Services In Rural Settings Research Articles

Determinants of access to and use of maternal health care services in the Eastern Cape, South Africa: a quantitative and qualitative investigation.

BackgroundThe main aim of the study is to examine whether women in Mdantsane are accessing and using maternal health care services. Accessibility of maternal health care facilities is important in ensuring that lives are saved through the provision and use of essential maternal services. Therefore, access to these health care services directly translates to use – that is, if women cannot access life-saving maternal health care services, then use of such services will be limited.FindingsThe study makes use of mixed methods to explore the main factors associated with access to and use of maternal health care services in Mdantsane. For the quantitative approach, we collected data using a structured questionnaire. A sample of 267 participants was selected from health facilities within the Mdantsane area. We analyzed this data using bivariate and multivariate models. For the qualitative approach, we collected data from health care professionals (including nurses, doctors, and maternal health specialists) using one-on-one interviews. The study found that women who were aged 35–39, were not married, had secondary education, were government employees, and who had to travel less than 20 km to get to hospital were more likely to access maternal health services. The qualitative analysis provided the insights of health care professionals regarding the determinants of maternal health care use. Staff shortages, financial problems, and lack of knowledge about maternal health care services as well as about the importance of these services were among the major themes of the qualitative analysis.ConclusionA number of strategies could play a big role in campaigning for better access to and use of maternal health services, especially in rural areas. These strategies could include (a) the inclusion of the media in terms of broadcasting information relating to maternal health services and the importance of such services, (b) educational programs aimed at enhancing the literacy skills of women (especially in rural areas), (c) implementing better policies that are aimed at shaping the livelihoods of women, and (d) implementing better delivery of maternal health care services in rural settings.

Community stigma endorsement and voluntary counseling and testing behavior and attitudes among female heads of household in Zambézia Province, Mozambique

BackgroundSome aspects of HIV-related stigma have been shown to be a barrier to HIV services uptake and adherence to antiretroviral treatment (ART). Distinguishing which domains of stigma impact HIV services uptake can enhance the efficacy and efficiency of stigma-reduction interventions.MethodsThe relationships between use of voluntary counseling and testing (VCT) services and two domains of community stigma identified through factor analysis, negative labeling/devaluation and social exclusion, were investigated among 3749 female heads of household. Data were from a general household survey conducted in rural Mozambique. Multivariable logistic regression outcomes were: lifetime VCT use, past-6-months VCT use and VCT endorsement.ResultsThirteen percent (13%) of the participants reported lifetime VCT use, 10% reported past-6-months VCT use and 63% endorsed VCT. A 25-point decrease (from 50 to 25) in the score for negative labeling and devaluation stigma was associated with increased lifetime VCT use (adjusted OR: 1.6, 95% CI: 1.1-2.3) and past-6-months VCT use (adjusted OR: 1.6, 95% CI: 1.1-2.4). A decrease from 50 to 25-points in the score for social exclusion stigma was associated with 1.5 and 1.3-fold increase in odds for past-6-months VCT use and endorsing VCT use, respectively (p < 0.001 for both). Compared with never-testers, considerably high endorsement of VCT use was observed among testers who did not receive HIV test results (adjusted OR: 2.7, 95% CI: 1.6-4.6) and much higher among testers who received results (adjusted OR: 7.3, 95% CI: 4.9-11.0). Distance from health facilities was associated with lower VCT use, but not lower endorsement of VCT.ConclusionsVCT use and endorsement might differ by domains of stigma held by individuals in the community. Greater uptake and favorable disposition towards use of VCT services in rural settings might be achieved by addressing stigma via domain-specific interventions and by improving the proximity of services and the dissemination of HIV test results.

