Rural Health Promotion Research Articles

A rural dental health promotion plan in Japan: An interim evaluation of dental health in the Nagano Prefecture health promotion movement “Health Grade Up NAGANO 21”

A rural dental health promotion plan in Japan: An interim evaluation of dental health in the Nagano Prefecture health promotion movement “Health Grade Up NAGANO 21”

A rural dental health promotion plan in Japan: An interim evaluation of dental health in the Nagano Prefecture health promotion movement “Health Grade Up NAGANO 21”

The Nagano Prefecture health promotion program “Health Grade Up Nagano 21” contains specific goals for dental health. These goals were evaluated in 2004, the middle the health promotion project period. Concerning the program's main goals, the proportion of 3-year-old children without caries of deciduous teeth improved from 63.6% (baseline) to 71.4% in 2004. DMFT index at 12 years old fell from 2.3 (baseline) to 1.6 in 2004. Thus, the main targets generally improved, although certain areas require further improvement. For infants, we strongly advocate that parents refrain from giving sugary foods between meals. For school-aged children, it is necessary to provide personal guidance about how to clean the teeth and oral cavity and to stress the importance of the fluoride application program. For adults, we need to further encourage periodic dental health check-ups, and it is also necessary to cooperate with industrial health programs on this matter. It is important for us to develop a plan to improve these areas.

Variations in perceptions of urban and rural health promotion competencies

Issue addressed: To identify perceptions of essential competencies by rural and urban-based health promotion practitioners. Methods: Data were collected using two rounds of a Delphi to rank competencies as either not relevant, a specific competency relevant to some but not all health promotion practitioners, a desirable or essential competency. The sample consisted of members of the Australian Health Promotion Association (AHPA) and the Public Health Association of Australia (PHAA) Special Interest Group in health promotion. A snowballing technique was also used to increase rural representation. Results: Two rounds of the Delphi resulted in 207 duplicate responses, 148 (72%) urban and 57 (27%) rural. Rural practitioners were significantly more likely to perceive the skills required to implement health promotion strategies as essential (t=-2.4, p=0.015). Statistically significant competencies in rural areas included media skills, research/evaluation skills and use of information technology. Conclusions: There are some significant variations in the perceived essential competencies required by rural health promotion practitioners. (author abstract)

Health promotion in communities: holistic and wellness approaches

Part 1 Theory and concepts: a model for health and wellness promotion in the communities health promotion with changing and vulnerable populations. Part 2 Developing programmes in the community: community self-assessment principles of planning effective community health programmes community mobilization marketing community health promotion programmes evaluating community health programmes health promotion in rural settings health promotion on the Internet. Part 3 Strategies for wellness: wellness nutrition fitness and flexible movement communicable disease - promoting community resiliency stress management smoking cessation violence prevention skills environmental wellness complementary health care practices. Part 4 Interaction skills: advanced communication skills with individuals and groups working with groups working with families. Part 5 Health promotion in cultural context: health promotion with African American women establishing a lay health promotion programme in a Hispanic community working with elderly diabetics in a Hawaiian community parish nursing. Part 6 Lessons from sample health promotion programmes: conducting a survey - the example of a youth service organization violence prevention in schools - a model violence prevention centre evaluating small community-based health promotion programmes - lessons learned from Colorado health promotion initiatives health promotion in a homeless centre.

Effects of hormone replacement therapy on C-reactive protein levels in healthy postmenopausal women: comparison between oral and transdermal administration of estrogen

