Rural Settings Research Articles

Antiarrhythmic preferences and outcomes post DC cardioversion for atrial fibrillation, an Australian rural perspective.

Direct current cardioversion (DCCV) remains one of the recommended management strategies for symptomatic atrial fibrillation (AF). Antiarrhythmic drugs (AAD) are prescribed post procedure to maintain sinus rhythm (SR). Limited literature exists on the AAD prescribing practices and their efficacy, post-DCCV in rural Australia. The primary aim was to determine the preferred AAD post-DCCV and the factors affecting AAD prescribing practices. The secondary aim was to assess the efficacy of the AAD in maintaining SR. A retrospective observational audit of patients with non-valvular AF who underwent successful elective DCCV for symptomatic AF, during 2015-2020 at a regional hospital in New South Wales (NSW) (Dubbo Base Hospital). Patients were followed up for a duration of 12 months post-DCCV. 233 patients underwent successful DCCV during the study duration. Amiodarone was the preferred AAD of choice post-DCCV followed by sotalol and flecainide, respectively (36.5% vs. 27.8% vs. 1.3%). 35.2% patients were not prescribed AAD. Amiodarone and sotalol had similar but modest efficacies and neither were superior to no AAD, in maintaining SR 12 months post-DCCV (AF recurrence rate 61.5% vs. 68.2% vs. 71.6% respectively, p = 0.37). Antecedent cerebrovascular accident (CVA), pulmonary disease, smoking, prior treatment with digoxin, diuretics and left ventricular (LV) dysfunction were factors that influenced AAD prescribing practices. The study demonstrates equal efficacies of amiodarone, sotalol and no AAD in maintaining SR 12 months post-DCCV. Prescribing practices post-DCCV at Dubbo Base Hospital differ from observed national trends and guidelines. AAD prescription requires a multifaceted approach with a key consideration to prioritise safety over efficacy, being mindful of challenges in delivering optimal healthcare in a rural setting.

Measures during the COVID-19 pandemic in public primary health care in Greece: is there still a missing link to universal health coverage?

The PRICOV-19 study aimed to assess the organization of primary health care (PHC) during the COVID-19 pandemic in 37 European countries and Israel; and its impact on different dimensions of quality of care. In this paper, we described measures taken by public PHC centers in Greece. Additionally, we explored potential differences between rural and non-rural settings. The study population consisted of the 287 public PHC centers in Greece. A random sample of 100 PHC centers stratified by Health Region was created. The online questionnaire consisted of 53 items, covering six sections: general information on the PHC center, patient flow, infection prevention, information processing, communication to patients, collaboration, and collegiality. Seventy-eight PHC centers (78%) - 50 rural and 28 non-rural - responded to the survey. Certain measures were reported by few PHC centers. Specifically, the use of online messages about complaints that can be solved without a visit to the PHC center (21% rural; and 31% non-rural PHC centers), the use of video consultations with patients (12% rural; and 7% non-rural PHC centers), and the use of electronic medical records (EMRs) to systematically identify the list of patients with chronic conditions (5% rural; and 10% non-rural PHC centers) were scarcely reported. Very few PHC centers reported measures to support identifying and reaching out to vulnerable population, including patients that may have experienced domestic violence (8% rural; and 7% non-rural PHC centers), or financial problems (26% rural; and 7% non-rural PHC centers). Providing administrative documents to patients through postal mail (12% rural; and 21% non-rural PHC centers), or regular e-mail (11% rural; and 36% non-rural PHC centers), or through a secured server (8% rural; and 18% non-rural PHC centers) was rarely reported. Finally, providing information in multiple languages through a PHC website (12% rural PHC centers only), or an answering machine (6% rural PHC centers only), or leaflets (3% rural PHC centers only; and for leaflets specifically on COVID-19: 6% rural; and 8% non-rural PHC centers) were lacking in most PHC centers. Our study captured measures implemented by few PHC centers suggesting potential priority areas of future improvement.

Wound colonization with methicillin-resistant Staphylococcus aureus and hypotheses about acquisition routes in rural healthcare settings in Sub-Saharan Africa: Perspective from a Center devoted to the treatment of cutaneous neglected tropical diseases.