A Palliative Care Needs Assessment of Rural Hospitals

Palliative care services are lacking in rural hospitals. Implementing palliative care services in rural and remote areas requires knowledge of available resources, specific barriers, and a commitment from the hospital and community. The purpose of the study was to determine awareness, knowledge, barriers, and resources regarding palliative care services in rural hospitals. A descriptive survey design used an investigator-developed needs assessment to survey 374 (40% response rate) health care providers (chief executive officers, chiefs of medical staff, chief nursing officers, and social worker directors) at 236 rural hospitals (<100 beds) in seven Rocky Mountain states. Significant barriers to integrating palliative care exist: lack of administrative support, mentorship, and access to palliative care resources; inadequate basic knowledge about palliative care strategies; and limited training/skills in palliative care. Having contractual relationships with local hospices is a key facilitator. Respondents (56%) want to learn more about palliative care, specifically focusing on pain management, communication techniques, and end-of-life care issues. Webinar and online courses were suggested as strategies to promote long distance learning. It is imperative for quality of care that rural hospitals have practitioners who are up to date on current evidence and practice within a palliative care framework. Unique challenges exist to implementing palliative care services in rural hospitals. Opportunities for informing rural areas focus around utilizing existing hospice resources and relationships, and favoring Web-based classes and online courses. The development of a multifaceted intervention to facilitate education about palliative care and cultivate palliative care services in rural settings is indicated.

Consumers’ experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

BackgroundCoordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.MethodsFourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.ResultsFive key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.ConclusionsConsumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

Recall of lost-to-follow-up pre-antiretroviral therapy patients in the Eastern Cape: Effect of mentoring on patient care

In 2011 an experienced HIV nurse from the UK was deployed for 3 months to act as a mentor to nurses learning to initiate antiretroviral therapy (ART) in primary care clinics in a small town in the Eastern Cape, South Africa. A review of existing pre-ART patient files (N=286) was carried out and lost-to-follow-up (LTFU) HIV patients were recalled. Only 24% of patients had attended the clinics within the preceding 6 months and 20% had not attended for longer than 2 years. Two lay counsellors visited 222 patients to encourage them to return to care; 65/286 (23%) were untraceable, 11/286 (4%) had relocated, 30/286 (10%) declined, and 8/286 (3%) had died. In the 6 weeks following recall, 51/286 patients (18%) returned to the clinics. CD4 count testing was repeated and screening for tuberculosis (TB) and other opportunistic infections was performed for all patients; ART was initiated in 13/51 (25%), 1 patient tested positive for TB, and isionazid (INH) prophylaxis was initiated in 23/51 (45%). The cost of recall was R130/patient. Within 6 months, all clinics began providing full ART services, 17 professional nurses were mentored and they initiated ART in 55 patients. Mentoring plays an important role in professional nurse training and support. Recall of LTFU patients is feasible and effective in improving ART services in rural settings.

Utility of Oral Reading and Retell Fluency in Predicting Proficiency on the Montana Comprehensive Assessment System

The purpose of this study was to document the relationship between two commonly-used indicators of reading proficiency (i.e., Oral Reading Fluency [ORF] and Retell Fluency [RTF]) and two reading outcome tests in the state of Montana. Third and fourth grade students were assessed over 1 school year (2005-2006). Each student was assessed at three time points (fall, winter, and spring) with both the ORF and RTF measures. In addition, students participated in the standard, end-of-year, state comprehensive reading assessment. Both indicators displayed strong correlations with the criterion tests at the end of the school year. RTF added a small portion of unique variance explained to end-of-year outcomes when the raw scores (rather than ratio scores) were used. We highlight the way in which the ORF and RTF measures might be used together as efficient, economical predictors of important reading outcomes. We also provide information regarding the way in which the findings from this study impact special education services in rural settings.

Recovery services in rural settings: Strengths and challenges influencing behavioral healthcare service delivery.

Recovery services in rural settings: Strengths and challenges influencing behavioral healthcare service delivery.

Preceptorship Placements in Western Rural Canadian Settings: Perceptions of Nursing Students and Preceptors

This article reports on one theme from a grounded theory study examining the experiences of fourth year nursing undergraduate students and their rural-based preceptors. The preceptors reported issues concerning orientation and communication with faculty, integration of students into care, severe weather conditions, and lack of resources whereas the students reported issues with relocation to rural centers, accessing information, faculty contact, travel and accommodation. Addressing these issues as well as increasing theoretical content related to rural nursing practice may be effective in recruiting younger nurses via positive preceptorship experiences to rural practice, thus ensuring rural residents continue to have access to limited health services in rural settings. The findings have implications for the role of faculty in preparing, orienting, and supporting both preceptors and students.

