Rural Health Initiative Research Articles

Comparison of In-person VS remote learning modalities for ultrasound-guided knee arthrocentesis training using formalin-embalmed cadavers

ObjectivesThis study aims to compare the efficacy of remote versus in-person training strategies to teach ultrasound guided knee arthrocentesis using formalin embalmed cadavers.Methods30 first-year medical student participants were randomly assigned to remote or in-person training groups. Pre- and post- training surveys were used to evaluate participant’s self-confidence in their ability to perform the procedure. Participants were asked to watch a 30-minute training video and then attend a skills training workshop. The workshops consisted of 20 min of hands-on instruction followed by a skills assessment.ResultsFollowing training, participant self-confidence increased significantly across all survey items in both groups (p = 0.0001). No significant changes in participant self-confidence were detected between the groups. Skills and knowledge-related metrics did not differ significantly between the groups with the exception of the “knowledge of instruments” variable.ConclusionsOur data suggests that remote ultrasound-guided procedure training, although logistically complex, is a viable alternative to traditional in-person learning techniques even for a notoriously hands on skill like ultrasound guided knee arthrocentesis. Novice first-year medical student operators in the remote-training group were able to significantly increase their confidence and demonstrate competency in a manner statistically indistinguishable from those trained in-person. These results support the pedagogical validity of using remote training to teach ultrasound guided procedures which could have implications in rural and global health initiatives where educational resources are more limited.

The Rural Interprofessional Health Initiative.

Innovative models that prepare students for careers in rural health are of increasing interest. The UNC Rural Interprofessional Health Initiative (RIPHI) is an intentional interprofessional model that has been in existence since 2017. This article provides an overview of this work, lessons learned, and opportunities for future partnerships.

The Rural Health Initiative: Advancing Pharmacist Care for Rural Communities in Washington State

The Rural Health Initiative: Advancing Pharmacist Care for Rural Communities in Washington State

Slum and Rural Health Initiative Research With Purpose Academy (SRA): Building Interdisciplinary Research Capacity and Leadership

Slum and Rural Health Initiative Research With Purpose Academy (SRA): Building Interdisciplinary Research Capacity and Leadership

Community overdose surveillance: Fentanyl involvement in overdose deaths in rural Michigan

PurposeExamine fatal overdose toxicology trends to contribute toward understanding the outreach and treatment needs of people who use drugs in rural areas. MethodsWe describe toxicology results from overdose deaths that occurred between January 1, 2018, and December 31, 2020, in 11 rural counties in Michigan, a state with relatively high rates of overdose mortality. One-way ANOVA with Tukey's HSD posthoc tests were used to test statistically significant differences in the frequency of substances detected between years. FindingsDecedents (N = 107) were male (72.9%), White (96.3%), non-military (96.3%), unemployed (71.0%), married (73.9%), and had a mean age of 47 years old. The number of observed overdose deaths increased considerably from 2019 to 2020, with an increase of 72.4%. Fentanyl was the most common substance detected and had a 94% increase during the three-year period to present in 70% of all the deaths in these counties in 2020. Among the deaths we examined where cocaine was detected, 69% also contained fentanyl, and in deaths where methamphetamine was detected, 77% also contained fentanyl. ConclusionFindings could inform rural health and outreach initiatives aimed at reducing overdose risks by providing education on the risks of stimulant and opioid couse but also the widespread saturation of illicit drugs that contain fentanyl. Lowthreshold harm reduction interventions are discussed amid limited prevention and treatment resources in rural communities.