We identified a high prevalence (46.4%) of wound colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized in a Center devoted to the treatment of cutaneous tropical diseases in Benin. The proportion of MRSA among S. aureus isolates was 54.3%. Thirty percent of these MRSA were identified in outpatients. Concurrently, 51% of MRSA were identified in patients for whom the time spent in the Center was between 20 days and 228 days. The analysis of pulsed-field gel electrophoresis demonstrated an important diversity of strains but also identified eight small clusters containing between two and four isolates suggesting cross-transmission. Based on these data, hypotheses about acquisition routes were suggested and measures for limiting the burden of antimicrobial resistance were envisaged.

Rural comprehensive cancer care: Qualitative analysis of current challenges and opportunities.

While limited resources can make high-quality, comprehensive, coordinated cancer care provision challenging in rural settings, rural cancer patients often rely on local hospitals for care. To develop resources and strategies to support high-quality local cancer care, it is critical to understand the current experiences of rural cancer care physicians, including perceived strengths and challenges of providing cancer care in rural areas. METHODS: Semi-structured interviews were conducted with 13 cancer providers associated with all 12 non-metropolitan/rural Iowa hospitals that diagnose or treat >100 cancer patients annually. Iterative thematic analysiswas conducted to develop domains. Participants identified geographic proximity and sense of community as strengths of local care. They described decision-making processes and challenges related to referring patients to larger centers for complex procedures, including a lack of dedicated navigators to facilitate and track transfers between institutions and occasional lack of respect from academic physicians. Participants reported a desire for strengthening collaborations with larger urban/academic cancer centers, including access to educational opportunities, shared resources and strategies to collect and monitor data on quality, and clinical trials. Rural cancer care providers are dedicated to providing high-quality care close to home for their patients and would welcome opportunities to increase collaboration with larger centers to improve coordination and comprehensiveness of care, collect and monitor data on quality of care, and access continuing education opportunities. Further research is needed to develop implementation approaches that will extend resources, services, and expertise to rural providers to facilitate high-quality cancer care for all cancer patients.

Assessing prescribing practices in a rural hospital: A cross-sectional study using WHO prescribing indicators

This cross-sectional study aims to assess the prescribing practices of physicians at a rural hospital in Western India, focusing on adherence to WHO prescribing indicators. The main research question addressed the extent of alignment with optimal prescribing standards. 1: Evaluate prescribing patterns in a rural hospital using WHO indicators. 2: Assess alignment with WHO standards and identify areas for improvement. 3: Understand demographic influences on prescribing. 4: Provide insights for optimizing rural healthcare delivery.A prospective, descriptive, cross-sectional approach was employed in the outpatient department of the rural hospital. A total of 604 prescriptions were sampled over two months, and data were collected using a random sampling method. The study followed ethical standards, and prescriptions were analyzed for demographic characteristics, prescribing patterns, and adherence to WHO indicators. The average number of drugs per prescription was 3.5, indicating a tendency towards polypharmacy. While 86% of drugs were prescribed generically, the study revealed areas of suboptimal adherence to WHO prescribing indicators, including antibiotic prescriptions (29%) and injectable use (50%). The analysis also highlighted disparities in prescribing patterns based on gender and age. The study provides valuable insights into prescribing practices in a rural healthcare setting, emphasizing the need for interventions to streamline prescriptions and enhance adherence to global standards. The identified areas for improvement include addressing polypharmacy, promoting generic prescribing, and optimizing antibiotic and injectable use.

The Impact of School Environment on Student Health Behaviors: Insights from Qualitative Interviews

The relationship between the school environment and student health behaviors is increasingly pertinent amidst rising health concerns among youths. This qualitative study, conducted across diverse socioeconomic backgrounds in Vietnam, explores the multifaceted influences of school settings on the health behaviors of students. Data were collected through semi-structured interviews and focus group discussions involving students, teachers, parents, and administrators from three schools, each representing urban, suburban, and rural settings. The study identified key factors within schools' physical and social environments that significantly impact health behaviors. These include the availability and condition of physical facilities, the nutritional quality of food offered, peer influences, teacher engagement in health education, and the availability of mental health resources. Socioeconomic factors and cultural attitudes towards health and education also emerged as significant determinants. The findings suggest that improvements in physical resources, enhanced teacher training in health education, standardized healthy food offerings, and greater availability of mental health services are critical for fostering healthier behaviors among students. This study underscores the need for holistic policy interventions tailored to diverse educational settings to promote overall student health.

