Rural Health Network Research Articles

Community-based Geriatric Assessments: Is There an Urban/Rural Divide?

Abstract Background There is a paucity of literature describing urban/rural differences in baseline demographic factors and patterns of referral for those undergoing community based comprehensive geriatric assessment (CGA) in Ireland. We analysed differences in baseline demographics, referral sources and referral reasons among older persons who underwent CGA with a community specialist team, which accepts referrals from one predominantly rural community health network (CHN) and one predominantly urban CHN. Methods Data including baseline demographic characteristics, reasons for referral, referral sources, clinical frailty score (CFS), prevalence of polypharmacy (more than 10 prescribed medicines) and location of CGA was prospectively collected on all persons referred to an older persons' integrated care service from February 2023 to March 2024 and who underwent CGA. Data was stored on a secure database. Persons were categorised as either urban dwelling or rural dwelling, based on their local CHN. Descriptive statistics were used to describe differences between the urban and rural cohorts. Results 235 persons characterised as urban underwent CGA and 191 persons characterised as rural underwent CGA. There was a higher median CFS score amongst rural persons (CFS = 5, IQR=2) compared to urban persons (CFS=4, IQR=2). Urban persons were more likely to be referred by their G.P. (81% of total referrals) compared with rural persons (67%). Rural persons were more likely to be male (48% vs 37%) and experience polypharmacy (33% vs 27%) than urban persons. A similar proportion of persons underwent initial CGA in their home (20% rural vs 19% urban). Conclusion Here we describe the characteristics of urban and rural users attending an integrated care service. Future research should examine how these differences might affect healthcare utilisation and outcomes and provide opportunity to inform regional health and social care planning.

Authentic nurse leadership: A perspective among nurses in a rural health network.

Authentic nurse leadership: A perspective among nurses in a rural health network.

Research on Improving the Quality of Rural Medical Services in Shandong Province Based on the SERVQUAL Model

Rural healthcare is an essential aspect to consider in rural revitalization. Using the SERVQUAL model to examine the present state and challenges of healthcare service quality in Shandong Province, it was observed that rural people's perception of actual value falls short of their expectations in five different areas: tangibility, reliability, responsiveness, assurance, and empathy. The primary challenges entail inadequate public health consciousness among particular villagers, deficient modernization of rural healthcare facilities, and illogical regional health strategizing. Hence, to enhance the standard of living in rural regions and foster the building of a rural public health network, it is imperative to take initiatives to enhance villagers' hygiene awareness, promote the modernization of rural medical aid, and enhance practitioners' expertise via various means.

The development of a rural breast reconstruction service: patient reported outcomes and benefits.

In 2021, breast cancer was one of the most commonly diagnosed cancer in Australia. While a mastectomy remains a treatment of choice, only a small percentage of women have access to a breast reconstruction after. Women living in a rural area are less likely to have a breast reconstruction; compared to their metropolitan counterparts. This study analyses the impact of single breast reconstruction service on a Modified Monash 3 (MM3) region and informs consumers and providers of the importance of a breast reconstruction unit embedded in a rural health network. [Corrections added on 2 May 2023, after online publication. Expanded reference citations have been deleted from Abstract section.] METHODS: Following ethics approval, all 64 patients who had undergone a breast reconstruction with this service between 2017 and 2021 were contacted. Patient reported outcomes were recorded through phone interviews, using a standardized questionnaire. For each patient that presented to the rural centre, cost of travel and productivity loss were also calculated, and compared to the closest metropolitan centre. Ninety-seven percent of the 38 participants strongly valued having a breast reconstruction service within their community. Eighty percent of participants were satisfied with their result. Patients were estimated to save on average $8478, by attending the rural breast reconstruction service. Access to a breast reconstruction is significantly impacted by geographical barriers. A rural breast reconstruction service can improve patient access and satisfaction, while also reducing the financial burden on patients.

