastoma Treatment with Temozolomide and Bevacizumab and Overall Survival in a Rural Tertiary Healthcare Practice

Background The efficacy of temozolomide (TMZ) chemotherapy for treating newly diagnosed glioblastoma (GBM), a primary brain tumor with short survival, was demonstrated in a clinical trial in 2005, and since then, the standard-of-care for newly diagnosed GBM has been maximal safe surgery followed by 60 Gray of radiation with concomitant and adjuvant TMZ (standard radiotherapy and TMZ). In 2009, clinical trials also reported on the efficacy of bevacizumab for treating recurrent GBM. We performed a retrospective cohort study to evaluate the impact of treatment regimens on overall survival for patients with GBM at a rural tertiary healthcare practice. Methods We retrospectively reviewed the medical records of 307 consecutive, newly diagnosed GBM patients at one institution between 1995 and 2012 and assessed treatment patterns. We also compared overall survival according to the treatment received. Results Only 0.6% (1/163) of patients diagnosed before 2005 received standard radiotherapy and TMZ versus 36.1% (52/144) of patients diagnosed since 2005 (P < 0.0001). For patients who received standard radiotherapy and TMZ, the median overall survival was 17.0 months versus 7.0 months for patients who received 60 Gray of radiation but no chemotherapy (P = 0.0000078). The median overall survival was 15.4 months in the 19 patients treated with bevacizumab monotherapy at first GBM recurrence versus 6.8 months in the 32 patients with no treatment at first GBM recurrence (P = 0.00015), but patients who received bevacizumab were younger and more likely to have had a surgical resection and 60 Gray of radiation at diagnosis. Conclusions TMZ and bevacizumab therapies were rapidly adopted in a rural tertiary healthcare setting, and patients who received these treatments had increased overall survival. However, advantageous prognostic factors in patients who received bevacizumab at recurrence may have influenced the extent of the increase in overall survival attributed to this treatment.

Experiences of Rural Nurses who Commute to Larger Communities

Background: Healthcare disparities for rural U.S. populations occur in part due to lack of healthcare providers. Increasing numbers of registered nurses (RNs) commuting away from rural communities for employment contributes to the rural population’s challenges accessing healthcare. It is largely assumed in the literature that wages are the driving force behind rural nurses’ commuting decisions. However, the actual experiences of RNs living in rural communities who commute to larger communities for employment is absent in the extant literature. Purpose: This descriptive, phenomenological study explored the phenomenon of commuting away among RNs living in rural communities who commuted to larger communities for employment. Methods: Participants included currently licensed RNs, residing in rural communities with a critical access hospital, that had a population of less than 2,500, who commuted for employment in larger communities. Purposeful sampling with snowballing led to 16 RNs from two Midwestern states, providing rich variations in personal and professional experiences. Data were collected via semi-structured interviews. Findings: The core meaning, or essence, of the phenomenon of commuting away was found to be “Commuting to achieve personal and professional goals while being a nurse in a rural community.” Multifaceted reasons surfaced for RNs to commute for employment. Most noteworthy reasons for employment decisions included opportunities for specialized areas of nursing not available in rural healthcare settings, along with advancement opportunities. Additionally, all RNs in the study were found to appreciate feeling valued as a nurse by members of their rural communities. Conclusion: The multi-faceted reasons for commuting away indicated that “one size fits all” plans for recruitment and retention efforts will not meet the needs of rural nurses, and neither will simply increasing rural nurse wages. Study results are relevant to policy development, nursing practice, nursing education, and future development, recruitment, and retention efforts of nurses serving rural populations. Keywords: Nurses, rural nurses commuting, employment, job DOI: http://dx.doi.org/10.14574/ojrnhc.v18i2.540

Modeling Health Disparities and Outcomes in Disenfranchised Populations.

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Health needs and challenges of rural adolescents

The purpose of the study was to gain understanding of the health issues and needs of rural adolescents by listening to their voices and eliciting their personal perspectives. Rural counties in the USA are defined as having 6-19.9 persons per square mile. Focus group interviews were conducted with 65 adolescents aged between 13 and 19 years old, from four rural counties in the USA. These counties are medically underserved with one primary care physician per 3500 population. Grounded theory analysis was utilized to identify overarching themes. Thematic content analysis revealed two themes of health issues - making healthy choices and lack of pro-social, health-promoting role models - and four themes of health needs - privacy, reliable information, accessible health care, and prioritizing health. The findings that speak to the complexity of adolescent health go beyond the inability to access health care and may provide important information that can help mitigate some of the obstacles to adolescents accessing health care in rural settings. A main contributor to adolescents' health choices is the lack of positive role models. Adolescents look for role models in their parents, siblings, peers and adults in their communities. The absence of positive role models means adolescents lack guidance at an age when they are highly impressionable. Contrary to general perceptions that adolescents do not want to affiliate with their parents, adolescents in this study desired connection with their parents and adults in general. Adolescents in the study called for 'frank' discussions with adults about stress management, consequences of substance abuse, realities of adolescent pregnancy and sexual health. It is through open dialogue and frank conversations with adults that adolescents believe they would best obtain the type of credible, realistic health information they need. Common features of rural settings such as familiarity and close-knit communities, though integral in developing a sense belonging, can be an impediment to privacy. Lack of exposure and resources to educate residents of rural communities may enhance biases against the mentally and physically ill. Biases can lead to the stigma associated with seeking health care that in turn leads to distancing and fear promotion, making it difficult, and at times impossible, for adolescents to seek the health care they need. Barriers to developmentally necessary health care and health information that all adolescents need are compounded by the unique rural socio-environment and the involvement of multiple systems - family, school, peers, and healthcare providers - rooted within communities that may hinder adolescents from becoming thriving, contributing citizens. It is crucial that adults in rural communities seek to hear, strengthen, and empower young people through education, sharing of personal experiences and struggles, focusing adolescents' time and energies on positive, pro-health activities, and providing positive role models. Attaining and maintaining good health is a lifelong process. Learning how to be healthy takes time and effort. Communities that lack recreational resources for adolescents to have positive 'down time to unwind', engage with others in the community and re-energize do a disservice to adolescents who want to be active and thriving. The lack of healthy forms of recreation and community engagement can lead to boredom, and engagement in activities that may not be the safest or healthiest.

Nutritional status of rural community-dwelling older people and changes after following nutritional recommendations.

It is crucial that community nurses in remote areas are competent to recognize the risk of malnutrition in older people and be able to help them to improve their nutritional status. To examine the factors associated with malnutrition and the impact of nutritional recommendations in rural community-dwelling older people. This was a cross-sectional descriptive study. The study was conducted in 2014 in a rural primary health care setting in Lithuania with 169 older people. Nutritional status was assessed using the Mini Nutritional Assessment tool. Older people who were at risk of malnutrition or were already malnourished (n=82) received written nutritional recommendations and were reassessed after 6months. Nutritional status was normal for 51.5% of participants, 43.2% had risk of malnutrition, and 5.3% had malnutrition. Risk of malnutrition or malnutrition was associated with chronic and intermittent pain, chewing difficulties, swallowing disorders, dental problems, and medication use. The nutritional status of participants at risk of malnutrition or malnourished had improved 6months later. Risk of malnutrition or malnutrition was prevalent among rural community-dwelling older. The study highlighted that positive health outcomes are achievable in undernourished or at risk of malnutrition older people when nutritional recommendations are applied with minimal resources.