How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists?

To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. Cross-sectional population-based analysis. 2019 Medicare Provider Utilization and Payment Dataset. Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vscommunity). Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval,CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.

Prevalence of different variations of non-consented care during the childbirth process in Mexico by geographical regions: comparing ENDIREH survey data from 2016 to 2021

IntroductionNon-consented care, a form of obstetric violence involving the lack of informed consent for procedures, is a common but little-understood phenomenon in the global public health arena. The aim of this secondary analysis was to measure the prevalence and assess change over time of non-consented care during childbirth in Mexico in 2016 and 2021, as well as to examine the association of sociodemographic, pregnancy-, and childbirth-factors with this type of violence.MethodsWe measured the prevalence of non-consented care and three of its variations, forced sterilization or contraception, forced cesarean section, and forced consent on paperwork, during childbirth in Mexico for 2016 (N = 24,036) and 2021 (N = 19,322) using data from Mexico’s cross-sectional National Survey on the Dynamics of Household Relationships (ENDIREH). Weighted data were stratified by geographical regions. We performed adjusted logistic regression analyses to explore associations.ResultsThe national prevalence of non-consented care and one of its variations, pressure to get a contraceptive method, increased from 2016 to 2021. A decrease in the prevalence was observed for forced contraception or sterilization without knowledge, forcing women to sign paperwork, and non-consented cesarean sections nationally and in most regions. Women between the ages of 26 and 35 years, married, cohabiting with partner, living in urban settings, who do not identify as Indigenous, and who received prenatal services or gave birth at the Mexican Institute of Social Security (IMSS) facilities experienced a higher prevalence of non-consented care. Being 26 years of age and older, living in a rural setting, experiencing stillbirths in the last five years, having a vaginal delivery, receiving prenatal services at IMSS, or delivering at a private facility were significantly associated with higher odds of reporting non-consented care.ConclusionWhile a decrease in most of the variations of non-consented care was found, the overall prevalence of non-consented care and, in one of its variations, pressure to get contraceptives, increased at a national and regional level. Our findings suggest the need to enforce current laws and strengthen health systems, paying special attention to the geographical regions and populations that have experienced higher reported cases of this structural problem.

Online palliative care education and mentorship in Nepal: Project ECHO - a novel approach to improving knowledge and self-efficacy among interprofessional health-care providers.

Palliative care access in Nepal is severely limited, with few health-care providers having training and skills to pain management and other key aspects of palliative care. Online education suggests an innovation to increase access to training and mentoring, which addresses common learning barriers in low- and middle-income countries. Project ECHO (Extensions for Community Health Care Outcomes) is a model of online education which supports communities of practices (COPs) and mentoring through online teaching and case discussions. The use of online education and Project ECHO in Nepal has not been described or evaluated. An online course, consisting of 14 synchronous weekly palliative care training sessions was designed and delivered, using the Project ECHO format. Course participants included health-care professionals from a variety of disciplines and practice settings in Nepal. The goal of this study was to evaluate the impact of a virtual palliative care training program in Nepal on knowledge and attitudes of participants. Pre- and post-course surveys assessed participants' knowledge, comfort, and attitudes toward palliative care and evaluated program acceptability and barriers to learning. Forty-two clinicians, including nurses (52%) and physicians (48%), participated in program surveys. Participants reported significant improvements in their knowledge and attitudes toward core palliative care domains. Most participants identified the program as a supportive COP, where they were able to share and learn from faculty and other participants. Project ECHO is a model of online education which can successfully be implemented in Nepal, enhancing local palliative care capacity. Bringing together palliative care local and international clinical experts and teachers supports learning for participants through COP. Encouraging active participation from participants and ensuring that teaching addresses availability and practicality of treatments in the local health-care context addresses key barriers of online education. This study describes a model of structured virtual learning program, which can be implemented in settings with limited access to palliative care to increase knowledge and attitudes toward palliative care. The program equips health-care providers to better address serious health-related suffering, improving the quality of life for patients and their caregivers. The program demonstrates a model of training which can be replicated to support health-care providers in rural and remote settings.