Iranian Health System Response to the COVID-19 Pandemic

Introduction: The COVID-19 pandemic has created several challenges for countries all over the world. Different countries have taken different measures to fight this pandemic and reduce its challenges depending on their cultural, economic, and social structures. This study aims to understand and explain the Iranian health system's response to fighting the COVID-19 pandemic from the managers' and authorities' perspective. Method: This study is a basic applied research performed under a qualitative approach. In the survey, 30 experts including the managers of health centers and deputies and heads of the Ministry of Health and Medical Education and Medical Universities were selected by purposive snowball sampling and participated in semi-structured interviews from March to May 2020. The researchers explained the actions of the Iranian health system in fighting the COVID-19 pandemic in 2020 by content analysis. Results: As a result, 14 subthemes were found and classified into four major themes, including the informative and regulative actions (two subthemes), administrative and supportive actions (six subthemes), preventive and curative actions (three subthemes), and resource-related actions (three subthemes). Conclusions: Due to its strong health structures, such as urban and rural health networks, various general and specialized hospitals, experienced doctors, and committed health staff, Iran has taken practical actions in fighting the COVID-19 pandemic. However, the findings of this study and its relevant measures can help combat this pandemic in countries with similar social and cultural structures or counter future similar crises.

Full agonist opioid prescribing by primary care clinicians after buprenorphine training

Background While primary care clinicians are being trained to use buprenorphine for the treatment of Opioid Use Disorder (OUD) in order to increase access to addiction treatment, it is not known what impact such training and subsequent experience treating patients with OUD has on full agonist opioid prescribing. Methods: This retrospective cohort study compares the full agonist opioid prescribing patterns of Drug Addiction Treatment Act (DATA)-waivered (“X-waivered”) primary care clinicians to non-trained, non-waivered clinicians in a rural health network. X-waivered clinicians also received Project ECHO training and telementoring support for one year. Using prescriber data generated by an electronic medical record system, opioid prescribing and morphine milligram equivalents (MME) per day per patient were calculated. A between-group analysis was used to compare the study groups six months pre-versus post-training. Results: Although the mean number of full agonist opioid prescriptions per clinician and per 100 patient encounters decreased among all clinicians, there was no change in full agonist opioid prescribing MME. As expected, buprenorphine prescribing by X-waivered, trained clinicians increased significantly post-training. Conclusions: X-waivers plus Project ECHO support for the treatment of OUD using buprenorphine had no effect on full agonist opioid prescribing by primary care clinicians.

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1-38) years and had used an electronic medical record for 7.0 (1-20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.

Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementation

BackgroundRural hospitals face unique challenges to adopting Enhanced Recovery protocols after colorectal surgical procedures. There are few examples of successful implementation in the United States, and fewer yet of prospective, outcomes-based trials.MethodsThis study drew data from elective bowel resection prospectively collected, retrospectively analyzed cases 2 years prior (n = 214) and 3 years after (n = 224) implementing an ERAS protocol at a small, rural health network in upstate New York. Primary outcomes were cost, length-of-stay, readmission rate, and complications.ResultsThe implementation required changes and buy-in at multiple levels of the institution. There was a statistically significant reduction in mean length of stay (6.9 versus 5.1 days) and per-patient savings to hospital ($3000) after implementation of ERAS protocol. There was no significant change in rate of 30-day readmissions or complications.ConclusionsThe authors conclude that for rural-specific barriers to implementation of Enhanced Recovery protocols there are specific organizational strategies that can ultimately yield sustainable endpoints.

Rural Health Networks: How Network Analysis Can Inform Patient Care and Organizational Collaboration in a Rural Breast Cancer Screening Network.

Rural health networks have the potential to improve health care quality and access. Despite this, the use of network analysis to study rural health networks is limited. The purpose of this study was to use network analysis to understand how a network of rural breast cancer care providers deliver services and to demonstrate the value of this methodology in this research area. Leaders at 47 Federally Qualified Health Centers and Rural Health Clinics across 10 adjacent rural counties were asked where they refer patients for mammograms or breast biopsies. These clinics and the 22 referral providers that respondents named comprised the network. The network was analyzed graphically and statistically with exponential random graph modeling. Most (96%, n = 45) of the clinics and referral sites (95%, n = 21) are connected to each other. Two clinics of the same type were 62% less likely to refer patients to the same providers as 2 clinics of different types (OR = 0.38, 95% CI = 0.29-0.50). Clinics in the same county have approximately 8 times higher odds of referring patients to the same providers compared to clinics in different counties (OR = 7.80, CI = 4.57-13.31). This study found that geographic location of resources is an important factor in rural health care providers' referral decisions and demonstrated the usefulness of network analysis for understanding rural health networks. These results can be used to guide delivery of patient care and strengthen the network by building resources that take location into account.

CE: Original Research: Intimate Partner Violence: The Knowledge, Attitudes, Beliefs, and Behaviors of Rural Health Care Providers.