C-reactive protein, an acute phase reactant, is a sensitive marker of inflammation ( 1 Ridker P.M. Haughie P. Prospective studies of C-reactive protein as a risk factor for cardiovascular disease. J Invest Med. 1988; 46: 391-395 Google Scholar ). High plasma levels of C-reactive protein are associated with an increased risk of myocardial infarction and stroke among apparently healthy subjects, as well as among those at higher risk because of age, smoking, or previous coronary artery disease, and are useful in cardiovascular risk stratification ( 2 Ridker P.M. Cushman M. Stampher M.J. et al. Inflammation, aspirin, and risks of cardiovascular disease in apparently healthy men. N Engl J Med. 1997; 336: 973-979 Crossref PubMed Scopus (4851) Google Scholar , 3 Ridker P.M. Buring J.E. Shih J. et al. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation. 1998; 98: 731-733 Crossref PubMed Scopus (1444) Google Scholar , 4 Tracy R.P. Lemaitre R.N. Psaty B.M. et al. Relationship of C-reactive protein to risk of cardiovascular disease in the elderly results from the Cardiovascular Health Study and the Rural Health Promotion Project. Arterioscler Thromb Vasc Biol. 1997; 17: 1121-1127 Crossref PubMed Scopus (765) Google Scholar , 5 Kuller L.H. Tracy R.P. Shaten J. et al. MRFIT Research GroupRelationship of C-reactive protein and coronary heart disease in the MRFIT nested case-control study. Am J Epidemiol. 1996; 144: 537-547 Crossref PubMed Scopus (989) Google Scholar , 6 Haverkate F. Thompson S.G. Pyke S.D.M. et al. for the European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group. Production of C-reactive protein and risk of coronary events in stable and unstable angina. Lancet. 1997; 349: 462-466 Abstract Full Text Full Text PDF PubMed Scopus (1403) Google Scholar , 7 Ridker P.M. Rifai N. Pfeffer M.A. et al. for the Cholesterol And Recurrent Events (CARE) Investigators. Inflammation, pravastatin, and the risk of coronary events after myocardial infarction in patients with average cholesterol levels. Circulation. 1998; 98: 839-844 Crossref PubMed Scopus (1273) Google Scholar , 8 Liuzzo G. Biasucci L.M. Gallimore J.R. et al. The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina. N Engl J Med. 1994; 331: 417-424 Crossref PubMed Scopus (2088) Google Scholar , 9 Ridker P.M. Glynn R.J. Hennekens C.H. C-reactive protein adds to the predictive value of total and HDL cholesterol in determining risk of first myocardial infarction. Circulation. 1998; 97: 2007-2011 Crossref PubMed Scopus (882) Google Scholar , 10 Ridker P.M. Hennekens C.H. Buring J.E. Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000; 342: 836-843 Crossref PubMed Scopus (4968) Google Scholar ). Moreover, statins have been shown to lower C-reactive protein levels ( 11 Ridker P.M. Rifai N. Pfeffer M.A. et al. Long-term effects of pravastatin on plasma concentration of C-reactive protein. The Cholesterol And Recurrent Events (CARE) Investigators. Circulation. 1999; 100: 230-235 Crossref PubMed Scopus (1398) Google Scholar , 12 Ridker P.M. Rifai N. Clearfield M. et al. Air Force/Texas Coronary Atherosclerosis Prevention Study Investigators. Measurement of C-reactive protein for the targeting of statin therapy in the primary prevention of acute coronary events. N Engl J Med. 2001; 344: 2016-2018 Crossref PubMed Scopus (1460) Google Scholar ). In contrast, oral hormone replacement therapy appears to increase C-reactive protein levels ( 13 Cushman M. Legault C. Barrett-Connor E. et al. Effect of postmenopausal hormones on inflammation-sensitive proteins the Postmenopausal Estrogen/Progestin Interventions (PEPI) Study. Circulation. 1999; 100: 717-722 Crossref PubMed Scopus (621) Google Scholar , 14 Ridker P.M. Hennekens C.H. Rifai N. et al. Hormone replacement therapy and increased plasma concentration of C-reactive protein. Circulation. 1999; 100: 713-716 Crossref PubMed Scopus (424) Google Scholar , 15 Cushman M. Meilahn E.N. Psaty B.M. et al. Hormone replacement therapy, inflammation, and hemostasis in elderly women. Arterioscler Thromb Vasc Biol. 1999; 19: 893-899 Crossref PubMed Scopus (220) Google Scholar ). However, the effects of different hormonal preparations and their routes of administration are not known. We therefore compared the effects of oral estrogen and transdermal estradiol on C-reactive protein plasma levels in healthy postmenopausal women.

Challenges in evaluating rural health programs.