A "food insecurity poverty line" to replace the official threshold in Canadian rural and urban settings? A single-person household perspective.

Household food insecurity is associated with both low income and high cost of living, it is a potentially better measure for consumption compared to income. We use data on food insecurity and income from 10years of the Canadian Community Health Survey (2007-2017) of single-person households (n = 145,044) to estimate the probability of being food insecure at the Canadian poverty thresholds (Market Basket Measure thresholds, or MBMs), and determine the income required to reach that probability in each MBM region, aggregated by province and rural/urban status. A regression model shows the probability of being food insecure at the MBM is approximately 30% which we call the Food Insecurity Poverty Line (FIPL). The income required to meet the FIPL is substantially different from the MBM, sometimes 1.25 times the MBM. This implies that food insecurity is a potential sentinel measure for poverty.

How social innovations emerge in a rigid regulatory context: the case of demand responsive transport in Switzerland

ABSTRACT Demand responsive transport (DRT) solutions may improve rural transport systems. These solutions often emerge as social innovations in rural areas. In Switzerland, their planning process is embedded in a rigid regulatory framework of the public transport system. The objective of this paper is to understand in which way the regulatory framework of the public transport system influences planning processes of a DRT solution in a rural setting. The methodological approach of social innovation biographies helps to examine the necessary planning steps to start mybuxi, a DRT in two Swiss rural municipalities. Our findings show that regulatory constraints dominate the final planning stage of the social innovation. Protections of current public transport regulations hinder federal offices from subsidizing the DRT, having direct implications on the financial sustainability of the system. The findings of this paper help actors to better address regulatory questions in the early stage of the respective innovation process.

Promoting equity in civics education: Teaching marginalized students in Israel's remote areas

Significant civic education transpires through establishing connections with students' local realities. Nevertheless, a literature gap exists concerning civic education in rural settings, which introduces concerns regarding equity influenced by the neoliberal educational paradigm. Through interviews with twelve Israeli civics teachers working in the country's peripheral regions, we investigated their perspectives on classroom practices. We identified four primary approaches: Spoon-feeding, Redeeming, Demanding, and Empowering. These perceptions of practices contribute to the development of a theoretical model that advocates for a place-based approach. This model promotes equitable practices by concentrating on the unique needs and contexts of students in peripheral areas.

Addressing food insecurity in rural primary care: a mixed-methods evaluation of barriers and facilitators

BackgroundFood insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices.MethodsWe conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes.ResultsParticipants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were “very important” for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming.ConclusionsRural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI.

RURAL WOMEN PERCEPTIONS OF DIGITAL MEDIA INFLUENCE ON AWARENESS CREATION ABOUT MATERNAL HEALTH INFORMATION IN PUNJAB, PAKISTAN

In rural settings, access to maternal health information is often limited, contributing to disparities in maternal healthcare utilization and outcomes. The main objective of the study is to find the rural women perceptions of digital media influence on awareness creation about maternal health information in Punjab, Pakistan. This cross-sectional study was conducted at the University of Lahore from August 2023 to January 2024. Data was collected from 350 participants using convenience sampling methods. Data collection involved the administration of structured surveys to participants, either in-person or through electronic means, depending on their accessibility and preferences. The survey instrument was designed to capture demographic information, including age, education level, household income, and parity, as well as assess participants' access to digital media, frequency of usage, preferred platforms, and perceived usefulness of digital media for obtaining maternal health information. Data was collected from 350 participants. The mean age of the participants was 32.9±6.5 years Education levels varied, with 60% having primary education, 30% secondary, and 10% tertiary education. Regarding household income, 70% fell below the poverty line, while 30% were above it. Participants reported relatively high mean scores for their engagement with digital media platforms. Social media received the highest mean score of 3.8, followed by search engines with a mean score of 3.5, and maternal health websites/apps with a slightly lower mean score of 3.2. It is concluded that digital media, particularly social media platforms, play a significant role in providing access to maternal health information among rural women, despite variations in access and perceived usefulness across demographic groups.

