Rural Medicine—Making It Now,and the Problems Ahead

King City, California, a small remote town among thousands in the nation, has demonstrated that private physicians and federal funds can jointly develop effective health care delivery mechanisms to serve residents of all incomes with a full complement of hospital and outpatient services as well as community health programs. Young health care professionals can be drawn to the traditionally difficult-to-serve rural areas. Unanswered is the problem of developing and maintaining an adequate funding base for health services in rural communities in the face of a disproportionately large number of poor people with a sub-optimal job future. The dollar resources in the rural community are often simply inadequate to buy needed health and social services.     

OMA's Continuing Education Program

Confronted with the inability to offer access to trained mental health personnel to their remote rural community, a private medical group practice in California recruited and integrated psychiatric social workers in their clinic. The rapid acceptance of these newer mental health professionals by community members of all economic levels and by group physicians confirms the success of this program, now in its fourth year, and rising community interest in mental health services.The group practice prototype affords a unique opportunity for innovation in community health care delivery in outlying areas with their traditional difficulties in attracting health care professionals.     

甘肃康乐县基层卫生机构门诊临床路径管理探讨

为了有效发挥基层医疗卫生机构健康“守门人”职能,康乐县借助卫XI项目支持,积极开展基层医疗卫生机构门诊临床路径管理探索,有效发挥了新农合与定点医疗机构管理的协同作用,实现了医疗质量提高与费用控制的有效结合,并在规范诊疗行为、减低医疗服务成本、改善医患关系等方面发挥了积极作用。

     

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou,China

Objectives

China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China.

Methods

The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores.

Results

After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001).

Conclusions

This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care.     

全科医学人才培养与继续教育形式的探讨

在分析全科医学人才培养现状的基础上,提出了开展全科医学人才培养和继续教育的必要性。探讨提高全科医师社区服务技能的办法,分析当前落实新医改工作中出现的矛盾和存在的关键问题,并提出在社区卫生服务工作中,要采取最好的学习方式和选择适合基层服务的内容来培养全科医学合格人才。     

Endo Echo Improves Primary Care Provider And Community Health Worker Self-Efficacy In Complex Diabetes Management In Medically Underserved Communities

Objective: To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions.Methods: We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline.Results: PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs (P<.0001) and by 60% in PCPs (P<.0001), with an overall large Cohen's effect size.Conclusion: Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services.Abbreviations: CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider     

Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesotho

Background

Although it is now widely recognized that reductions in maternal mortality and improvements in women''s health cannot be achieved through simple, vertical strategies, few programs have provided successful models for how to integrate services into a comprehensive program for maternal health. We report our experience in rural Lesotho, where Partners In Health (PIH) in partnership with the Ministry of Health and Social Welfare implemented a program that provides comprehensive care of pregnant women from the community to the clinic level.

Methods

Between May and July 2009, PIH trained 100 women, many of whom were former traditional birth attendants, to serve as clinic-affiliated maternal health workers. They received performance-based incentives for accompanying pregnant women during antenatal care (ANC) visits and facility-based delivery. A nurse-midwife provided ANC and delivery care and supervised the maternal health workers. To overcome geographic barriers to delivering at the clinic, women who lived far from the clinic stayed at a maternal lying-in house prior to their expected delivery dates. We analyzed data routinely collected from delivery and ANC registers to compare service utilization before and after implementation of the program.

Results

After the establishment of the program, the average number first ANC visits increased from 20 to 31 per month. The clinic recorded 178 deliveries in the first year of the program and 216 in the second year, compared to 46 in the year preceding the program. During the first two years of the program, 49 women with complications were successfully transported to the district hospital, and no maternal deaths occurred among the women served by the program.

Conclusions

Our results demonstrate that it is possible to achieve dramatic improvements in the utilization of maternal health services and facility-based delivery by strengthening human resource capacity, implementing active follow-up in the community, and de-incentivizing home births.     