Complex community-based prevention programs are being held to scientific evidence of their effectiveness and rural public health departments that implement such programs often are not equipped to evaluate them. Rural public health departments are fettered by small budgets, small staffs, and less access to evaluation experts and similar resources. Community-based health promotion programs can include complex designs that may work differently in rural areas and evaluation of rural programs can be hampered by lack of control groups and the instability of results from small populations. The University of Kentucky has entered into a contract with the state Department for Public Health to implement an internal, participatory model of evaluation. In this model, the university evaluation expert trains local public health department staff in technical skills for program evaluation and acts as mentor and technical consultant to local public health departments on an ongoing basis. Through training and site visits, this model is one approach to addressing the challenges of evaluating rural health promotion programs.

Plasma concentration of C-reactive protein and risk of ischemic stroke and transient ischemic attack: the Framingham study.

The role of C-reactive protein (CRP) as a novel plasma marker of atherothrombotic disease is currently under investigation. Previous studies have mostly related CRP to coronary heart disease, were often restricted to a case-control design, and failed to include pertinent risk factors to evaluate the joint and net effect of CRP on the outcome. We related plasma CRP levels to incidence of first ischemic stroke or transient ischemic attack (TIA) in the Framingham Study original cohort. There were 591 men and 871 women free of stroke/TIA during their 1980 to 1982 clinic examinations, when their mean age was 69.7 years. CRP levels were measured by using an enzyme immunoassay on previously frozen serum samples. Analyses were based on sex-specific CRP quartiles. Risk ratios (RRs) were derived, and series of trend analyses were performed. During 12 to 14 years of follow-up, 196 ischemic strokes and TIAs occurred. Independent of age, men in the highest CRP quartile had 2 times the risk of ischemic stroke/TIA (RR=2.0, P=0.027), and women had almost 3 times the risk (RR=2.7, P=0.0003) compared with those in the lowest quartile. Assessment of the trend in risk across quartiles showed unadjusted risk increase for men (RR=1.347, P=0.0025) and women (RR=1.441, P=0.0001). After adjustment for smoking, total/HDL cholesterol, systolic blood pressure, and diabetes, the increase in risk across CRP quartiles remained statistically significant for both men (P=0.0365) and women (P=0.0084). Independent of other cardiovascular risk factors, elevated plasma CRP levels significantly predict the risk of future ischemic stroke and TIA in the elderly.

Proposed Cardiovascular Risk Assessment Algorithm Using High-Sensitivity C-Reactive Protein and Lipid Screening

Several prospective epidemiologic studies from the United States and Europe have demonstrated that high-sensitivity C-reactive protein (hs-CRP) is a predictor of future coronary events among apparently healthy men and women. For example, findings from the Multiple Risk Factors Intervention Trial demonstrated a correlation between hs-CRP and coronary heart disease mortality among male smokers followed over a 17-year period \[relative risk (RR) = 2.8; 95% confidence interval (CI), 1.4–5.4\] (1). A similar positive association between hs-CRP and future coronary events was noted in the Cardiovascular Health Study and Rural Health Promotion Project, which included elderly men and women with subclinical cardiovascular disease (2). A direct positive association between hs-CRP and future coronary events was also reported in apparently healthy men from the Physician’s Health Study (PHS); those in the highest quartile of hs-CRP had twice the risk of future stroke (RR = 1.9; 95% CI, 1.1–3.3), three times the risk of future myocardial infarction (RR = 2.9; 95% CI, 1.8–4.6), and four times the risk of future peripheral vascular disease (RR = 4.1; 95% CI, 1.2–6.0) (3)(4). Furthermore, both the MONICA-Augsburg cohort (5) and the Helsinki Heart Study (6) showed that compared with those with low hs-CRP, individuals with the highest hs-CRP concentrations were at approximately three times the risk of developing future coronary events. Finally, two reports from the Women’s Health Study (WHS) showed that hs-CRP is also a strong predictor of future cardiovascular events in women (RR = 4.4; 95% CI, 2.2–8.9) (7)(8). In fact, in that study, which directly compared several novel risk factors to standard lipid screening, hs-CRP was the single strongest predictor of future vascular risk …

A community needs assessment for rural mental health promotion.

