Rural Public Health Research Articles

Protocol: the complexity of informal caregiving for Alzheimer's disease and related dementias in rural South Africa.

With aging, many people develop Alzheimer's disease or related dementias (ADRD) as well as chronic physical health problems. The consequent care needs can be complicated, with heavy demands on families, households and communities, especially in resource-constrained settings with limited formal care services. However, research on ADRD caregiving is largely limited to primary caregivers and high-income countries. Our objectives are to analyse in a rural setting in South Africa: (1) how extended households provide care to people with ADRD; and (2) how the health and wellbeing of all caregivers are affected by care roles. The study will take place at the Agincourt health and socio-demographic surveillance system site of the MRC/Wits Rural Public Health and Health Transitions Research Unit in Mpumalanga Province, northeast South Africa. We will recruit 100 index individuals predicted to currently have ADRD or cognitive impairment using data from a recent dementia survey. Quantitative surveys will be conducted with each index person's nominated primary caregiver, all other household members aged over 12, and caregiving non-resident kin and non-kin to determine how care and health are patterned across household networks. Qualitative data will be generated through participant observation and in-depth interviews with caregivers, select community health workers and key informants. Combining epidemiological, demographic and anthropological methods, we will build a rich picture of households of people with ADRD, focused on caregiving demands and capacity, and of caregiving's effects on health. Our goal is to identify ways to mitigate the negative impacts of long-term informal caregiving for ADRD when formal supports are largely absent. We expect our findings to inform the development of locally relevant and community-oriented interventions to improve the health of caregivers and recipients, with implications for other resource-constrained settings in both higher- and lower-income countries.

Facilitators of Multisector Collaboration for Delivering Cancer Control Interventions in Rural Communities: A Descriptive Qualitative Study.

Purpose and ObjectivesMultisector collaboration is a widely promoted strategy to increase equitable availability, access, and use of healthy foods, safe places for physical activity, social supports, and preventive health care services. Yet fewer studies and resources exist for collaboration among governmental and nongovernmental agencies to address public problems in rural areas, despite an excess burden of risk factors for cancer morbidity and mortality. We aimed to learn about cancer prevention activities and collaboration facilitators among rural informal interagency networks.Evaluation MethodsIn 2020, researchers conducted semistructured interviews with staff from rural public health and social services agencies, community health centers, and extension offices. Agency staff were from 5 service areas across 27 rural counties in Missouri and Illinois with high poverty rates and excess cancer risks and mortality. We conducted a thematic analysis to code interview transcripts and identify key themes.ResultsExchanging information, cohosting annual or one-time events, and promoting other agencies’ services and programs were the most commonly described collaborative activities among the 32 participants interviewed. Participants indicated a desire to improve collaborations by writing more grants together to codevelop ongoing prevention programs and further share resources. Participants expressed needs to increase community outreach, improve referral systems, and expand screenings. We identified 5 facilitator themes: commitment to address community needs, mutual willingness to collaborate, long-standing relationships, smaller community structures, and necessity of leveraging limited resources. Challenges included lack of funding and time, long travel distances, competing priorities, difficulty replacing staff in remote communities, and jurisdictional boundaries. Although the COVID-19 pandemic further limited staff availability for collaboration, participants noted benefits of remote collaborative meetings.Implications for Public HealthRural areas need consistent funding and other resources to support health-improving multisector initiatives. Existing strengths found in the rural underresourced areas can facilitate multisector collaborations for cancer prevention, including long-standing relationships, small community structures, and the need to leverage limited resources.

