Rural Health Workers Research Articles

Mobile Phone Support for Rural Health Workers in Nepal through ‘Celemedicine’

Globally, there is a shortage of health workers in rural areas. Effective health systems depend on having sufficient, accessible health workers with the right skills. In countries like Nepal, highly skilled health workers often prefer to work overseas or in urban centres, and therefore, in the short term, it may be pragmatic to focus on ensuring support and skills development of mid level or paramedical health workers. Information technology has the potential to support these health workers. We describe a pilot intervention undertaken in Gulmi District, whereby all mid level health workers in the district have been provided with a free phone number to call three General Practitioner Doctors (GPs) in the District Hospital. The intervention aims to increase appropriate referral, and increase connectivity between the District centre and peripheral health facilities. We hope that our intervention will provide support to rural health workers, and, if implemented as part of a package of interventions, may increase retention. We present some initial findings from discussions with health workers and analysis of call-log data, and describe our next phase evaluation and possible scale-up.

Causes of non-malarial fever in Laos: a prospective study

SummaryBackgroundBecause of reductions in the incidence of Plasmodium falciparum malaria in Laos, identification of the causes of fever in people without malaria, and discussion of the best empirical treatment options, are urgently needed. We aimed to identify the causes of non-malarial acute fever in patients in rural Laos.MethodsFor this prospective study, we recruited 1938 febrile patients, between May, 2008, and December, 2010, at Luang Namtha provincial hospital in northwest Laos (n=1390), and between September, 2008, and December, 2010, at Salavan provincial hospital in southern Laos (n=548). Eligible participants were aged 5–49 years with fever (≥38°C) lasting 8 days or less and were eligible for malaria testing by national guidelines.FindingsWith conservative definitions of cause, we assigned 799 (41%) patients a diagnosis. With exclusion of influenza, the top five diagnoses when only one aetiological agent per patient was identified were dengue (156 [8%] of 1927 patients), scrub typhus (122 [7%] of 1871), Japanese encephalitis virus (112 [6%] of 1924), leptospirosis (109 [6%] of 1934), and bacteraemia (43 [2%] of 1938). 115 (32%) of 358 patients at Luang Namtha hospital tested influenza PCR-positive between June and December, 2010, of which influenza B was the most frequently detected strain (n=121 [87%]). Disease frequency differed significantly between the two sites: Japanese encephalitis virus infection (p=0·04), typhoid (p=0·006), and leptospirosis (p=0·001) were more common at Luang Namtha, whereas dengue and malaria were more common at Salavan (all p<0·0001). With use of evidence from southeast Asia when possible, we estimated that azithromycin, doxycycline, ceftriaxone, and ofloxacin would have had significant efficacy for 258 (13%), 240 (12%), 154 (8%), and 41 (2%) of patients, respectively.InterpretationOur findings suggest that a wide range of treatable or preventable pathogens are implicated in non-malarial febrile illness in Laos. Empirical treatment with doxycycline for patients with undifferentiated fever and negative rapid diagnostic tests for malaria and dengue could be an appropriate strategy for rural health workers in Laos.FundingWellcome Trust, WHO–Western Pacific Region, Foundation for Innovative New Diagnostics, US Centers for Disease Control and Prevention.

Physicians as Advocates Oral Abstracts

Physicians as Advocates Oral Abstracts

“Quality of prenatal and maternal care: bridging the know-do gap” (QUALMAT study): an electronic clinical decision support system for rural Sub-Saharan Africa