Access to health services for chronic disease care during the COVID-19 pandemic in Ecuador: A qualitative analysis using a Social Determinants of Health approach

ABSTRACT This qualitative study aims to explore how the COVID-19 pandemic impacted healthcare access for patients with chronic conditions in Ecuador from the patient’s perspective. We interviewed 19 patients diagnosed with arterial hypertension or type 2 diabetes in rural and urban areas of Ecuador during August and September 2020. We used the Framework Method to analyse the interview transcripts with ATLAS.Ti 8.4 and organised the ideas discussed using categories from the World Health Organization Commission on the Social Determinants of Health conceptual framework. Reorganization of health services during the pandemic meant that patients with arterial hypertension or diabetes could no longer attend face-to-face appointments for disease follow-up. System failures related to medication supply led to increased out-of-pocket payments, which, together with reduced or absent earnings, and in a context with limited social protection policies, meant that patients frequently went for prolonged periods without medication. Rural health initiatives, support from family and use of traditional medicine were reported as ways to manage their chronic condition during this time. Barriers to disease management disproportionately affected individuals with low socioeconomic positions. Stock shortages, lack of protective labour policies and limited reach of anticipatory policies for health emergencies likely worsened pre-existing health inequities in Ecuador.

Estimated versus observed 10-year atherosclerotic cardiovascular event rates in a rural population-based health initiative: The Heart of New Ulm Project

ObjectiveAssess discrepancy between estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and observed 10-year event rates in a rural population participating in cardiovascular health initiative. MethodsThe study included a rural sample of individuals participating in the Heart of New Ulm (HONU), a population-based health initiative aimed at reducing ASCVD risk in a rural community. HONU conducted over 100 baseline screening events with 5221 individuals participating in 2009. For this analysis, we included participants who were aged 40–79 years, free of ASCVD at baseline, and had adequate data to calculate 10-year ASCVD risk. Electronic health record data and state death records were used to determine rates of non-fatal myocardial infarction and stroke, and ASCVD death from 2010–2019. ASCVD event rates were compared to estimated 10-year risks calculated using the Pooled Cohort Equations, stratified by sex and clinically relevant risk categories. ResultsThe sample (n = 2819, mean ± SD age 56.1 ± 9.9 years, 59.6% female) had a low prevalence of tobacco use (8.1% current smokers) and diabetes (6.5%) and a high prevalence of hypertension (44.4%) and hyperlipidemia (56.6%). The median estimated 10-year ASCVD risk for the entire sample was 5.7% (IQR 2.3–13.5%) with an observed 10-year ASCVD event rate of 3.4%. The largest gap between observed and estimated risk was in those at intermediate/high (≥7.5%) ASCVD risk (median 10-year risk 15.8% [IQR 10.4–29.0], observed ASCVD event rate 6.4%). ConclusioIn a sample of rural participants exposed to a multifaceted ASCVD prevention initiative, observed rates of ASCVD were substantially lower compared to estimated ASCVD risk. The potential for significantly lower than predicted ASCVD event rates in certain populations should be included in the clinician-patient risk discussion.

Challenging terrains: socio-spatial analysis of Primary Health Care Access Disparities in West Virginia.

Challenging terrains: socio-spatial analysis of Primary Health Care Access Disparities in West Virginia.

Relational experiences of community members participating in a rural health initiative with interprofessional students

Background. A South African faculty of health sciences created a forum for the community to voice their relational experiences with interprofessional students through visual projections. No other studies that explore such experiences using the Mmogo method could be located.
 Objective. To gain an understanding of the relational experiences of community members participating in Lifestyle-groups as part of a rural health initiative with interprofessional student groups.
 Methods. The Mmogo method is a qualitative, structured, observation technique. Participants constructed visual projections representing specific relationships. Thereafter, during a group discussion, participants explained the meaning of their projections. The visual data were analysed according to their literal presentation and subjective, symbolic meaning. A thematic analysis was used for the transcribed data.
 Results. Thirteen of the 24 visual projections were of a quality that allowed visual analysis; all 24 members participated in the discussions. Light was identified as an overarching theme to represent the community-student interaction. Sub-themes and categories associated with light were healthier lifestyles (knowledge sharing, lifestyle transformation, improved health outcomes), solidarity (reciprocity, collaboration, person centredness, multidimensional approach) and affirmation (gratitude and acceptance).
 Conclusion. Though some statements by participants related to health education as opposed to health dialogue highlighted areas requiring improvement, the findings correlated with the outcomes prescribed for students by this rural health initiative. Emotional connections in relational experiences could facilitate higher levels of self-efficacy in communities. The question is whether a stronger emphasis on health dialogue can be a catalyst for improved self-efficacy.