Pharmaceutical care integration in rural public health districts

Pharmaceutical care integration in rural public health districts

Supporting rural public health practice to address local-level social determinants of health across Northwest states: Development of an interactive visualization dashboard

BackgroundRural local health departments (LHDs) lack adequate capacity and funding to effectively make data-driven decisions to support their communities that face greater health disparities compared to urban counterparts. The need, therefore, exists for informatics solutions to support rural LHDs. PurposeWe describe the user-centered design (UCD) of SHARE-NW: Solutions in Health Analytics for Rural Equity across the Northwest, a website (sharenw.nwcphp.org) with data visualization dashboards for rural LHD practitioners in Alaska, Idaho, Oregon, and Washington to help them identify health disparities in their jurisdictions. MethodsIn this UCD study guided by Munzner’s Nested Model for Visualization Design and Validation, we (1) completed a needs assessment, (2) created and evaluated mockups, and (3) conducted usability testing of a functional alpha testing website. Potential end-users (rural LHD practitioners) and Equity Advisory Committee members (public health experts from state, rural local, and tribal public health agencies) across our four-state catchment area were engaged throughout the website development and testing. We adapted traditional in-person UCD methods to be remote to reach participants across a large geographic area and in rural/frontier areas of Alaska, Idaho, Oregon, and Washington. ResultsWe recruited participants from all four states to engage in each stage of the project. Needs assessment findings informed the mockup development, and findings from the mockup evaluations informed the development of the functional website. Usability testing of the website overall was positive, with priority usability issues identified. ConclusionsBy applying Munzner’s Nested Model and UCD, we could purposefully and intentionally design evidence-based solutions, specifically for rural LHD practitioners. Adaptations of traditional UCD methods were successful and allowed us to reach end-users across a large geographic area. Future work on SHARE-NW will involve the evaluation of the website. We provide insights on our lessons learned to support future public health informatics solution development.

Perceptions of COVID-19 Mitigation Strategies between Rural and Non-Rural Adults in the US: How Public Health Nurses Can Fill the Gap.

The purpose of this study was to capture the perceptions of COVID-19 mitigations’ efficacy of rural and non-rural participants, using the health belief model (HBM), as well as to describe where public health nursing may be able to fill behavior gaps in rural communities. Rural and non-rural participants completed electronic surveys. Surveys collected demographic information and perceptions of various mitigation strategies’ effectiveness. Rurality was significantly associated with perceptions of the effectiveness of public health mitigation strategies including wearing facemasks, limiting time indoors, avoiding gatherings, non-essential business closure, and staying home. Our findings suggest people in rural areas perceive mitigations to be effective. Other researchers have consistently shown rural residents are least likely to partake in the same mitigations. Rural public health nurses on the front line serve as the key to closing the aforementioned gap. Understanding where their community’s perceptions lie is pivotal in creating educational programs to continue mitigation efforts as we embark on the second year of this pandemic.

What shapes research and research capacity building in rural health services? Context matters.

ObjectiveTo determine the contextual factors influencing research and research capacity building in rural health settings.DesignQualitative study using semi‐structured telephone interviews to collect data regarding health professionals’ research education and capacity building. Analysis involved inductive coding using Braun and Clark’s thematic analysis; and deductive mapping to the Consolidated Framework for Implementation Research (CFIR).SettingVictorian rural health services and university campuses.ParticipantsTwenty senior rural health managers, academics and/or research coordinators. Participants had at least three years’ experience in rural public health, health‐related research or health education settings.Main outcome measuresContextual factors influencing the operationalisation and prioritisation of research capacity building in rural health services.ResultsFindings reflected the CFIR domains and constructs: intervention characteristics (relative advantage); outer setting (cosmopolitanism, external policies and incentives); inner setting (implementation climate, readiness for implementation); characteristics of individuals (self‐efficacy); and process (planning, engaging). Findings illustrated the implementation context and the complex contextual tensions, which either prevent or enhance research capacity building in rural health services.ConclusionsRealising the Australian Government’s vision for improved health service provision and health outcomes in rural areas requires a strong culture of research and research capacity building in rural health services. Low levels of rural research funding, chronic workforce shortages and the tension between undertaking research and delivering health care, all significantly impact the operationalisation and prioritisation of research capacity building in rural health services. Effective policy and investment addressing these contextual factors is crucial for the success of research capacity building in rural health services.