BackgroundDespite strong efforts to improve maternal care, its quality remains deficient in many countries of Sub-Saharan Africa as persistently high maternal mortality rates testify. The QUALMAT study seeks to improve the performance and motivation of rural health workers and ultimately quality of primary maternal health care services in three African countries Burkina Faso, Ghana, and Tanzania. One major intervention is the introduction of a computerized Clinical Decision Support System (CDSS) for rural primary health care centers to be used by health care workers of different educational levels.MethodsA stand-alone, java-based software, able to run on any standard hardware, was developed based on assessment of the health care situation in the involved countries. The software scope was defined and the final software was programmed under consideration of test experiences. Knowledge for the decision support derived from the World Health Organization (WHO) guideline “Pregnancy, Childbirth, Postpartum and Newborn Care; A Guide for Essential Practice”.ResultsThe QUALMAT CDSS provides computerized guidance and clinical decision support for antenatal care, and care during delivery and up to 24 hours post delivery. The decision support is based on WHO guidelines and designed using three principles: (1) Guidance through routine actions in maternal and perinatal care, (2) integration of clinical data to detect situations of concern by algorithms, and (3) electronic tracking of peri- and postnatal activities. In addition, the tool facilitates patient management and is a source of training material. The implementation of the software, which is embedded in a set of interventions comprising the QUALMAT study, is subject to various research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users) and its health economic aspects. The software will also be assessed for its usability and acceptance, as well as for its influence on workflows in the rural setting of primary health care in the three countries involved.ConclusionThe development and implementation of a CDSS in rural primary health care centres presents challenges, which may be overcome with careful planning and involvement of future users at an early stage. A tailored software with stable functionality should offer perspectives to improve maternal care in resource-poor settings.Trial registrationhttp://www.clinicaltrials.gov/NCT01409824.

Motivating health workers for the provision of directly observed treatment to TB patients in rural China: does cash incentive work? A qualitative study

As a key component of DOTS (directly observed treatment, short course) strategy, DOT is essential in the prevention of drug-resistant tuberculosis. However, DOT had very poor implementation in rural areas of China. One major reason to this problem was the lack of incentives for DOT providers. In 2005, the Chinese Minister of Health released an incentive strategy that aimed to improve the DOT performance of rural health workers by providing allowances. Our study used a qualitative method to explore the practical impact of this incentive strategy in motivating rural DOT providers, and searched for other potential incentive measures as well. A total of 16 focus group discussions were carried out among 102 rural health workers in eight counties of China. A semi-structured theme outline was used to collect the perception, attitude and experiences of health workers toward the DOT implementation as well as the cash incentive strategy. Findings showed that DOT allowance had some incentive effect to DOT providers, but its extent was circumscribed by the small amount and operational problems. Raising DOT allowance and removing existing barriers to DOT provision might result in a greater motivational impact, particularly in less developed areas of China, where health workers were more likely to encounter financial and other obstacles in delivering DOT services to TB patients in rural areas.

The Lancet Global Health: a call for papers

The Lancet, we hope, is at least partly known for being committed to supporting global health research and policy. Publication last year of a series of colossal research papers on the global burden of disease was just one example of our enthusiasm. But there is another side to global health—the work of researchers in low-income and middle-income countries who address urgent domestic concerns that don't always make it onto the front pages of general medical journals. The treatment of a little-known yet devastating childhood infection in Papua New Guinea; the delivery of antiretroviral treatment by nurses in South Africa; diabetes case management by rural health workers in Iran. All these research topics, and more, deserve high-profile dissemination.

Measuring health workers’ motivation in rural health facilities: baseline results from three study districts in Zambia

IntroductionHealth worker motivation can potentially affect the provision of health services. Low morale among the workforce can undermine the quality of service provision and drive workers away from the profession. While the presence of high-quality, motivated staff is a key aspect of health system performance, it is also one of the most difficult factors to measure.MethodsWe assessed health worker motivation as part of the baseline assessment for a health system strengthening intervention in three rural districts in Zambia. The intervention (Better Health Outcomes Through Mentoring and Assessment (BHOMA)) aims to increase health worker motivation through training, mentoring and support. We assessed motivation by examining underlying issues grouped around relevant outcome constructs such as job satisfaction, general motivation, burnout, organization commitment, conscientiousness and timeliness that collectively measure overall levels of motivation. The tools and the concepts have been used in high-income countries and they were recently applied in African settings to measure health worker motivation.ResultsFemale participants had the highest motivation scores (female: mean 78.5 (SD 7.8) vs male: mean (SD 7.0)). By type of worker, nurses had the highest scores while environmental health technicians had the lowest score (77.4 (SD 7.8 vs 73.2 (SD 9.3)). Health workers who had been in post longer also had higher scores (>7 months). Health workers who had received some form of training in the preceding 12 months were more likely to have a higher score; this was also true for those older than 40 years when compared to those less than 40 years of age. The highest score values were noted in conscientiousness and timeliness, with all districts scoring above 80.ConclusionsThis study evaluated motivation among rural health workers using a simple adapted tool to measure the concept of motivation. Results showed variation in motivation score by sex, type of health worker, training and time in post. Further research is needed to establish why these health worker attributes were associated with motivation and whether health system interventions targeting health workers, such as the current intervention, could influence health worker motivation.