Community co-produced mental health initiatives in rural Australia: A scoping review.

Inaccessibility of mental health services in rural Australia is widely reported. Community co-produced mental health and well-being initiatives could fill gaps and complement other services. This scoping review summarises findings from peer-reviewed articles to identify the key features of co-produced Australian rural mental health initiatives that engage communities in their design, delivery or evaluation processes. Between 2009 and 2019 inclusive, 14 articles met inclusion criteria and were reviewed using Arksey and O'Malley's review methodology. Communities co-produced initiatives through informing, collaborating and instigating them. Some initiatives operated in specific places, for example an art gallery, while others operated across regions. Only two initiatives involved community members in multiple activities targeting prevention, early intervention, education and service accessibility; other initiatives were more focused, for example designing a new service. Over half of initiatives found were targeted at Aboriginal and Torres Strait Islander Peoples. Most articles discussed evaluation approaches, though methods were diverse. Published peer-reviewed evidence about Australian rural community co-produced mental health initiatives appears scant. Evidence found suggests they generate a range of supports that could complement or mitigate for lack of, public health services. The overall lack of evidence, diversity of initiatives and inconsistent evaluation makes it difficult to assess effectiveness and which activities might be scaled-up for wider benefit. Rural communities have limited resources, and evidence of what constitutes best practice in co-producing mental health services would help to avoid 'reinventing the wheel.' Greater efforts in evaluating and publishing about initiatives would be helpful.

Increasing rural patient access using clinical pharmacy specialist providers: Successful practice integration within the Department of Veterans Affairs.

Access to care is a critical issue facing healthcare and affects patients living in rural and underserved areas more significantly. This led the Department of Veterans Affairs (VA) to launch a project that leveraged the expertise of the clinical pharmacy specialist (CPS) provider, embedding 180 CPS providers into primary care, mental health, and pain management across the nation. This multidimensional project resulted in hiring 111 CPS providers in primary care, 40 CPS providers in mental health, and 35 CPS providers in pain management to serve rural veterans' needs. From October 2017 to March 2020, CPS providers provided direct patient care to 213,477 veterans within 606,987 visits. This was an average of 43,000 additional visits each quarter to support comprehensive medication management services, demonstrating an additional 219,823 visits in fiscal year 2018 and 232,030 visits in fiscal year 2019. Over the course of the project, the team provided mentorship to 164 CPS providers, performed consultative visits at 27 VA facilities, and trained 180 CPS providers in educational boot camps. VA funding of rural health initiatives adding CPS providers to primary care, mental health, and pain teams has resulted in positive measures of comprehensive medication management, interdisciplinary team satisfaction, facility leadership acceptance, and multiple positive outcomes.

University of Alberta Faculty of Medicine and Dentistry.

University of Alberta Faculty of Medicine and Dentistry.