Health equity in urban and rural settings: implementation of the place standard tool in Spain

The physical, social, and economic characteristics of neighborhoods and municipalities determine the health of their residents, shaping their behaviors and choices regarding health and well-being. Addressing local environmental inequalities requires an intersectoral, participatory, and equity-focused approach. Community participation plays a vital role by providing deeper insights into local contexts, integrating community knowledge and values into processes, and promoting healthier, fairer, and more equitable actions. In recent years, various tools have been developed to assess places and transform them into health-promoting settings. One such tool, the Place Standard Tool (PST), facilitates discussions on Social Determinants of Health grouped into 14 themes, serving as a starting point for local health interventions. In this study, that took place between August 2019 and February 2020, we described the resident’s perceptions of two municipalities in the Valencian Community, Spain, using the validated Spanish version of the PST. A mixed-method convergent-parallel design was used to gain a holistic insight into residents’ experiences concerning their physical, economic, and social environment. A total of 356 individuals from both municipalities participated in the study through discussion groups, structured interviews, and online survey. Descriptive analysis of the individual questionnaire answers was conducted, and differences between municipalities were explored. Qualitative thematic analysis was conducted on structured interviews and discussion groups. Quantitative and qualitative data were integrated to facilitate their comparison and identify areas of convergence or divergence in the findings. Overall, rural areas received more favorable evaluations compared to urban ones. Public Transport as well as Work and Local Economy were consistently rated the lowest across all groups and contexts, while Identity and Belonging received the highest ratings. In the urban area, additional negative ratings were observed for Traffic and Parking, Housing and Community, and Care and Maintenance. Conversely, Identity and Belonging, Natural Spaces, Streets and Spaces, Social Interaction, and Services emerged as the highest-rated themes overall. In the rural context, positive evaluations were given to Walking or Cycling, Traffic and Parking, Housing and Community, and Influence and Sense of Control. Significant differences (p &amp;lt; 0.01) between urban and rural settings were observed in dimensions related to mobility, spaces, housing, social interaction, and identity and belonging. Our study illustrated the capacity of the PST to identifying aspects within local settings that influence health, revealing both positive and challenging factors. Successful implementation requires appropriate territorial delineation, support from local authorities, and effective management of expectations. Furthermore, the tool facilitated community participation in decision-making about local environments, promoting equity by connecting institutional processes with citizen needs.

Examining the social and behavioral dynamics of substance use in a longitudinal network study in rural Appalachia

BackgroundPrior studies have shown that individuals and their peers often have similar substance use behaviors, but the mechanisms driving these similarities – particularly in rural settings, are not well understood. The primary objectives of this analysis are to (1) identify factors that contribute to relationship turnover and maintenance within a rural network of persons who use drugs (PWUD), (2) determine whether assimilation and/or homophily shape participants use of injection drugs, heroin, and stimulants (methamphetamine and cocaine), and (3) assess the extent that these mechanisms influence networks ties and/or behaviors and whether these effects vary across time. MethodsSociometric network data were collected from a cohort of PWUD in rural Eastern Kentucky at baseline (2008–2010) and at four follow-up visits conducted approximately semiannually. Stochastic actor-oriented models (SAOMS) were used to model network structure and participant behaviors as jointly dependent variables and to identify characteristics associated with the maintenance, dissolution, and formation of network ties and changes in drug use behaviors. ResultsFindings suggest (1) greater network stability over time for reciprocal and transitive relationships, (2) both homophily and assimilation played a greater role in shaping injection drug use (IDU) initiation and cessation than they did in shaping heroin and stimulant use, and (3) the importance of these mechanisms appeared consistent over time. ConclusionGiven the stability of particular network structures and evidence of both homophily and assimilation with respect to drug-use behaviors, interventions that leverage social networks could be used to motivate health-promoting behaviors.