: Intimate partner violence (IPV) continues to be a pervasive health and social problem in the United States with serious short- and long-term consequences. Women in rural areas face particular challenges. Health care providers can play an important role in the lives of women who experience IPV; yet among providers, lack of knowledge, negative attitudes and beliefs, and low rates of screening are common. Though a large body of research exists regarding health care providers' IPV-related knowledge, attitudes, beliefs, and behaviors, little is known specifically with regard to rural providers. Given the challenges faced by rural women and the potential influence of their providers, it's important to understand rural providers' IPV-related knowledge, attitudes, beliefs, and behaviors. We conducted a study to learn more. Health care providers working in a large rural health network were asked to complete electronic surveys that examined their IPV-related knowledge, attitudes, beliefs, and behaviors. Descriptive and correlational statistical analyses of the data were conducted. A total of 93 health care providers returned completed surveys. In general the respondents demonstrated good overall knowledge, judicious attitudes, and beliefs congruent with the available evidence related to IPV. Of concern were their knowledge and practice gaps regarding the prevalence of IPV, the higher risk of injury faced by women who leave their abusers, the ability of women to make appropriate choices about their situations, and what actions to take when someone discloses abuse. The results of this study were encouraging with regard to the IPV-related knowledge, attitudes, beliefs, and behaviors of rural health care providers. But the findings also indicated important knowledge and practice gaps. Preparing providers to deliver compassionate, effective care to women who experience IPV is essential for the health and well-being of women and their families.

Rural Health Networks and Care Coordination: Health Care Innovation in Frontier Communities to Improve Patient Outcomes and Reduce Health Care Costs.

Rural residents' health is challenged by high health care costs, chronic diseases, and policy decisions affecting rural health care. This single-case, embedded design study, guided by community-based participatory research principles and using mixed methods, describes outcomes of implementation of a community care team (CCT) and care coordination to improve outcomes of patients living in a frontier community. Seventeen organizations and 165 adults identified as potential care coordination candidates constituted the target populations. Following CCT development, collaboration and cohesion increased among organizations. Patients who participated in care coordination reported similar physical and lower emotional health quality of life than national counterparts; emergency department use decreased following care coordination. Key components identified as successful in urban settings seem applicable in rural settings, with emphasis on the key role of team facilitators; need for intense care coordination for people with complex health needs, especially behavioral health needs; and access to specialty care through technology.

Engaging Underrepresented Minorities in Research: Our Vision for a "Research-Friendly Community".

This article introduces our "Research-Friendly Community" vision, placing research in the arena of social justice by giving citizens a voice and opportunity to actively determine research agendas in their community. The mission of Tri-County Rural Health Network, a minority-owned, community-based nonprofit serving 16 counties in Arkansas' Mississippi River Delta region, is to increase access to health-related services and opportunities to both participate in and shape research. Tri-County has built trust with the community through the use of Deliberative Democracy Forums, a model devised by the Kettering Foundation and through a community health worker program called Community Connectors. Over time, a partnership was formed with investigators at the University of Arkansas for Medical Sciences (UAMS). Tri-County serves as a boundary spanner to link community members, other community organizations, local politicians, policy maker, and researchers. We describe our experience for other nonprofits or universities who might want to develop a similar program.

Task shifting of traditional birth attendants in rural China: a qualitative study of the implementation of institution-based delivery policy

Abstract Background Institution-based delivery, with the ultimate goal of universal access to skilled birth attendance, has been selected as a key strategy to reduce maternal mortality rate in many developing countries. However, the question of how to engage traditional birth attendants in the advocacy campaign for skilled birth attendance poses several challenges. Here, we use the experience of task shifting of traditional birth attendants in rural Guangxi Zhuang Autonomous Region, China, as a case study to illustrate how traditional birth attendants could be well integrated into the health system in rural regions. Methods We used qualitative research methods, including 28 document reviews (17 published manuscripts, six policy documents, one research report, one doctoral dissertation, and three websites) and 32 individual in-depth interviews with regional and local politicians, policy makers, health-care managers, health-care providers, civil society members, village women cadres, traditional birth attendants, village maternal health workers, mothers, and mother-in-laws. The research has been approved by the Ethical Board of School of Public Health, Fudan University, China. Findings From 1998 to 2012, the rate of institutional-based childbirth increased from 45·7% to 99·7%, and maternal mortality rate decreased from 86·0 per 100 000 livebirths to 27·2 per 100 000 livebirths in Guangxi Zhuang Autonomous Region. Traditional birth attendants' role of providing in-home care during childbirth was restructured, and their social role was strengthened as a result of task shifting. Traditional birth attendants were shifted to act as village maternal health workers to promote perinatal care and institution-based delivery. They were designed to function at the bottom level of the rural health network (county–township–village), acting as the link between women and the health system. A key policy document formalised the role of village maternal-health workers and supported the task-shifting process, which involved engaging with all government and non-governmental organisations (eg, women's federation, youth organisations, and academic associations), training traditional birth attendants for their new role, and providing incentives and sanctions for human resources management. Interpretation The task-shifting experience, implemented in accordance with the key policy document, in Guangxi was an example of successfully engaging traditional birth attendants in the promotion of institution-based delivery. Funding The study was supported by the China–UK Global Health Support Programme (GHSP-CS-OP1-02) and partly by the European Union Sixth Framework Programme HEPVIC (EU517746).