Digital Healing: People, Information, Healthcare

Digital Healing takes the reader on an evolutionary journey focusing on the deployment of electronic health record systems across the United States from 2000 to 2018. The author, Marc Ringel, M.D., studied at the Abraham Lincoln School of Medicine in Chicago, Illinois followed by postgraduate training in pediatrics at Cook County Hospital (Chicago). He later became a general practitioner in Yuma, Colorado (population 2,000) as part of the National Health Service Corps where he fell in love with rural medicine and became Board Certified as a family physician. He has also practiced in rural Wisconsin and taught at the North Colorado Family Medicine Residency Training Program in Greeley, Colorado. He is an eloquent writer and speaker, and is dedicated to writing about rural health care, telemedicine, and continuing medical education. Dr. Ringel weaves relevant scholarly references and personal stories about his role as a family medicine physician to engage the reader in a thoughtful discussion about ways in which people are better than computers and vice versa in health care.A recurrent theme throughout the book is that no matter how sophisticated or impressive technology is, the determining factor for its successful implementation is the people involved in deploying and using the technology. Personal stories and clever examples of telemedicine applications are interwoven throughout the book in a way that draws the reader in. Dr. Ringel cleverly depicts the improvement offered by electronic health records while describing the importance of the human component of health care, focusing on patients’ stories and relationships, while using clever chapter titles such as “Left-Handed Pregnant Women,” “Everybody Wants Your Data,” and “Financial and Human Costs of EHRs.” The author commands an encyclopedic knowledge of medical history and integrates it well with the rapidly evolving digital revolution that is affecting health systems throughout the world.The central thesis of the book explores the ways in which human beings can utilize digital information and resources to improve health, while also allowing people to be more human. The author intercalates stories describing entire health systems, such as those in rural and urban centers in Colorado, with individual anecdotes that highlight the strengths and limitations of electronic health records. The author’s views, particularly advocating for rural health initiatives and reducing health services disparities, are prevalent throughout the text.As a rural practitioner, Dr. Ringel recognizes the importance of interventions that address disparities in healthcare access, particularly in remote areas of the country. All forms of telemedicine are emphasized, from phone calls to virtual consults with intensivists who offer around-the-clock expertise to clinicians in remote hospitals with limited or no access to specialists.The book is carefully organized into chapters focusing on specific areas ranging from virtual reality to artificial intelligence to clinical decision support. The author avoids jargon and aims for a balanced presentation that is accessible to medical and general readers alike. This book offers a set of perspectives on the evolution of the electronic health record system, but is not a comprehensive overview of the field. The book is available in hardback and eBook formats through a variety of services. Readers of all levels of experience will enjoy this welcome reality check in today’s digitally connected world.

Dietary Sodium Reduction Reduces Albuminuria: A Cluster Randomized Trial

The objective of the study was to assess the impact of sustained dietary salt reduction on albuminuria in nearly 2000 community-dwelling adults. The present study is a prespecified secondary analysis of the China Rural Health Initiative Salt Reduction Study cluster randomized trial undertaken in 120 villages in rural China. Villages were randomized to a sodium reduction program of education and access to reduced-sodium salt substitute or control. Urinary albumin-to-creatinine ratio (uACR) and albuminuria (uACR ≥22.1 or 31.0 mg/g for men and women, respectively) were assessed at 18 months in a stratified random sample of predominantly older individuals living in participating rural villages. A total of 2,566 participants from 119 villages provided 1,903 eligible urine samples. The sodium reduction program reduced sodium intake by an equivalent of 0.82g of salt/day (0.06-1.68 g) (322 [24-661] mg sodium/day). The mean uACR was 8.85 (8.05-9.82) mg/g (1.00 [0.91-1.11] mg/mmol) in intervention participants compared with 10.53 (9.73-11.33) mg/g (1.19 [1.10-1.28] mg/mmol) in control participants (p=0.008). The corresponding odds ratio for albuminuria was 0.67 (0.46-0.99). Dietary sodium reduction was associated with significantly lower uACR and less albuminuria after 18 months. Whether CKD progression can be slowed by dietary sodium reduction should be a global research priority. CLINICALTRIALS.GOV: NCT01259700.

Briefly Noted

Alcoholism & Drug Abuse WeeklyVolume 30, Issue 47 p. 7-8 Briefly Noted Briefly Noted First published: 14 December 2018 https://doi.org/10.1002/adaw.32204Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Abstract Andrew Kessler, principal with Slingshot Solutions, lays it out for ADAW: President Trump is threatening a government shutdown, and most of the Department of Health and Human Services (HHS) is already set with funding — but not all of it. “Even within HHS, the Food and Drug Administration, as well as the Indian Health Service, remain unfunded for FY 2019,” Kessler told us last week. “Then, there are several departments of government that remain completely unfunded, and many maintain programs that impact substance abuse prevention, treatment and recovery. The Department of Justice is chief among these, as they invest heavily in treatment and recovery. We also need to be concerned about programs at the Department of Agriculture, which fund rural health initiatives, and the Departments of both Transportation and Housing and Urban Development.” The following appropriations subcommittees are not yet finished: Homeland Security, Interior, Agriculture, Commerce/Justice/Science, Transportation/Housing and Urban Development, Financial Services and State Department/Foreign Operations. Volume30, Issue4717 December 2018Pages 7-8 RelatedInformation