Effectiveness of Supply Chain Planning in Ensuring Availability of CD/NCD Drugs in Non-Metropolitan and Rural Public Health System

Several studies have reported on the shortage of drugs with the changing demographic and disease profile, especially triggered by the growing burden of lifestyle diseases. However, very few have evaluated the demand-side challenges from the objective of universalisation of healthcare. Therefore, this study was designed to evaluate the factors that have impeded access to affordable generic and essential drugs in non-metropolitan urban and rural India. The study was conducted in six states and responses were elicited from a sample of doctors, pharmacists, nurses, accredited social health activist (ASHA) workers, state officials, warehouse managers and patients across the study states. The study reveals that while the acceptance of prescribing generic drugs has improved over the last decade, the use of branded drugs has been restricted only to complex cases or where generic drug efficacy has not been established. The centralised procurement efficiencies seem to have hit a plateau in terms of assuring drug availability to the last mile, thereby impacting local purchase, especially pandemic procurement. Most states have also established dedicated corporations for drug procurement, albeit at different levels of organisational maturity as far as adherence to the processes and systems are concerned. However, supply chain phenomena like the bullwhip effect gets accentuated given the levels of our public health system. Learnings from other consumer-facing sectors with similar challenges of increased variability and uncertainty are yet to be explored for the health sector to leapfrog towards achieving improved ‘drug availability’ or ‘zero stock-out’. Standardising drug categories, regular updating of the essential drug list (EDL) reflecting the demographic and disease profile, various practices like complete digitisation, rolling forecasts, stock-keeping unit rationalisation, flexible public procurement contracts, etc., have been explored as potential solutions in this paper. Creating a dedicated team of forecasters within the procurement organisations, well adept at using analytics, could be key to real-time demand estimation, paving the way for a quarterly rolling forecast to facilitate procurement using well-designed rate contracts with suppliers that captures variability in such rolling forecasts.

Prediction model using readily available clinical data for colorectal cancer in a chinese population

BackgroundIn China, health screening has become common, although colonoscopy is not always available or acceptable. We sought to develop a prediction model of colorectal cancer (CRC) for health screening population based on readily available clinical data to reduce labor and economic costs. MethodsWe conducted a cross-sectional study based on a health screening population in Karamay Central Hospital. By collecting clinical data and basic information from participants, we identified independent risk factors and established a prediction model of CRC. Internal and external validation, calibration plot, and decision curve analysis were employed to test discriminating ability, calibration ability, and clinical practicability. ResultsIndependent risk factors of CRC, which were readily available in primary public health institutions, included high-density lipoprotein cholesterol, male sex, total cholesterol, advanced age, and hemoglobin. These factors were successfully incorporated into the prediction model (AUC 0.740, 95% CI 0.713-0.767). The model demonstrated a high degree of discrimination and calibration, in addition to a high degree of clinical practicability in high-risk people. ConclusionsThe prediction model exhibits good discrimination and calibration and is pragmatic for CRC screening in rural areas and primary public health institutions.

Rural health in the Progressive Era: revisiting the hookworm intervention in the American South.

Objective: In this study, we investigated Progressive Era public health interventions and connected two subsequent efforts to improve outcomes in the American South: the Rockefeller Sanitary Commission's hookworm eradication efforts in the early 1910s and investments in local health infrastructure between the 1910s and the 1930s. We tested whether hookworm eradication had the largest effects in areas that invested in public health and whether county health organizations-cooperative public-private institutional arrangements-impacted the Rockefeller Sanitary Commission program's success. Materials and Methods: The methods used to measure the effects involved estimation of difference-in-difference and triple-difference models across the geographic samples of the Rockefeller Sanitary Commission's surveyed area, the American South, and the United States. Material on hookworm infection rates and activities by the Rockefeller Sanitary Commission is obtained from the Rockefeller Foundation Annual Reports. Material on the activities, spending, and duration of the different county health organizations is obtained from the Public Health Service Bulletin 222 titled, "A history of county health organizations in the United States: 1908-1933". Results: By comparing similar cooperative and independent county health organizations in the American South with the rest of the United States, we find that cooperative efforts are generally important and strengthen the Rockefeller Sanitary Commission's impact on human capital outcomes in the American South. Simultaneously, independent county health organizations produced negative or non-significant effects. Conclusion: The Rockefeller Sanitary Commission is important in guiding local health efforts. Our results are robust in both the short and long runs. This study sheds light on the effectiveness of public-private partnerships in rural public health during the Progressive Era.