EURIPA – THE PAST, PRESENT AND FUTURE

EURIPA (European Rural and Isolated Practitioners Association) is a regional rural health network, which was founded by family doctors to address the health and well-being needs of rural communities, on one hand, and the practitioners’ needs across Europe, on the other. EURIPA began its activity in 1995 with a small group of family doctors from across Europe, and in 1997 the structure was formalised into that of EURIPA today. EURIPA was initially recognized by WONCA Europe as a special interest group and subsequently as a representative network for rural family doctors across Europe. Now, it actively participates in WONCA Europe meetings and their annual conferences. The constitution was revised in 1997 when the International Advisory Board was created to support the work of EURIPA and its Executive Committee. EURIPA has worked hard to raise the profile of rural general practice, from its first research project in 1997, to the series of Annual Rural Health Forums, which started in 2010. These forums have focussed on quality, education and research with the 5th Forum taking place in September 2014 focussing on policy engagement. EURIPA uses social media to engage its membership and publishes regular newsletters - “Grapevine”, as well as encourages rural GPs to publish in the European Section of the Journal of Rural and Remote Health.

Do the Guidelines for Adolescent Preventive Services (GAPS) Facilitate Mental Health Diagnosis?

To determine if the Guidelines for Adolescent Preventive Services (GAPS) increases detection or shortens time to diagnosis of mental health (MH) disorders, particularly adolescent depression. Starting in May 1999, GAPS questionnaires were routinely administered at adolescent annual visits at 1 primary care clinic in a rural health network. Using an administrative database, we enumerated all MH diagnostic codes for outpatient visits of adolescents aged 13 to 15 years. Population based rates were derived using school enrollment data. Using time series, the rates of MH diagnoses were compared pre- and post-GAPS. Using survival analysis, the time to any MH diagnosis subsequent to index annual visits was also compared pre- and post-GAPS. Because the GAPS questionnaire includes questions for depressed mood, anhedonia, and suicidality, ICD-9-CM codes for depression and mood disorder were also analyzed separately. Time series analysis included 8112 adolescents. The rate of MH diagnosis did not change pre- and post-GAPS (P = .13). Time to any MH diagnosis was similar pre-GAPS (9.0 months) and post-GAPS (7.0 months, log rank P = .30). Time to any first diagnosis of depression or mood disorder was similar post-GAPS (12.2 months) versus pre-GAPS (11.0 months, log rank P = .34). Use of the GAPS was not associated with change in the rate of or time to MH diagnosis. Our results challenge the prevalent expectation that requiring mental health screening will reduce unmet need for MH treatment. Validated MH screening tools, primary care provider training, and access to MH services may also be needed but further study is required.

Rural Health Networks: Adapting to a Changing Health Care Environment

Unemployment and financial struggles affect big and small communities alike. The current economic climate, coupled with changes to the health care environment, presents a unique opportunity for health care providers and community leaders to collaborate, integrate and network. The benefits of health networks are and can be tremendous during times of economic hardships. It takes great effort to assimilate different entities, but the effort is well worth the positive health impact on a community. The Rural Health Network Development Program (RHND) in the federal Office of Rural Health Policy (ORHP) provides an opportunity not only to assist rural communities in meeting unmet health needs, but also to collect data to document health impact in a way that can allow duplication of successes in both rural and urban communities. A rural health network is defined as “a formal organizational arrangement among rural health care providers (and possibly insurers and social service providers) that uses the resources of more than one existing organization and specifies the objectives and methods by which various collaborative functions are achieved.” Rural health networks are designed to respond to an unmet community need and provide benefits to both network partners and the community served by the network in a collaborative or integrative matter. Rural health care providers and rural communities have a plethora of stories relating to how networks have provided substantial benefit in the form of cost savings, implementation of electronic health records, integration of behavioral health care in primary care settings, and a multitude of other healthrelated projects. Yet, there is very little evidence-based data to support the claim that networks can and have improved the rural health care system, which limits the duplication of many of these rural health network projects. The RHND Program was initially created in the late 1990s in response to modifications to the health care delivery system that directly impacted rural providers. During that era, changes were being made to the underlying system of health care financing and delivery, including: a move from fee-for-service payments to capitation and other risk-sharing payment methods; the implementation of market-based strategies for containing costs; an increase in integrated health care organizations; and a move toward more managed care. Rural stakeholders were concerned that the shift to more managed costs would cause people to lose sight of the unique needs of rural patients and providers. Similarly, there are significant changes to our current health care environment, and rural communities and their providers will need to adapt to ensure adequate health services. The current changes that may affect rural health care providers and communities include: (1) improving the quality of care by focusing on patient value as opposed to patient volume;