Domestic Violence and Pregnancy: A CBPR Coalition Approach to Identifying Needs and Informing Policy.

Community engagement-the collaborative process of addressing issues that impact the well-being of a community-is a strategic effort to address community issues. The Gulf States Health Policy Center (GS-HPC) formed the Hattiesburg Area Health Coalition (HAHC) in November 2014 for the purpose of addressing policies impacting the health of Forrest and Lamar counties in Mississippi. To chronicle the community-based participatory research (CBPR) process used by HAHC's identification of infant and maternal health as a policy area, domestic violence in pregnancy as a priority area within infant and maternal health, and a community action plan (CAP) regarding this priority area. HAHC reviewed data and identified infant and maternal health as a priority area. They then conducted a policy scan of local prenatal health care to determine the policy area of domestic violence in pregnancy. HAHC developed a CAP identifying three goals with regard to domestic violence and pregnancy that together informed policy. Changes included the development of materials specific to resources available in the area. The materials and recommended changes will first be implemented by Southeast Mississippi Rural Health Initiative (SeMRHI) through a screening question for all pregnant patients, and the adoption of policies for providing information and referrals. The lack of community-level data was a challenge to HAHC in identifying focus and priority areas, but this was overcome by shared leadership and community engagement. After completion of the CAP, 100% of expecting mothers receiving prenatal care in the area will be screened for domestic violence.

Perception of preventive care and readiness for lifestyle change in rural and urban patients in Poland: a questionnaire study.

The idiosyncrasies of rural health demand further research to instigate rural health initiatives and to monitor progress in rural health care. In 2008, a study examined health-related behaviour, perception of importance of preventive interventions, readiness to change lifestyle and willingness to receive support from GPs, according to gender and place of residence. A cross-sectional survey was conducted among patients who visited any of ten randomly-selected general practices in Poland. Four hundred patients were enrolled: 50% from rural areas, 50.3% were females; 23.8% declared a primary level of education (35% rural vs. 12.5% urban) respondents; the median age was 50 years (IQR=18), The predicted means for prevention importance scores for rural residents were 0.623 and for urban residents - 0.682. Place of residence had a significant effect on the importance of prevention (p<0.05; ICC=0.048). Area and gender have a statistically significant effect on preventive behaviour importance scores (p<0.05; ICC=0.0526). Patient expectations of individual counselling by GPs were highest for eating habits - 35.5% rural vs. 16% urban residents (p<0.0001). Patient importance scores for prevention were associated with residence and gender. The villagers attached less importance to prevention. They also declared less willingness to change their lifestyle. Women had higher scores regarding prevention than men. More rural respondents would like to receive individual counselling from their GP regarding eating habits, physical activity, body weight, giving up smoking and safe alcohol use. Urban respondents were more likely to expect leaflets from their GPs on normalizing body weight.