Febrile illness management in children under five years of age: a qualitative pilot study on primary health care workers’ practices in Zanzibar

BackgroundIn Zanzibar, malaria prevalence dropped substantially in the last decade and presently most febrile patients seen in primary health care facilities (PHCF) test negative for malaria. The availability of rapid diagnostic tests (RDTs) allows rural health workers to reliably rule out malaria in fever patients. However, additional diagnostic tools to identify alternative fever causes are scarce, often leaving RDT-negative patients without a clear diagnosis and management plan. This pilot study aimed to explore health workers’ practices with febrile children and identify factors influencing their diagnostic and management decisions in non-malarial fever patients.MethodsSemi-structured key informant interviews were conducted with 12 health workers in six PHCFs in North A district, Zanzibar, April to June 2011. Interviews were coded using Atlas.ti to identify emerging themes that play a role in the diagnosis and management of febrile children.ResultsThe following themes were identified: 1) health workers use caregivers’ history of illness and RDT results for initial diagnostic and management decisions, but suggest caregivers need more education to prevent late presentation and poor health outcomes; 2) there is uncertainty regarding viral versus bacterial illness and health workers feel additional point-of-care diagnostic tests would help with differential diagnoses; 3) stock-outs of medications and limited caregivers’ resources are barriers to delivering good care; 4) training, short courses and participation in research as well as; 5) weather also influences diagnostic decision-making.ConclusionsThis pilot study found that health workers in Zanzibar use caregiver history of fever and results of malaria RDTs to guide management of febrile children. However, since most febrile children test negative for malaria, health workers believe additional training and point-of-care tests would improve their ability to diagnose and manage non-malarial fevers. Educating caregivers on signs and symptoms of febrile illness, as well as the introduction of additional tests to differentiate between viral and bacterial illness, would be important steps to get children to PHCFs earlier and decrease unnecessary antibiotic prescribing without compromising patient safety. More research is needed to expand an understanding of what would improve fever management in other resource-limited settings with decreasing malaria.

Intensive Play Therapy Training for Rural Mental Health Counselors

Play therapy can be an effective, integrative, and best practices intervention for work with children and families. Although play therapy is becoming a significant part of counselor education training programs, many real-world practitioners have not had training and cannot access continuing education. This lack of training access is particularly evident in rural settings. This brief study demonstrates that an intense play therapy workshop for rural mental health workers can have a significant impact on the knowledge and skills of the counseling professionals. Following a 2-day play therapy training session specifically designed for mental health professionals in rural areas, the levels of play therapy knowledge and skills showed statistically significant increases from pretraining to the end of the second day. The findings show that an intense play therapy workshop for rural mental health workers can have a significant impact on the knowledge and skills in play therapy.

'It's the sense of responsibility that keeps you going': stories and experiences of participation from rural community health workers in Guatemala.

BackgroundIn 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.MethodsThis study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.ResultsWe found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.ConclusionAttention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.

Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers

Since 2007, Townsville Cancer Centre (Queensland, Australia) has provided routine and urgent medical oncology services to rural and remote communities through videoconferencing. At remote sites, patients were accompanied by doctors and other health workers. The aim of this study was to describe satisfaction of patients and rural health workers with this model of teleoncology. Between May 2007 and June 2010, 55 videoconferencing patients were invited to participate in a questionnaire-based telephone survey after informed consent. The survey included responses to 16 satisfaction statements using a 5-point Likert scale. Perspectives of health workers involved were recorded using open-ended questions on six themes related to telehealth. Among the 50 participating cancer patients, median age was 56 years (range 28-83). Seventy-six per cent of patients thought specialist physical examination was important despite local doctors performing it. Seventy-six per cent of patients felt the presence of accompanying local health workers was not important. Seventy-eight per cent of patients preferred to be seen in Mt Isa for the first consultation through videoconferencing than travelling to Townsville. More than 80% of patients were in agreement with the rest of the satisfaction statements. Ninety-six per cent of patients were in agreement with the question relating to overall satisfaction. Eighteen health workers participated and their responses and attitudes were favourable towards telehealth. Satisfaction with this model of care was proven to be high among both patients and health workers. Benefits perceived included effective communication between patients and specialists, reduced travel time and money expenditure, and superior specialist support for rural health workers.