This paper describes the needs assessment phase of a mental health promotion programme for rural communities in Ireland. As part of a larger study encompassing four rural communities, a cross-sectional study of the mental health beliefs and perceptions of 1014 people was carried out. Employing a combination of interviewer-administered questionnaire and the vignette method, the needs assessment explores the levels of awareness, current practices, attitudes and stigma concerning depression and suicide among a randomly selected quota sample of community members. Lower levels of awareness, less confidence in dealing with mental health issues, negative attitudes to help-seeking and social stigma emerge as particular issues for men and the under 40 age group. Women were found to have more positive attitudes generally, were more likely to use informal social support networks and were more open about discussing mental health matters. The predominant interpretation of the depression vignette was to view it as a mental health problem with good prospects for recovery given appropriate help. Social relationships, negative thinking patterns and social stresses were perceived as being particularly important in explaining the origins of depression. The implications of the findings for planning the intervention phase of the project are considered.

Getting it Together: A Rural Health Promotion Program

The Getting It Together Rural Health Promotion project was established by a group of community health providers in Gippsland, Victoria. The overall aim of Getting It Together was to extend and improve health promotion practice amongst participating organisations. This was achieved through collaboration around health promotion training and planning. Complementary strategies addressing Cardio-Vascular Disease (CVD) were developed across four Local Government Areas (LGAs). Central resourcing was provided for coordination of the project, and for marketing and network support tasks. The project was based on an integrated and coordinated health promotion model, which contained overlapping strategies combining to create a broadly based partnership of action. At the commencement of the project, health promotion workers from each LGA were provided with a three-day training course conducted by the Royal Melbourne Institute of Technology University (RMIT). Participants developed Action Plans based around the three driving strategies of community wide-strategies, targeted strategies and marketing. A special feature of Getting It Together was a common media strategy, to support and reinforce action at the local level. An overall slogan was adopted, 'Slicker Ticker - A Gippsland Healthy Heart Project'. Uniting themes included 'Stress Less Week' and 'Gippsland Get Up and Go'. Latrobe Community Health Service facilitated the project and senior managers from the partnering agencies formed a Steering Committee, which met at key intervals to monitor the project.

Prevalence and sociodemographic determinants of cardiovascular risk in a rural area.

Non-metropolitan areas have a higher mortality from cardiovascular disease than metropolitan areas. The study's aim was to establish the prevalence of cardiovascular disease risk factors in a rural area and identify their sociodemographic determinants. Adults, randomly selected from Ballarat's electoral rolls, were invited to complete a questionnaire and have their height, weight, blood pressure and fasting lipids measured. Three hundred and thirty-eight eligible persons participated (67% response). The data were analysed using logistic and multiple regression analyses. Increasing age was associated with hypertension, high plasma cholesterol, overweight/obesity, high plasma triglyceride levels and increasing plasma fibrinogen. Women were less likely to be overweight/obese and have a high plasma triglyceride. Not having completed high school was associated with hypertension, high plasma cholesterol and triglyceride levels and physical inactivity. Smoking was associated with employment and being in a non-professional/managerial occupation. Rural health promotion initiatives should take account of the needs of these population subgroups.

Relationship of C-reactive protein to risk of cardiovascular disease in the elderly. Results from the Cardiovascular Health Study and the Rural Health Promotion Project.

Markers of inflammation, such as C-reactive protein (CRP), are related to risk of cardiovascular disease (CVD) events in those with angina, but little is known about individuals without prevalent clinical CVD. We performed a prospective, nested case-control study in the Cardiovascular Health Study (CHS; 5201 healthy elderly men and women). Case subjects (n = 146 men and women with incident CVD events including angina, myocardial infarction, and death) and control subjects (n = 146) were matched on the basis of sex and the presence or absence of significant subclinical CVD at baseline (average follow-up, 2.4 years). In women but not men, the mean CRP level was higher for case subjects than for control subjects (P < or = .05). In general, CRP was higher in those with subclinical disease. Most of the association of CRP with female case subjects versus control subjects was in the subgroup with subclinical disease; 3.33 versus 1.90 mg/L, P < .05, adjusted for age and time of follow-up. Case-control differences were greatest when the time between baseline and the CVD event was shortest. The strongest associations were with myocardial infarction, and there was an overall odds ratio for incident myocardial infarction for men and women with subclinical disease (upper quartile versus lower three quartiles) of 2.67 (confidence interval [CI] = 1.04 to 6.81), with the relationship being stronger in women (4.50 [CI = 0.97 to 20.8]) than in men (1.75 [CI = 0.51 to 5.98]). We performed a similar study in the Rural Health Promotion Project, in which mean values of CRP were higher for female case subjects than for female control subjects, but no differences were apparent for men. Comparing the upper quintile with the lower four, the odds ratio for CVD case subjects was 2.7 (CI = 1.10 to 6.60). In conclusion, CRP was associated with incident events in the elderly, especially in those with subclinical disease at baseline.