Knowledge and preventive practices against malaria among pregnant women in urban and rural public healthcare facilities in nigeria’s federal capital territory

Background: Malaria is a life-threatening parasitic disease, and pregnant women are at risk of its adverse consequences. Objectives: The study aimed to determine knowledge and preventive practices against malaria among pregnant women at urban and rural public health facilities in Abuja, Nigeria. Materials and Methods: A cross-sectional study design was used. The two-stage sampling method was used to select 520 pregnant women in 16 health facilities. A structured questionnaire was used for data collection. Data analysis was done using SPSS statistical software version 22.0, and the level of statistical significance was determined at P-value of less than 0.05. Results: The mean age of respondents was 29.6±4.6 and 27.9±4.9 years in urban and rural areas, respectively (P≤0.001). A significantly higher proportion of women in the urban area (44.2%) had good knowledge of malaria than those in the rural area (26.2%) (P < 0.001). Comparable proportions of respondents in urban (13.1%) and rural (23.1%) areas had good preventive practices against malaria (P = 0.218). The predictor of good knowledge of malaria in the urban area was using secondary health facilities for antenatal care [95% confidence interval (CI): 1.3–4.4], whereas tertiary education (95% CI=1.1–2.3) and utilizing secondary health facilities (95% CI=1.2–2.8) were predictors in the rural area. Predictors of good preventive practice included being self-employed (95% CI=1.5–11.6) and having good knowledge of malaria (95% CI=1.3–6.4) in the urban area. Conclusion: Minor proportions of respondents in the study area had good knowledge of, and good preventive practices against, malaria. There is a need for relevant authorities to enlighten women on malaria and its preventive practices and to motivate them to practice malaria prevention throughout pregnancies.

Workforce problems at rural public health-centres in India: a WISN retrospective analysis and national-level modelling study

BackgroundRural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. Sanctioning under NRHM does not account for workload resulting in inadequate and inequitable HRH allocation. The Workforce Indicators of Staffing Needs (WISN) approach can identify shortages and inform appropriate sanctioning norms. India currently lacks nationally relevant WISN estimates. We used existing data and modelling techniques to synthesize such estimates.MethodsWe conducted a retrospective analysis of existing survey data for 93 facilities from 5 states over 8 years to create WISN calculations for HRH cadres at primary and community health centres (PHCs and CHCs) in rural areas. We modelled nationally representative average WISN-based requirements for specialist doctors at CHCs, general doctors and nurses at PHCs and CHCs. For 2019, we calculated national and state-level overall and per-centre WISN differences and ratios to depict shortage and workload pressure. We checked correlations between WISN ratios for cadres at a given centre-type to assess joint workload pressure. We evaluated the gaps between WISN-based requirements and sanctioned posts to investigate suboptimal sanctioning through concordance analysis and difference comparisons.ResultsIn 2019, at the national-level, WISN differences depicted workforce shortages for all considered HRH cadres. WISN ratios showed that nurses at PHCs and CHCs, and all specialist doctors at CHCs had very high workload pressure. States with more workload on PHC-doctors also had more workload on PHC-nurses depicting an augmenting or compounding effect on workload pressure across cadres. A similar result was seen for CHC-specialist pairs—physicians and surgeons, physicians and paediatricians, and paediatricians and obstetricians–gynaecologists. We found poor concordance between current sanctioning norms and WISN-based requirements with all cadres facing under-sanctioning. We also present across-state variations in workforce problems, workload pressure and sanctioning problems.ConclusionWe demonstrate the use of WISN calculations based on available data and modelling techniques for national-level estimation. Our findings suggest prioritising nurses and specialists in the rural public health system and updating the existing sanctioning norms based on workload assessments. Workload-based rural HRH deployment can ensure adequate availability and optimal distribution.