The evaluation of a model of primary mental health care in rural Tasmania

The aim of this study was to evaluate the effectiveness of a primary care mental health service. The study used a naturalistic longitudinal design to follow groups of participants who received intervention from a rural mental health worker, or 'usual' mental health service, or no treatment, over a period of 12 months. The service was evaluated in a rural primary care setting. One hundred and forty-five primary care patients. Changes in symptomatology were assessed using the SCL-90R summary scales, and changes in quality of life were assessed using the EuroQOL. Those participants treated by the primary mental health worker showed significant improvements in symptoms and quality of life compared to both the usual and no-treatment groups. There are few studies evaluating mental health services in rural settings. This study demonstrated that a particular model of primary mental health care was more effective than usual mental health care and no treatment at resolving symptoms and improving quality of life.

Access to Transportation and Health Care Utilization in a Rural Region

Access to transportation to transverse the large distances between residences and health services in rural settings is a necessity. However, little research has examined directly access to transportation in analyses of rural health care utilization. This analysis addresses the association of transportation and health care utilization in a rural region. Using survey data from a sample of 1,059 households located in 12 western North Carolina counties, this analysis tests the relationship of different transportation measures to health care utilization while adjusting for the effects of personal characteristics, health characteristics, and distance. Those who had a driver's license had 2.29 times more health care visits for chronic care and 1.92 times more visits for regular checkup care than those who did not. Respondents who had family or friends who could provide transportation had 1.58 times more visits for chronic care than those who did not. While not significant in the multivariate analysis, the small number who used public transportation had 4 more chronic care visits per year than those who did not. Age and lower health status were also associated with increased health care visits. The transportation variables that were significantly associated with health care visits suggest that the underlying conceptual frameworks, the Health Behavior Model and Hagerstrand's time geography, are useful for understanding transportation behavior. Further research must address the transportation behavior related to health care and the factors that influence this behavior. This information will inform policy alternatives to address geographic barriers to health care in rural communities.

Complicated deliveries, critical care and quality in Emergency Obstetric Care in Northern Tanzania

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

Practising Psychology in Rural Settings: Issues and Guidelines.

Abstract Rural practice presents important yet challenging issues for psychology, especially given the North American and international distribution of the population, levels of need for psychological services in rural settings, limited availability of rural services, and migration of rural residents to urban centres. Direct service issues include the need to accommodate a wide variety of mental health difficulties, issues related to client privacy and boundaries, and practical challenges. Indirect service issues include the greater need for diverse professional activities, including collaborative work with professionals having different orientations and beliefs, program development and evaluation, and conducting research with few mentors or peer collaborators. Professional training and development issues include lack of specialized relevant courses and placements, and such personal issues as limited opportunities for recreation and culture, and lack of privacy. Psychology will need to address more fully these complex issues if rural residents are to receive equitable treatment and services. Psychologists who practice in rural settings face many challenges, including geographic issues, unique qualities of rural residents, and considerable need for but lesser availability of services. We document these and other challenges, suggest how psychologists can adapt to rural settings, and identify areas for further research. The paper reviews literature in rural psychology and related areas (e.g., community psychology, rural sociology), and is illustrated by experiences working in rural and northern Manitoba. The issues are also relevant to urban practitioners wishing to adapt services to clients who have migrated from rural settings. Although the world is increasingly urban, many people remain in rural areas (Murray & Keller, 1991). The last Canadian census (Statistics Canada, 1996) classified 22.1% of Canadians as rural, a total of over 6.3 million people. The percentage rural varied from 55.8% for Prince Edward Island to 16.7% for Ontario, but even the latter figure represented 2 million people. In 1990, 24.8% of the U.S. population was rural, representing over 60 million people (Ricketts, Johnson-Webb, & Randolph, 1999). The number and percentage of people in rural areas is even more dramatic globally, which is relevant to international development and training practitioners for non-Western countries. In 1990 (United Nations, 1991), the percent of people in nonurban regions was over 66% for Oceania (excluding Australia and New Zealand), Asia (excluding Japan), and Africa, and was 25-35% for Eastern and Southern Europe, the USSR, Latin America, North America, and Japan. The figures were under 20% only for Western and Northern Europe, and Australia and New Zealand. Even the relatively low percentages still represented large numbers of rural citizens. International statistics also showed a strong association between ruralness and economic development, with the percent nonurban decreasing markedly from least (80%) to most (27%) developed nations. Although distinct definitions of rural are used for such statistics, ruralness varies in degree. Some rural regions are close to urban centres, such as the regions of Manitoba that surround Winnipeg, the provincial capital with 600,000 people. At the other extreme are isolated or frontier regions remote from large centres or psychological services, and perhaps accessible only by plane or seasonal ice roads. Many communities fall between these extremes, such as Thompson, Manitoba, a town 800 kilometres north of Winnipeg with approximately 15,000 people. Whether people live in rural areas close to major centres or in more remote locations, the challenges of rural practice (e.g., isolation, transportation, lack of privacy) remain problematic to some degree. The preceding statistics change constantly as people move between rural and urban settings. …