Rural health workers and their work environment: the role of inter-personal factors on job satisfaction of nurses in rural Papua New Guinea.

BackgroundJob satisfaction is an important focal attitude towards work. Understanding factors that relate to job satisfaction allows interventions to be developed to enhance work performance. Most research on job satisfaction among nurses has been conducted in acute care settings in industrialized countries. Factors that relate to rural nurses are different. This study examined inter-personal, intra-personal and extra-personal factors that influence job satisfaction among rural primary care nurses in a Low and Middle Income country (LMIC), Papua New Guinea.MethodsData was collected using self administered questionnaire from rural nurses attending a training program from 15 of the 20 provinces. Results of a total of 344 nurses were available for analysis. A measure of overall job satisfaction and measures for facets of job satisfaction was developed in the study based on literature and a qualitative study. Multi-variate analysis was used to test prediction models.ResultsThere was significant difference in the level of job satisfaction by age and years in the profession. Higher levels of overall job satisfaction and intrinsic satisfaction were seen in nurses employed by Church facilities compared to government facilities (P <0.01). Ownership of facility, work climate, supervisory support and community support predicted 35% (R2 =0.35) of the variation in job satisfaction. The factors contributing most were work climate (17%) and supervisory support (10%). None of these factors were predictive of an intention to leave.ConclusionsThis study provides empirical evidence that inter-personal relationships: work climate and supportive supervision are the most important influences of job satisfaction for rural nurses in a LMIC. These findings highlight that the provision of a conducive environment requires attention to human relations aspects. For PNG this is very important as this critical cadre provide the frontline of primary health care for more than 70% of the population of the country. Many LMIC are focusing on rural health, with most of the attention given to aspects of workforce numbers and distribution. Much less attention is given to improving the aspects of the working environment that enhances intrinsic satisfaction and work climate for rural health workers who are currently in place if they are to be satisfied in their job and productive.

Sana: democratizing access to quality healthcare using an open mhealth architecture

Introduction: Sana is a cell phone-facilitated clinical information system that connects community health workers and medical specialists, to improve screening and diagnostics in resource-constrained settings. Aims and objectives: The platform allows the transmission of any type of medical data—text, audio, video or photo—from a rural health worker to a remote medical specialist for real-time decision support, and for incorporation into an electronic medical record in order to facilitate care, quality control and allow statistical analysis. By functioning as a portable medical record, Sana also offers the ability to track patients more easily. The point-of-care platform is open source and customizable, allowing doctors to encode new assessments onto smart-phones for a specific application, or to use existing ones. The Sana team partners with universities, social enterprises, governments, NGOs and health organizations in resource-poor countries to assist with implementations of the Sana platform. There are currently eight deployments of Sana in Brazil, Greece, India, the Philippines, Swaziland and Zimbabwe, covering a range of clinical areas. Results: One of the most urgent problems in resource-poor areas of the world is a shortage of doctors, and especially medical specialists. The biggest implementation of the Sana platform so far has been for the early detection of oral cancer in rural south India. It enables frontline community health workers to screen for precancerous and cancerous lesions by using Sana’s clinical decision support tools in dental hospitals and primary health clinics. Diagnosing oral cancer lesions at an early stage can reduce morbidity, mortality and cost of treatment. Screening processes also increase awareness of risk factors for oral cancer among the population, such as smoking and betel nut chewing. The solution was first implemented in June 2010 and more local health workers and support staff were brought on board in February 2011. By August 2010, up to 6000 people had been screened for oral cancer in the state of Karnataka. 300 patients were identified as high risk and their clinical data, including a photo of the inside of their mouth, were reviewed by an oral cancer specialist at a large tertiary care centre. The plan over the next year is to scale the project to screen one and a half million people in the province of Karnataka. The developed world, meanwhile, is facing a crisis of an ageing population and a growing burden of chronic disease. In Greece, Sana has been deployed to treat one of the complications of a chronic disease, diabetes. Diabetes continues to be the most common underlying cause of nontraumatic lower extremity amputations, mainly due to foot ulcerations. Sana has developed a mobile health platform for diabetic foot tele-health and a pilot clinical trial to evaluate it is under development in Central Greece. The patients are offered