Feasibility assessment and implementation strategies of green care in rural Taiwan

Pursuing the rural idyll for retirement is especially a popular age-old dream for Taiwan people. Farming for health is an emerging trend, which drivers to initiate a green care service based on a combination of agriculture resources and traditional care. The purposes of this study were to assess the feasibility of green care in rural communities and to propose implementation strategies for varied rural area types in Taiwan. This study was conducted with two stags. A feasibility study comprising two aspects of political and environmental feasibilities was assessed in the first stage. The political feasibility was assessed based on social demand and government policies. Accordingly, three alternative models for senior green care participation were proposed, including green occupational therapy (for residents), rural long-stay tourism (for tourists), and agricultural working holiday (for volunteers). The environmental feasibility assessment was conducted in 102 rural communities in northern Taiwan. Five indexes, including the natural environment, rural resources, public facilities, senior care, and community capacity, were used to evaluate the potential of communities for developing green care. The results showed that green care implementing active aging in place in rural areas is feasible. Seventeen communities with plentiful or unique rural resources and high-quality community capacity were recommended as potential communities. In the second stage, a multiple case study was conducted in three communities representing different alternative models of green care. The community leader interviews, on-site investigations, vision forum, and operation workshop were adopted to propose the implementation strategies of green care for three communities, respectively, including human resource, volunteer or tourist management, revenue distribution, and marketing.

     

Politics, Practical Logic, and Primary Health Care in Rural Haiti

During the 1980s, an ambitious project for health development restructured medical services throughout rural Haiti. The "Rural Health Delivery System" (RHDS) pursued several goals of primary health care, including dispensary-based maternal and child health services and the provision of low–cost drugs. Based on fieldwork in a single village, this article examines how local residents pushed the project in unpredictable and ironic directions. People did not regard dispensary services—which were planned and financed by international health agencies—as essentially foreign elements in the local health–care system. They rather engaged with the dispensary according to long–standing local strategies for prestige and economic advance. Despite the dramatically new shape of biomedicine introduced by the RHDS, the dispensary remained for most people a recognizable arena to gain access to state resources or to contest state control over their lives. The "success" of clinic services, and the "failure" of the project to distribute essential drugs arose more from people's practical routes to symbolic and material power than from the formal plans of health planners or state bureaucrats. This practice-based analysis provides another dimension to both the liberal and neo-Marxist critiques of international health development, [primary health care, community participation, planned development, Haiti]     

Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women

Objective

In order to develop patient-centered care we need to know what patients want and how changing socio-demographic factors shape their preferences.

Methods

We fielded a structured questionnaire that included a discrete choice experiment to investigate women’s preferences for place of delivery care in four rural districts of Pwani Region, Tanzania. The discrete choice experiment consisted of six attributes: kind treatment by the health worker, health worker medical knowledge, modern equipment and medicines, facility privacy, facility cleanliness, and cost of visit. Each woman received eight choice questions. The influence of potential supply- and demand- side factors on patient preferences was evaluated using mixed logit models.

Results

3,003 women participated in the discrete choice experiment (93% response rate) completing 23,947 choice tasks. The greatest predictor of health facility preference was kind treatment by doctor (β = 1.13, p<0.001), followed by having a doctor with excellent medical knowledge (β = 0.89 p<0.001) and modern medical equipment and drugs (β = 0.66 p<0.001). Preferences for all attributes except kindness and cost were changed with changes to education, primiparity, media exposure and distance to nearest hospital.

Conclusions

Care quality, both technical and interpersonal, was more important than clinic inputs such as equipment and cleanliness. These results suggest that while basic clinic infrastructure is necessary, it is not sufficient for provision of high quality, patient-centered care. There is an urgent need to build an adequate, competent, and kind health workforce to raise facility delivery and promote patient-centered care.     

A University/Community Hospital Family Practice Residency Program

A residency program associated with a major university has many obvious advantages. On the other hand, a residency program located in an area of health manpower shortage is a major advantage to that community. This paper describes the development of a university affiliated family practice residency in the Mojave Desert of Southern California. It reports that it is possible to form a successful alliance between a medical center and a rural community, bringing increased primary care to the community, upgrading the quality of medicine practiced in the community and augmenting the staff of the local hospital without sacrificing training for the family practice residents. Furthermore, the residency program can become financially self-sufficient.     