Structural quality of reproductive health services in South-Central Ethiopia

Background: The quality of health services has been known to be grossly deficient in developing countries, but only few studies were carried out to document the deficiencies in a systematic manner. Objective: To assess the quality of reproductive health services in rural settings with emphasis on the structural aspect. Methods: This is a descriptive cross-sectional study conducted in the peripheral health institutions of two administrative zones in South-Central Ethiopia. Data were collected using an interview questionnaire and observation checklist adopted from the WHO Safe Motherhood Need Assessment and the WHO training modules for EPI and STDs. Findings: Multiple structural deficiencies were identified in all components of reproductive health care. Adequate amounts of the absolute minimum equipment required for maternity and neonatal care were not available in many health institutions. Sterilizers were available in 11(15.3%), essential drugs like iron tablets in 14 (19.4%), and ergometrine injection in 48 (66.7%) of the health institution. In the EPI section, refrigerator was available in 57(79.2%) and steam sterilizer in 43(59.7%) of the institutions. Mix of contraceptives was not available widely. Important laboratory tests like syphilis test, were available in only one (1.4%) health institution. Only 8(11.1%) health institutions had adequate IEC materials on all national reproductive health components. (Ethiopian Journal of Health Development, 2000, 14(3): 317-326)

Understanding the Cultural Characteristics of American Indian Families: Effective Partnerships under the Individualized Family Service Plan (IFSP)

Public Law 99–457 provides the opportunity to reshape and redirect early intervention services to infants and toddlers and their families. Effective partnerships developed under the Individualized Family Service Plan (IFSP) between families and early intervention professionals require trust, sharing and cooperation. Because a majority of American Indians receive services in rural settings, it is essential that rural early intervention professionals understand the cultural characteristics of American Indian families. Only through such understanding can the effective partnerships that are necessary to assure positive outcomes for American Indian early intervention constituents be developed. This understanding will also serve to eliminate long standing assumptions that American Indian children are deficient in their preparation for school and that their families have given them a bad start in life. Instead, it will foster a more positive view of these children and their families. While recognizing that there may be gaps in the experience of American Indian children and families, respect for their cultural background will allow professionals to build on the experience base of children and families.

AIDS and drug abuse in rural America.

This paper reviews the nature and extent of drug abuse-related HIV disease services in the rural United States. Issues concerning the delivery of HIV disease and substance abuse health care services in rural settings are outlined and discussed.

Delivery of services in rural settings to the elderly mentally retarded-mentally ill.

A number of controversial arguments exist regarding the ability of sparsely populated areas to adequately provide for their elderly mentally retarded; the elements of distance, education, and capital are said to effectively obstruct access to psychiatric and social support. Yet several facts speak soundly for the necessity to overcome these obstacles: a five-fold increase in the life spans of the mentally retarded in recent decades, and the amply demonstrated reality that individuals with mental retardation are nearly twice as likely as the general population to develop severe behavioral disorders. This article examines both the methods and the reasons for ensuring that rural populations of elderly mentally retarded citizens receive modern psychiatric assistance and community support.