Health workers’ capacity of infectious disease reporting in rural Jiangxi Province, China

Background: A nationwide web-based case reporting system for notifiable infectious disease has been established in China after SARS outbreak. The effectiveness of this system depends majorly on health workers’ capacity of identifying and awareness of reporting infectious cases. Methods: Two counties in Jiangxi Province were purposively selected as study sites. All the clinic doctors from township hospitals and village health stations at the study sites were chosen as subjects. Self-designed questionnaires were applied to collect information on their knowledge and experiences of infectious disease surveillance. Hardware conditions and laboratory equipments of all healthcare institutions at the study sites were investigated as well. Totally 79 township doctors and 355 village doctors from 392 healthcare institutions were investigated in October, 2010. Results: Village health stations had no equipment for laboratory test, and only a part of township hospitals had the ability to carry out blood test (73.0%), urine test (78.4%), liver function test (35.1%), hepatitis B test (51.4%) and renal function test (27.0%). For common infectious diseases like tuberculosis, influenza, hepatitis A&B and infectious diarrhea, most township and village doctors were able to identify their main symptoms, but when came to less common infectious diseases, a considerable part of doctors failed to report the main symptoms due to limited knowledge and experience, including plague (73.3%), cholera (42.5%), rabies (47.3%), schistosomiasis (48.0%), malaria (31.4%) and epidemic hemorrhagic fever (21.0%). Although 100% township hospitals and 81.6% village health stations had at least one computer for daily work, doctors used paper-based outpatient log to record patients’ demographic, clinical and treatment information. Based on their self-reporting, only 80.2% doctors kept a complete record of each visiting patient on the outpatient log, which constituted the source data for national surveillance system. Conclusion: Mainly relying on clinical diagnosis, doctors may not have sufficient capacity in identifying less common infectious diseases. Incomplete outpatient log recording could jeopardize the quality of surveillance data and case tracing in an outbreak. Training on infectious disease surveillance should be strengthened among rural health workers. The study is part of a big project-ISSC financially supported by a grant under the European Union Framework Program 7 (project no: 241900).

Attitudes of Physicians, Patients, and Village Health Workers Toward Glaucoma and Diabetic Retinopathy in Rural China

OBJECTIVE To understand the knowledge and attitudes of rural Chinese physicians, patients, and village health workers (VHWs) toward diabetic eye disease and glaucoma. METHODS Focus groups for each of the 3 stakeholders were conducted in 3 counties (9 groups). The focus groups were recorded, transcribed, and coded using specialized software. Responses to questions about barriers to compliance and interventions to remove these barriers were also ranked and scored. RESULTS Among 22 physicians, 23 patients, and 25 VHWs, knowledge about diabetic eye disease was generally good, but physicians and patients understood glaucoma only as an acutely symptomatic disease of relatively low prevalence. Physicians did not favor routine pupillary dilation to detect asymptomatic disease, expressing concerns about workflow and danger and inconvenience to patients. Providers believed that cost was the main barrier to patient compliance, whereas patients ranked poorly trained physicians as more important. All 3 stakeholder groups ranked financial interventions to improve compliance (eg, direct payment, lotteries, and contracts) low and preferred patient education and telephone contact by nurses. All the groups somewhat doubted the ability of VHWs to screen for eye disease accurately, but patients were generally willing to pay for VHW screening. The VHWs were uncertain about the value of eye care training but might accept it if accompanied by equipment. They did not rank payment for screening services as important. CONCLUSIONS Misconceptions about glaucoma's asymptomatic nature and an unwillingness to routinely examine asymptomatic patients must be addressed in training programs. Home contact by nurses and patient education may be the most appropriate interventions to improve compliance.