Helping and hindering: Perceptions of enablers and barriers to collaboration within a rural South Australian mental health network

To evaluate clinicians' perceptions of what helps and hinders the delivery of mental health care across a service network in a rural setting. Qualitative, semistructured interviews were conducted with 10 individuals who work in one rural mental health care service network. A regional centre in rural South Australia involving representatives of the mental health team, general practice, hospital, community health and nongovernment organisations. Clinicians' perceptions of barriers and enablers to working within their mental health care network were explored. Participants showed a strong shared commitment to effective mental health care delivery and a good understanding of the services that each offers. Interview data suggested that working relationships between local services could be perceived as stronger when a personal or historical element is recognisable. Similarly, the notion of familiarity and community involvement were perceived as facilitators in this network. A perceived barrier for participants was the failure to attract staff with mental health experience, leading to dependence upon the dedication and commitment of existing service providers. Collaboration is especially necessary in rural areas, where access to health care services is known to be difficult. The informality of relationships between service providers was shown to be the main facilitator in the network. This is both a strength as it promotes the communication between services and service providers that is essential for successful collaboration, yet is also a threat to the sustainability of the network based on the difficulties of staff recruitment and retention to rural settings.

Clinical and economic results from a randomized trial of clinical decision support in a rural health network.

Replication studies evaluate technologies in usual use settings. We conducted a clinical trial to determine whether reductions in clinical and economic results observed in a previous study could be replicated in a larger setting. Subjects were randomized to receive intervention (email notifications for sentinel health events sent to their care managers) or control. The primary outcome was the rate of emergency department visits for low severity conditions. Secondary outcomes included: medical costs and other clinical event rates. We randomized 13,454 individuals (intervention, 6740; control, 6714). Subjects in both groups had similar rates of clinical events and medical costs. The use of email notifications to care managers was associated with no reductions in clinical events or medical costs.

Sustaining an Inclusive Trauma System in a Rural State

Different approaches exist for developing inclusive trauma systems with a regional system approach. The purpose of this article is to describe a sustainable and replicable structure for developing a trauma system with urban and rural environments. A relatively new trauma system is presented to show (1) how rural health networks and relationships can support rural trauma system development; (2) how partnerships help to support trauma system development; and (3) how the trauma system infrastructure has used assessment and assurance strategies to support regional systems of care to foster optimal care of the trauma patient.

University rural health clubs: nurturing the future Australian rural workforce

Australian university rural health clubs (RHC) are part of a national strategy to address the rural health workforce shortage. The student members of these clubs throughout Australia comprise the National Rural Health Network (NRHN). The NRHN is a multidisciplinary body representing medical, nursing and allied health students, aiming to increase the health workforce and health outcomes for rural and remote Australians. The NRHN and its constituent clubs run a variety of activities to promote rural careers to both school-aged and university students. These have included events at local, state and national levels. The purpose of the present article is to describe the roles and activities of RHC and the NRHN as they aim to contribute towards developing a sustainable rural workforce. Key features of RHC and the NRHN are: (1) providing positive rural experiences; (2) peer promotion of rural health; (3) personal and professional development; (4) providing a volunteer workforce for rural health initiatives; and (5) cross-disciplinary interaction. The NRHN is currently investigating methods to quantify the impact of the RHC on the career choices of potential rural health professionals. The NRHN and its constituent clubs are student-driven initiatives occupying a unique place in addressing the rural workforce shortage. Although little formal evidence exists for their success, the issues raised in this article illustrate their importance and broader benefits in this field.