Effectiveness of an Indonesian model for rapid training of Guatemalan health workers in diarrhea case management

The aim of this study was to assess the effectiveness of a newly developed method for rapid tiered training of health workers in improving community health worker knowledge and case management skills. The interactive "Kader" method, developed in West Java, Indonesia, was compared with traditional didactic training in a prospective trial with rural health workers ("Tecnicos") and village health promoters ("Promotores") for the Public Health Department in the state of Alta Verapaz, Guatemala. Twenty-five tecnicos received one day of training concerning diarrhea and dehydration. One group was trained using the interactive Kader method of Indonesia; the other with didactic methods. A sample of these tecnicos then trained 49 randomized promotores utilizing the same training method with which they were trained. The tecnicos and promotores in each group completed a case-based pre-test and post-test before and after their training sessions. Both tecnicos and promotores trained using the Kader tiered training approach demonstrated significantly greater improvement in their ability to correctly diagnose and recommend treatment for diarrhea of varying type and severity. Non-significant differences favoring the experimental groups were found in the tecnicos' and promotores' general knowledge regarding diarrhea prevention practices, signs of dehydration and preparation of oral rehydration solution. This pilot study suggests that the Kader method for rapid tiered training of health workers has applicability to the populations of other developing nations and can be recommended for large scale implementation and evaluation in the training of public health workers, village health promoters and families in Guatemala.

Selection bias and nonresponse to health promotion in older adults.

Some epidemiologic studies have compared the characteristics of individuals who participate, refuse, and are unreachable in population studies, but results have been inconsistent. The Rural Health Promotion Project attempted to recruit all Medicare Part B noninstitutionalized individuals age 65-79 years in a rural community for a trial of preventive health services. Of 962 potential subjects, 360 (37.4%) participated, 253 (26.3%) refused, 176 (18.3%) were ineligible, and 152 (15.8%) were never reached by phone or mail. Approximately 3 years later, we reinterviewed the participants, refusals, and as many of the unreachables as possible. The 3-year mortality was similar for both refusals and participants (approximately 9%) but was much higher for ineligibles (29.0%) and unreachables (23.7%). Participants were more likely to have disease history, to have behavioral risk factors for disease, and to use health screening services. Refusals were the healthiest and possibly chose not to participate because they did not have risk factors targeted by the program. The unreachables had the highest prevalence of disability and health care inpatient reimbursement and may have been ineligible for the demonstration had they volunteered. We conclude that failure to reach potential participants for health promotion services may be a warning of "high risk."

Health Promotion Cooperatives: An Alternative Delivery System for Rural Health Promotion Programs

Abstract Health Promotion increasingly is considered an essential component in the reduction of the primary causes of morbidity and mortality. In medically under served communities, especially rural regions in the western hemisphere, health promotion is an important strategy to improve health status and enable economic development. This article examines the networking strategy that was utilized to develop a rural health promotion cooperative in the southwestern portion of Ohio in the United States. Special emphasis will be given to the success of this strategy as a technique for introducing change and reducing resistance to prevention programs. The cooperative, which has been in existence since 1987, has conducted health promotion programs on tobacco reduction, alcohol education, and nutrition. The impact of these programs has been diffused in six rural counties within the region. In addition, this paper includes considerations of obstacles that were confronted, the rationale for the cooperative, adoption...

Rural hospital health promotion: programs, methods, resource limitations.