Listening to the rural health workers in Papua New Guinea – The social factors that influence their motivation to work

Despite rural health services being situated and integrated within communities in which people work and live, the complex interaction of the social environment on health worker motivation and performance in Low Middle Income Countries has been neglected in research. In this article we investigate how social factors impact on health worker motivation and performance in rural health services in Papua New Guinea (PNG). Face-to-face in-depth interviews were conducted with 33 health workers from three provinces (Central, Madang, and Milne Bay) in PNG between August and November 2009. They included health extension officers, community health workers and nursing officers, some of whom were in charge of the health centres. The health centres were a selection across church based, government and private enterprise health facilities. Qualitative analysis identified the key social factors impacting on health worker motivation and performance to be the local community context, gender roles and family related issues, safety and security and health beliefs and attitudes of patients and community members. Our study identified the importance of strong supportive communities on health worker motivation. These findings have implications for developing sustainable strategies for motivation and performance enhancement of rural health workers in resource poor settings.

Obstacles to Obtaining Optimal Physiotherapy Services in a Rural Community in Southeastern Nigeria

Background. Many people continue to live with physical disabilities across the globe, especially in rural Africa despite expertise of Physiotherapists and available evidence of effectiveness of Physiotherapy. Objective. To determine the obstacles to obtaining Optimal Physiotherapy services in a rural community in Southeastern Nigeria. Methods. Population-based cross-sectional study of individuals and health facilities in a rural community in Southeastern Nigeria. Results. The obstacles to obtaining optimal physiotherapy services in this community were unavailability of physiotherapy services, poor knowledge of health workers and community dwellers of the roles and scope of physiotherapy, poor health care seeking behavior of community dwellers, patronage of traditional health workers, and poor referral practices by health workers. Conclusion. Rural health workers in Nkanu West Local Government and other rural communities in Nigeria and Africa should be educated on the roles and scope of physiotherapy. There is a need for raising awareness of the management options for movement/functional problems for rural indigenous communities in Nigeria in particular and Africa in general. Physiotherapists should be made aware of the growing need for physiotherapy in rural areas of Nigeria and Africa largely comprising of the elderly.

Text messaging to improve adherence to malaria guidelines

The massive increase in funding for malaria control in the past decade1 has led to a sharp rise in the procurement of artemisinin combination therapies (ACTs)-the recommended first-line treatment for uncomplicated Plasmodium falciparum malaria. However availability of these life-saving drugs varies between countries and positive health outcomes need not only ACTs to be available at all levels of the health-care system but also health workers to prescribe them according to national guidelines and patients to adhere to their treatment regimens. In The Lancet Dejan Zurovac and colleagues4 present encouraging results from a randomised controlled trial in Kenya that used mobile-phone text messaging to remind health workers to adhere to national treatment guidelines. Results from the trial which included 107 health facilities showed that text-message reminders improved ACT case-management practices by 23.7 percentage-points (95% CI 7.6-40.0; p=0.004) immediately after intervention and by 24.5 percentage-points (8.1-41.0; p=0.003) 6 months later. The recorded increases in the proportion of patients who received their first dose of ACT at a health facility and of those counselled on how to take the rest of their course are likely to have resulted in subsequent increases in patients adherence to treatment. Preliminary cost analysis suggests that this intervention would be cheap and easy to scale up nationally. Experience has shown that adherence to treatment guidelines is often low.6 Widely recommended strategies including training of health-care providers (often through a cascade training-of-trainers model) the use of guidelines and job aids and supportive supervision have been shown to improve adherence in many cases. Overall however results often remain suboptimal even after implementation of these interventions. In Uganda training across the country in the integrated management of childhood illness improved case management for malaria but resulted in only about half of children being correctly treated. An investigation in Kenya found that half of interviewed rural health workers reported receiving inaccurate messages during their training that could have encouraged them not to adhere to actual guidelines. The results of the study by Zurovac and colleagues suggest another potential way to improve the proportion of patients who are appropriately managed. As with other training initiatives health workers who received text messages did not perform perfectly. At the end of the study the improvement in correct management of patients-although impressive-resulted in only 51% of patients being managed according to guidelines. Nevertheless the low cost of mobile phone reminders needed to achieve this gain suggests that it could provide an evidence-based solution to complement the gains that can be achieved through more traditional interventions. Such cost-effective solutions could prove even more vital as guidelines begin to shift to recommend parasitological diagnosis of malaria rather than presumptive treatment. In 2010 WHO changed its guidelines to recommend that all cases be parasito-logically confirmed but health-worker adherence to such confirmation with results of diagnostic tests has been shown to be poor. Simple means by which adherence to these more complex guidelines can be improved will thus be crucial and additional studies especially in endemic settings with a low prevalence of malaria will be important to ensure that only positive cases receive treatment. Additionally it might be possible to expand such a system to the informal sector in which the introduction of subsidised ACTs has led to renewed discussion of the need to enhance diagnosis even in informal outlets where many individuals seek treatment for malaria. With funding commitments for malaria programmes now stagnating after years of rapid increase donors are increasingly looking for solutions to ensure that the interventions they fund provide the best possible value for money. Although careful cost-effectiveness analyses of strategies to improve the performance of health-care providers are scarce a comprehensive review6 has previously suggested that a combination of interventions will most likely be needed to improve adherence to national guidelines to acceptable levels. Zurovac and colleagues provide strong evidence that text-message reminders can be an effective low-cost component of such a package; rigorous assessment of how additional interventions-both traditional and innovative-can be combined with these efforts will be needed to achieve maximum effect and ensure that donors are aware of the value of continued investment in such strategies. We declare that we have no conflicts of interest.