Choosing Life in All Its Fullness: The Nature of the Abundant Life and Its Relationship to Abortion Politics

In John 10:7-10, Jesus promises that he has come so that we may have life in all its fullness. This article examines life in its fullness from an Anglican perspective, articulating a Christian ethic that asserts freedom, voice, identity, and an opportunity to flourish are essential components to such a life. Life experiences illuminate ways in which the choice about whether or not to terminate a pregnancy helped define full life for both mothers and children. These insights grow out of experiences working in a teenage parent program in Florida and as the director of a family planning clinic in the rural west. The premise of the article is that both scripture and our Anglican tradition imagine life to mean more than just subsistence, and that current prohibitions on abortion, even before fetus viability, thwart Christ’s vision for life, most poignantly for women and children in poor and rural settings.

Identification of the needs and priorities of older people and stakeholders in rural and urban areas of Santo Andre, Brazil.

There are few data reporting the needs and priorities of older adults in Brazil. This hampers the development and/or implementation of policies aimed at older adults to help them age well. The aim of this study was to understand areas of importance, priorities, enablers and obstacles to healthy ageing as identified by older adults and key stakeholders in both urban and rural environments. Two locations were selected, one urban and one rural in the municipality of Santo André, in the metropolitan region of São Paulo (SP). Workshops for older adults (>60 y) and stakeholders were conducted separately in each location. The workshops incorporated an iterative process of discussion, prioritisation and ranking of responses, in roundtable groups and in plenary. Areas of commonality and differences between older adult and stakeholder responses were identified by comparing responses between groups as well as mapping obstacles and enablers to healthy ageing identified by older adults, to the priorities identified by stakeholder groups. The socio-ecologic model was used to categorise responses. There were few shared responses between stakeholders and older adults and little overlap between the top ranked responses of urban and rural groups. With respect to areas of importance, both stakeholder groups ranked policies for older people within their top five reponses. Both older adult groups ranked keeping physically and mentally active, and nurturing spirituality. There was a marked lack of congruence between older adults' obstacles and enablers to healthy ageing and stakeholder priorities, in both urban and rural settings. Most responses were located within the Society domain of the socio-ecologic model, although older adults also responded within the Individual/ Relationships domains, particularly in ranking areas of most importance for healthy ageing. Our results highlight substantial differences between older adults and stakeholders with respect to areas of importance, priorities, enablers and obstacles to healthy ageing, and point to the need for more engagement between those in advocacy and policymaking roles and the older people whose needs they serve.

Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper

Background Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery. Methods The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.

Oncologic Outcomes for Squamous Cell Carcinoma In Situ With a Clinically Resolved Biopsy Site Managed by Watchful Waiting

BACKGROUND Treatment option decisions for low-risk squamous cell carcinoma in situ (SCCIS) are hampered by a paucity of management-type–specific outcomes data. OBJECTIVE Describe SCCIS tumor outcomes managed by watchful waiting and risk factors associated with poor cancer outcomes. MATERIALS AND METHODS Retrospective cohort study. Setting: Single academic hospital in a rural setting. Patients: Adults with SCCIS diagnosed between January 01, 2014, and December 31, 2016. Main Outcomes and Measures: Hazard ratios (HRs) for local recurrence (LR), nodal metastases (NM), distant metastases (DM), and disease-specific death (DSD). RESULTS A total of 411 consecutive SCCIS tumors that were considered clinically resolved at follow-up and managed with watchful waiting were included. Seventeen tumors recurred locally. No instances of NM, DM, or DSD were identified. Multivariate analysis found that solid-organ transplant recipient status conferred the highest risk of local recurrence [HR, 9.979 (95% CI, 2.249–39.69)]. Additional risk factors predicting LR include anatomic location on the vermilion lip or ear [HR, 9.744 (95% CI, 1.420–69.28)], anatomic location on the head and neck [HR, 6.687 (95% CI, 1.583–36.15)], and a biopsy with tumor extending to the deep edge [HR, 6.562 (95% CI, 1.367–39.04)]. CONCLUSION Watchful waiting for SCCIS with a clinically resolved biopsy site has a local recurrence rate of 4%.