Nurses’ and midwives’ knowledge and practice of recommended evidence-based preterm care interventions in rural Kenya

BackgroundApproximately 25% of four million neonatal deaths globally are due to preterm birth, a majority occurring within the first week of life and, 60% in sub-Saharan Africa. Clinical interventions to improve preterm babies’ outcomes are often not used. The study assessed the availability of preterm care guidelines and resources in rural public health facilities in Kenya and nurses/midwives’ knowledge and practice of preterm care interventions as per the current preterm policies and guidelines in Kenya. MethodsA hospital-based cross-sectional design was conducted in 16 health facilities and among 102 nurses and midwives. Data were collected between January and March 2018 using the health assessment checklist and vignettes-based questionnaire. Frequencies and percentages were used to describe participants’ characteristics, availability of guidelines, equipment and medicines, and knowledge, and practice on preterm care interventions. All analyses were performed using Stata 13. ResultsSixteen public health facilities and 102 nurses were assessed. The mean age and period of clinical practice were 36 (SD: 9) and 12 (SD: 10) years, respectively. 71 (70%) participants were females, and 78 (77%) registered nurses. Three-quarters (n = 76, 74.5%) of them had in-service training in newborn care within the last two years, majority 67% (n = 69) worked at health centres/dispensaries. Vitamin K and chlorhexidine were available only in 60.8% and 47.1% of the facilities respectively. Guideline’s availability in facilities were 53%, 43%, and 32% for resuscitation, warmth provision, and breastfeeding within one hour respectively. None of the nurses would practice all the recommended preterm care intervention with 17 (16.7%) practicing none. The practice of the recommended preterm care intervention ranged from 7.6% for initiation of breathing to 29% for cord clamping, 32.4% use of chlorhexidine for cord care, 36.3% immediate feeding and 47.1% thermal protection. ConclusionThere exist gaps in the availability of medicines, equipment and guidelines for care of preterm babies, as well as implementation of evidence-based interventions to enhance the quality of care provided to preterm babies in the study area. We recommend increased provider-focussed strategies for improving the availability and implementation of low-cost high-impact evidence-based interventions for preterm care.

Rural Public Health Workforce Training Network Program (HRSA)

Rural Public Health Workforce Training Network Program (HRSA)

Research of Medical Service Quantity and Quality of Rehabilitation in a Rural Public Health Center

Research of Medical Service Quantity and Quality of Rehabilitation in a Rural Public Health Center

Qua Iboe by motorcycle and launch: brokering public health coverage in 1960s Southeastern Nigeria

ABSTRACT Long an expatriate-run concern, leprosy control was subsumed as a key component of rural public health in the years following Nigerian Independence in 1960 by the enlisting of a cadre of African inspectors, deployed across an existing institutional landscape by a newly Nigerianized medical bureaucracy. The performative norms of leprosy control, once thoroughly colonial and suffused with the ripe vocabulary of a long-entrenched missionary diaspora, were renovated at the heart of a new concern with rural public health more broadly, as the needs, expectations and hierarchies encoded in relations between patient, court, bureaucrat and medical worker shifted and settled in accordance with new political horizons. For health workers, issues of patient and worker mobility, drug delivery, patient and community expectation, and their own physical and financial security were dramatized in a series of commentaries, complaints and reports denoting deeply felt anxieties over the viability of careers in the service of Nigerian health. This article outlines struggles surrounding leprosy control and rural public health work in the Qua Iboe Mission catchment, administered by the newly created Ikot Ekpene Medical Field Unit. It documents a shift in medical work from European missionary to national and technocratic, the foregrounding of concerns with African (worker and patient) welfare and mobility, and the emergence of novel post-colonial forms of public health advocacy and politics along the highways and byways of Ibibio- and Annang-speaking areas of southeastern Nigeria in the 1960s.

“Agents of Change” in Maternal and Infant Care:Matronas,Parteras, and Public Health in Bolivia, 1950s–1970s

AbstractIn the 1950s and 1960s young women could study to become obstetric midwives (matronas) at two Bolivian universities. After the 1952 Bolivian Revolution, public health officials saw matronas' work in mining areas and rural public health programs as part of the government's effort to assimilate Indigenous Bolivians into a mestizo national culture, by reforming Indigenous mothers and eliminating demand for Andean midwives (parteras). By the 1970s, a military dictatorship had replaced the revolutionary government, and nursing schools had replaced midwifery programs. The last cohort of matronas now found jobs in public health offering trainings to parteras. Based on oral histories of matronas and parteras, this article examines these women's personal experiences with midwifery and public health. It argues that matronas and parteras shaped public maternal and infant care programs and contributed to the persistence of multiple forms of childbirth assistance in Bolivia.