The determinants of delivery care in Kenya

This paper examines the determinants of place of delivery and childbirth attendant in Kenya based on the 1993 Kenya Demographic and Health Survey data. The analysis utilizes multilevel logistic and multilevel multinomial regression models for the place of delivery and the type of childbirth attendant, respectively. The results show that delivery care in Kenya is determined by a wide range of factors: socioeconomic and cultural factors associated with the individual woman or her household, her demographic status or reproductive behavior relating to a specific birth, as well as availability and accessibility of health services within her community. In addition, a significant variation in delivery care behavior is observed between women and between communities, implying that there are unobserved factors within families and communities that have a significant effect on delivery care. The woman or family effect on delivery care is particularly strong, but varies by distance to the nearest delivery care facility.     

Distribution of triatomine (Hemiptera: Reduviidae) vectors of Chagas disease in the state of Hidalgo,Mexico

Chagas disease represents a significant public health problem in Mexico. In the state of Hidalgo, studies on the presence of triatomines are scarce and restricted to a few locations. To determine the risk of transmission in the state of Hidalgo and stratify the vector potential, the distribution of Triatominae was surveyed from 2015 to 2016 in collaboration with primary health care services and local communities. A total of 570 specimens was collected in 278 houses in 25 municipalities. The species of Triatominae detected were T. dimidiata with 391 samples, T. mexicana with 159 samples, T. gerstaeckeri with 17 samples, and T. barberi with three samples. The samples were collected in domestic and peridomestic areas. The general index of natural infection was 9.8%. Indices of colonization and crowding were determined for species and municipality and results were variable.     

Dementia care in rural China

Dementia is a major cause of disability and has immense cost implications for the individual suffering from the condition, family caregivers and society. Given the high prevalence of dementia in China with its enormous and rapidly expanding population of elderly adults, it is necessary to develop and test approaches to the care for patients with this disorder. The need is especially great in rural China where access to mental healthcare is limited, with the task made more complex by social and economic reforms over the last 30 years that have transformed the Chinese family support system, family values and health delivery systems. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for discussion of innovative approaches in the management of dementia in rural China, with particular focus on its implementation in the primary care system.     

Buffeted by harsh economic winds,medical schools turn a wary eye to the future

All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says.     

The history of the journal social biology: 1954 (Vol. 1) through 1999 (Vol. 46)

Abstract

This paper examines the determinants of place of delivery and childbirth attendant in Kenya based on the 1993 Kenya Demographic and Health Survey data. The analysis utilizes multilevel logistic and multilevel multinomial regression models for the place of delivery and the type of childbirth attendant, respectively. The results show that delivery care in Kenya is determined by a wide range of factors: socioeconomic and cultural factors associated with the individual woman or her household, her demographic status or reproductive behavior relating to a specific birth, as well as availability and accessibility of health services within her community. In addition, a significant variation in delivery care behavior is observed between women and between communities, implying that there are unobserved factors within families and communities that have a significant effect on delivery care. The woman or family effect on delivery care is particularly strong, but varies by distance to the nearest delivery care facility.     

Older Russian emigrés and medical care.

Although emigration from the former Soviet Union is dramatically increasing nationwide, little information has been reported on the medical problems of these emigrés. For older emigrés in particular, the medical realities of aging, in combination with cultural expectations, make the United States'' medical system an arena where the stresses of emigration are expressed and help is sought. We describe the influences of culture and aging on older emigrés'' health and interaction with the American medical system. A qualitative, exploratory study was done of problems and issues in health care use by older Russian emigrés at the ambulatory medical clinic of Mount Zion Medical Center, San Francisco. Cultural expectations and beliefs about health, adaptive health behaviors learned in the former Soviet Union, the stresses of emigration, and the medical realities of aging can result in serious problems in the care and treatment of older Russian emigrés. Recommended solutions include educating emigrés and health care professionals, integrating mental health services into the primary care setting, and expanding supportive services in the community such as adult day health care.     

Primary and managed care. Ingredients for health care reform.

The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.