Mandatory rural service for health care workers in Thailand

Throughout its history, the main problem for Thailand's health system in has been an inadequate number of physicians and other healthcare workers in rural areas. Due to this, for decades in Thailand, rural service has been mandatory for healthcare workers. Thailand's mandatory health service system commenced in 1889 and has been continuous until the present (2010). Under this system, all early-career health workers from public professional schools serve in rural areas as a governmental worker to maintain the rural health workforce. The system has ameliorated the shortage of physicians in rural areas by substantially decreasing the emigration of Thai physicians to foreign countries. Recently, an increasing number of healthcare workers have been streamed from mandatory rural service to urban private hospitals, leaving the mandatory rural service system at risk. This has led to a deterioration of shortage of rural healthcare workers. A number of strategies have been implemented in an attempt to solve this problem, such as one-year rural service prerequisite for specialist training for all new medical graduates; a special program in medical schools to produce rural physicians; setting a special salary rate for rural physicians; and founding new medical schools in rural areas. Thai mandatory rural health service has succeeded in ameliorating the shortage of rural health workers although it has its own limitations and problems. In order to maintain effectiveness, the system requires continuous amendments in response to rapid changes in the medical and economic landscape in Thailand.

Beyond 50. challenges at work for older nurses and allied health workers in rural Australia: a thematic analysis of focus group discussions

BackgroundThe health workforce in Australia is ageing, particularly in rural areas, where this change will have the most immediate implications for health care delivery and workforce needs. In rural areas, the sustainability of health services will be dependent upon nurses and allied health workers being willing to work beyond middle age, yet the particular challenges for older health workers in rural Australia are not well known. The purpose of this research was to identify aspects of work that have become more difficult for rural health workers as they have become older; and the age-related changes and exacerbating factors that contribute to these difficulties. Findings will support efforts to make workplaces more 'user-friendly' for older health workers.MethodsNurses and allied health workers aged 50 years and over were invited to attend one of six local workshops held in the Hunter New England region of NSW, Australia. This qualitative action research project used a focus group methodology and thematic content analysis to identify and interpret issues arising from workshop discussions.ResultsEighty older health workers from a range of disciplines attended the workshops. Tasks and aspects of work that have become more difficult for older health workers in hospital settings, include reading labels and administering medications; hearing patients and colleagues; manual handling; particular movements and postures; shift work; delivery of babies; patient exercises and suturing. In community settings, difficulties relate to vehicle use and home visiting. Significant issues across settings include ongoing education, work with computers and general fatigue. Wider personal challenges include coping with change, balancing work-life commitments, dealing with attachments and meeting goals and expectations. Work and age-related factors that exacerbate difficulties include vision and hearing deficits, increasing tiredness, more complex professional roles and a sense of not being valued in the context of greater perceived workload.ConclusionsOlder health workers are managing a range of issues, on top of the general challenges of rural practice. Personal health, wellbeing and other realms of life appear to take on increasing importance for older health workers when faced with increasing difficulties at work. Solutions need to address difficulties at personal, workplace and system wide levels.