Most hospitals provide health promotion programs for community residents. There is little information concerning the specific types of services offered by rural hospitals. A questionnaire was sent to every acute care hospital in Iowa (N = 124), including 99 rural hospitals and 25 urban hospitals. Surveys were returned from 95 rural hospitals (96%) and 20 urban hospitals (80%). Results indicated that 98.9% of rural hospitals offered health promotion services to community residents. These services provided on average 7.5 programs on a regular basis, while using only 1.2 full-time equivalent (FTE) employees. Urban hospitals provided 9.5 regular programs with 2.4 FTE. The most common types of rural promotion programs were blood pressure screening, cholesterol screening, safety and protection programs, diet/nutrition programs, prenatal/maternal health, and breast cancer screening. Over 40% of rural respondents stated that other less common programs, including substance abuse prevention and mental health promotion, were needed but could not be offered because of resource limitations; these types of services were offered more commonly in urban hospitals. Rural hospital health promotion programs are attempting to meet a wide variety of programming needs with limited resources, and attention may be well directed towards finding how best to provide various programs with limited resources to maximize their impact on community health.

The impact of cancer screening promotion by rural hospitals on cancer detection.

Hospitals almost universally provide health promotion programs for community residents. There is a lack of evidence regarding these programs' impact on the detection or prevention of disease. The purpose of the present study was to determine whether rural hospital-based health promotion programs for cancer screening were associated with detection of greater numbers of cancer cases in the communities served by the hospitals over the years that the promotion programs were offered. Data were collected from a survey of 95 rural Iowa hospitals and from state health registry data on 1985-1990 cancer occurrence. Breast and colon cancer screening promotion programs were related to detection of greater numbers of cases, after controlling for population, age and sex. These findings often held for both less advanced and more advanced cancer stages. Promotion of cervical cancer screening was not related to number of cervical cancers detected. The finding that the relationship between screening promotion and cancer detection persists irrespective of stage may have important policy and programmatic implications.

Comparison of recruitment strategies and associated disease prevalence for health promotion in rural elderly

Background. Although interest in health promotion for the elderly is increasing, the issues of recruitment into such programs and self-selection have not been well explored. While clinical studies require high participation levels and expensive recruitment, community efforts are satisfied with recruiting small numbers of volunteers from poorly defined populations. These small samples may not be representative of the populations at risk. Methods. As part of the Rural Health Promotion Project, a Medicare demonstration, community-based recruitment methods were evaluated and participant characteristics were compared. A total of 3,884 individuals ages 65–79 were recruited in northwestern Pennsylvania, using four sequential recruitment strategies, varying in aggressiveness. The methods were: (A) mail only, (B) mail with phone recruitment follow-up, (C) mail with phone recruitment and scheduling, and (D) mail with aggressive phone recruitment and scheduling. Results. Recruitment yields were Method A, 13.5%; B, 21.1%; and C, 31.6%. The most aggressive Method (D) yielded 37.0% participation. More aggressive methods (C and D) recruited more educated individuals. No other demographic or health status differences were noted. Conclusion. These data show that large numbers of the elderly can be recruited into a health promotion program using aggressive methods and professional interviewers.

The relative influence of the community and the health system on work performance: A case study of community health workers in Colombia

A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to effective implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-related factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters ( N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system. Work performance was shown to be more strongly associated with feedback factors such as the perceived value community members place on HP activities and direct observations of health improvement, than with the supervisory feedback. Work performance was also more strongly associated with the perceived reward of having influence in the community than with rewards associated with the health system, working with other HPs, written commendation and salary. These results suggest that the CHW may have stronger links to, and dependency on, the community for rewards, feedback and motivation to perform than has generally been acknowledged. The authors suggest a health system participation model that would focus management support on the worker-community interface rather than the worker-health service interface. It is argued that if the national health system were to consciously promote and strengthen the relationship between the CHW and her community, this would positively affect performance of CHWs.

Health promotion for the rural elderly.

There has been increased interest in developing health promotion programs for the rural elderly as a means to foster successful aging. The present study describes one such program and identifies rural and urban differences in health promotion activities. Data come from the California Preventive Health Care for the Aging Program (PHCAP) which is one of the oldest and largest such programs in the United States. A sample of over 5,000 PHCAP clients was drawn from rural, semi-rural and urban projects. Though the rural and urban clients differed significantly with respect to demographic characteristics, differences in health promotion practices were relatively minor. However, the health promotion practices of semi-rural residents differed considerably from that in rural projects. Though less disabled, semi-rural clients received a greater scope of health promotion activities than rural clients. The authors discuss possible site, practitioner and client factors which may have accounted for rural health promotion activities being more restricted. Regardless of project site, the California PHCAP detected many health problems and a majority of clients were referred to other health professionals for treatment.