Mental health academics in rural and remote Australia

The significant impact of mental ill health in rural and remote Australia has been well documented. Included among innovative approaches undertaken to address this issue has been the Mental Health Academic (MHA) project, established in 2007. Funded by the Australian Government (Department of Health), this project was established as a component of the University Departments of Rural Health (UDRH) program. All 11 UDRHs appointed an MHA. Although widely geographically dispersed, the MHAs have collaborated in various ways. The MHA project encompasses a range of activities addressing four key performance indicators. These activities, undertaken in rural and remote Australia, aimed to increase access to mental health services, promote awareness of mental health issues, support students undertaking mental health training and improve health professionals' capacity to recognise and address mental health issues. MHAs were strategically placed within the UDRHs across the country, ensuring an established academic base for the MHAs' work was available immediately. Close association with each local rural community was recognised as important. For most MHAs this was facilitated by having an established clinical role in their local community and actively engaging with the community in which they worked. In common with other rural health initiatives, some difficulties were experienced in the recruitment of suitable MHAs, especially in more remote locations. The genesis of this article was a national meeting of the MHAs in 2014, to identify and map the different types of activities MHAs had undertaken in their regions. These activities were analysed and categorised by the MHAs. These categories have been used as a guiding framework for this article. The challenge to increase community access to mental health services was addressed by (i) initiatives to address specific access barriers, (ii) supporting recruitment and retention of rural mental health staff, (iii) developing the skills of the existing workforce and (iv) developing innovative approaches to student placements. Strategies to promote awareness of mental health issues included workshops in rural and remote communities, specific suicide prevention initiatives and targeted initiatives to support the mental health needs of Indigenous Australians. The need for collaboration between the widely dispersed MHAs was identified as important to bridge the rural divide, to promote project cohesiveness and ensure new ideas in an emerging setting are readily shared and to provide professional support for one another as mental health academics are often isolated from academic colleagues with similar mental health interests. The MHA project suggests that an integrated approach can be taken to address the common difficulties of community awareness raising of mental health issues, increasing access to mental health services, workforce recruitment and retention (access), and skill development of existing health professionals (access and awareness). To address the specific needs and circumstances of their community, MHAs have customised their activities. As in other rural initiatives, one size was found not to fit all. The triad of flexibility, diversity and connectedness (both to local community and other MHAs) describes the response identified as appropriate by the MHAs. The breadth of the MHA role to provide university sponsored educational activities outside traditional student teaching meant that the broader health workforce benefited from access to mental health training that would not otherwise have occurred. Provision of these additional educational opportunities addressed not only the need for increased education regarding mental health but also reduced the barriers commonly faced by rural health professionals in accessing quality professional development.

Community Innovation Network Framework: A Model for Reshaping Community Identity

The REACH Healthcare Foundation created its Rural Health Initiative to encourage the development of innovative strategies to improve access to health care and reduce health inequities in three rural counties in Missouri and Kansas. The intent was to develop a systematic, sustainable, and coordinated approach to community change that would increase the odds of breaking through the persistent barriers to health care access for the rural poor and medically underserved in these counties.

Does education level affect the efficacy of a community based salt reduction program? - A post-hoc analysis of the China Rural Health Initiative Sodium Reduction Study (CRHI-SRS).

BackgroundWhether educational level influences the effects of health education is not clearly defined. This study examined whether the impact of a community-based dietary salt reduction program was affected by the level of education of participants.MethodsThe China Rural Health Initiative Sodium Reduction Study (CRHI-SRS) was a cluster-randomized controlled trial conducted in 120 villages from five Northern Chinese provinces. The intervention comprised a village-wide health education program and availability of salt substitute at village shops. 24-h urine samples were collected among 1903 participants for primary evaluation of the intervention effect. A post-hoc analysis was done to explore for heterogeneity of intervention effects by education level using generalized estimating equations. All models were adjusted for age, sex, body mass index and province.ResultsDaily salt intake was lower in intervention than in control at all educational levels with no evidence of a difference in the effect of the intervention across different levels of education. P value for the interaction term between education level and the intervention was 0.35. There was likewise no evidence of an interaction for effects of the intervention on potassium intake (p = 0.71), the sodium to potassium ratio (p = 0.07), or knowledge and behaviors related to salt (all p > 0.05).ConclusionsThe study suggests that the effects of the intervention were achieved regardless of the level of education and that the intervention should therefore be broadly effective in rural Chinese populations.Trial registrationThe trial was registered with clinicaltrial.gov (NCT01259700).