Improving equitable access to care via telemedicine in rural public libraries.

Rural public libraries have been proposed as ideal locations from which individuals can access a telemedicine visit, but limited adoption of this practice suggests significant barriers remain. The purpose of this study was to determine rural public librarians' perspectives on the benefits and barriers to offering patrons the ability to use their public library for a telemedicine video visit, and to suggest strategies for moving this practice forward. Qualitative content analysis. Fifteen rural US librarians and library directors. Individual interviews were conducted to determine perspectives on the benefits of and barriers to implementing telemedicine in public libraries. We identified four themes from the data: rural public libraries increase healthcare access in a trustworthy location, librarians are supportive of telemedicine, but have concerns, limited resources drive barriers to telemedicine implementation in rural libraries, and small rural libraries continued in-person service during the COVID-19 pandemic. Rural public libraries can be an important part of achieving equitable access to care, particularly with regard to chronic disease management in rural populations. Rural public health nurses can be instrumental in promoting collaborations between local libraries and regional health systems that may help libraries overcome financial barriers to this practice.

ASHA Kirana: when digital technology empowered front-line health workers

This practice paper describes our experience of implementing accredited social health activists (ASHA) Kirana, a digital technology-enabled Maternal Clinical Assessment Tool (M-CAT) and how the ASHAs felt empowered in the...

A prospective population-based study of stroke in the Central Region of Iran: The Qom Incidence of Stroke Study.

Based on the few population-based studies that have been conducted in the Middle East, we determined the incidence of stroke in Qom, one of the central provinces of Iran. The Qom province includes an estimated at-risk population of about 1 million. During a 12-month period (November 2018-November 2019), all first-ever strokes occurring in the target population were registered. Hospitalized cases were ascertained by discharge codes. Out-of-hospital cases were ascertained by a prospective screening of emergency medical services, emergency departments, ambulances records, primary care clinics, rural and urban public health centers, primary care physician offices, and neurologists' offices. Crude and age-adjusted incidence rates (per 100,000 person-years) were calculated. During the study period, 1462 first-ever strokes occurred with a mean age of 68.1 (17-103) years; of these 45.2% were females (661 cases). The crude annual incidence rate per 100,000 at-risk populations was 145.4 (95% confidence interval, 138.1-153.0) for all types of stroke (156.5 for males and 134.3 for females), 26.4 (95% confidence interval, 23.5-29.8) for hemorrhagic stroke, and 114 (95% confidence interval, 105-121) for ischemic stroke. The incidence rate adjusted to the world population was 201.4 (95% confidence interval, 193-210) per 100,000 at-risk populations (adj incidence, 218.5 for males vs 187.4 for females). The total fatality rate during the first 28 days was 19.6%. This study states that in this region there is a high incidence of stroke, which occurs at a younger age than the global average. There was a high prevalence of underlying stroke risk factors.

Research on efficiency measurement and spatiotemporal disparity of rural public health services in China.

ObjectiveBased on the rural public health services of 29 regions in China, a service efficiency evaluation index system consisting of input and output dimensions was constructed, and the coupling, coordination and disparity efficiencies of rural public health services in China were studied, providing information to redress the imbalance in the interregional coordinated development.MethodsThe efficiency, spatiotemporal disparity pattern, spatial correlation and evolutionary trend of the coordinated development of rural public health services of 29 regions in China from 2004 to 2018 were analyzed using efficiency and spatial analysis methods such as Data Envelopment Analysis (DEA), kernel density estimation and Moran’s Ⅰ analysis.ResultNowadays, there are problems of unbalanced and insufficient development between the fields and regions in the development of rural public health services in China. The development level of rural public health services in various regions shows a distribution pattern that the service efficiency is “high in the middle”, “middle in the east” and “low in the west”, indicating a spatial cluster effect.