Last-mile delivery increases vaccine uptake in Sierra Leone.

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care. OBJECTIVE: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved. DESIGN: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation. PARTICIPANTS: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast. APPROACH: Qualitative interviews were analyzed using a mixed inductive/deductive approach. KEY RESULTS: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership. CONCLUSIONS: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Telerheumatology Shared-Care Model: Leveraging the Expertise of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-Trained Extended Role Practitioner in Rural-Remote Ontario.

OBJECTIVE: A shortage of rheumatologists has led to gaps in inflammatory arthritis (IA) care in Canada. Amplified in rural-remote communities, the number of rheumatologists practicing rurally has not been meaningfully increased, and alternate care strategies must be adopted. In this retrospective chart review, we describe the impact of a shared-care telerheumatology model using a community-embedded Advanced Clinician Practitioner in Arthritis Care (ACPAC)-extended role practitioner (ERP) and an urban-based rheumatologist. METHODS: A rheumatologist and an ACPAC-ERP established a monthly half-day hub-and-spoke-telerheumatology clinic to care for patients with suspected IA, triaged by the ACPAC-ERP. Comprehensive initial assessments were conducted in-person by the ACPAC-ERP (spoke); investigations were completed prior to the telerheumatology visit. Subsequent collaborative visits occurred with the rheumatologist (hub) attending virtually. Retrospective analysis of demographics, time-to-key care indices, patient-reported outcomes, clinical data, and estimated travel savings was performed. RESULTS: Data from 124 patients seen between January 2013 and January 2022 were collected; 98% (n = 494/504 visits) were virtual. The average age of patients at first visit was 55.6 years, and 75.8% were female. IA/connective tissue disease (CTD) was confirmed in 65% of patients. Mean time from primary care referral to ACPAC-ERP assessment was 52.5 days, and mean time from ACPAC-ERP assessment to the telerheumatology visit was 64.5 days. An estimated 493,470 km of patient-related travel was avoided. CONCLUSION: An ACPAC-ERP (spoke) and rheumatologist (hub) telerheumatology model of care assessing and managing patients with suspected IA in rural-remote Ontario was described. This model can be leveraged to increase capacity by delivering comprehensive virtual rheumatologic care in underserved communities.

A Qualitative Study Defining Perspectives on Rurality and Surgery From Midwestern Medical Schools.

INTRODUCTION: Rural general surgery faces a crisis as more surgeons undergo fellowship training and then practice in metropolitan areas, leaving rural Americans with decreasing surgical care. This study aims to identify how hometown rurality affects medical students' current level of knowledge and potential educational gaps within their understanding of the definition, benefits, and challenges of rural general surgery to define the need for enhanced education within medical schools. METHODS: In Spring 2021, 11 Midwestern medical schools participated in an electronic survey. Participants were divided into three groups (rural, urban, or suburban) based on their hometown rurality using Rural-Urban Continuum Codes. Qualitative analysis was performed for three questions addressing the definition, benefits, and challenges of rural surgery. RESULTS: Responses were analyzed from 411 students whose hometowns were representative of 33 states. The majority of respondents were female (n = 260; 63.4%) and Caucasian (n = 230; 56.9%) from self-reported suburban backgrounds who grew up and remained in the Midwest for their education. Major themes identified across all students were defining rural surgery as "Rural"/"Farmland"/"Nowhere" and specified the challenges of rural surgery to be relating to funding, facilities, and/or technology. Benefits identified were breadth of surgical procedures and community engagement. CONCLUSIONS: Most students do not understand the concept of rurality by definition or Rural-Urban Continuum Codes. However, students were able to identify a broad range of challenges and benefits faced by rural surgeons today. This provides a foundational needs assessment to drive future educational efforts to increase exposure to and knowledge of rural general surgery.

Lessons Learned Implementing Syringe Services Programs at Rural Health Departments in Kentucky.

Until recently, most syringe services programs (SSPs) in the United States operated in metropolitan areas. This study explores how SSP implementers at rural health departments in Kentucky secured support for SSP operations. In late 2020, we conducted in-depth, semi-structured interviews with 18 people involved with rural SSP implementation in Kentucky. Participants were asked to reflect on their experiences building support for SSP operations among rural health department staff and community members. Participants reported that attitudes and beliefs about SSP implementation among rural health department staff shifted quickly following engagement in educational activities and interaction with SSP clients. Participants explained that successful SSP implementation at rural health departments required sustained educational activities among community members and authorizing authorities. Future work should explore how rural communities may advocate for low-threshold and evidence-based policies that support the provision of harm reduction services.

Uneven primary healthcare supply of rural doctors and medical equipment in remote China: community impact and the moderating effect of policy intervention.

BACKGROUND: Unequal access to primary healthcare (PHC) has become a critical issue in global health inequalities, requiring governments to implement policies tailored to communities' needs and abilities. However, the place-based facility dimension of PHCs is oversimplified in current healthcare literature, and formulating the equity-oriented PHC spatial planning remains challenging without understanding the multiple impacts of community socio-spatial dynamics, particularly in remote areas. This study aims to push the boundary of PHC studies one step further by presenting a nuanced and dynamic understanding of the impact of community environments on the uneven primary healthcare supply. METHODS: Focusing on Shuicheng, a remote rural area in southwestern China, multiple data are included in this village-based study, i.e., the facility-level healthcare statistics data (2016-2019), the statistical yearbooks, WorldPop, and Chinese GDP's spatial distribution data. We evaluate villages' PHC service capacity using the number of doctors and essential equipment per capita, which are the major components of China's PHC delivery. The indicators describing community environments are selected based on extant literature and China's planning paradigms, including town- and village-level factors. Gini coefficients and local spatial autocorrelation analysis are used to present the divergences of PHC capacity, and multilevel regression model and (heterogeneous) difference in difference model are used to examine the driving role of community environments and the dynamics under the policy intervention. RESULTS: Despite the general improvement, PHC inequalities remain significant in remote rural areas. The village's location, aging, topography, ethnic autonomy, and economic conditions significantly influence village-level PHC capacity, while demographic characteristics and healthcare delivery at the town level are also important. Although it may improve the hardware setting in village clinics (coef. = 0.350), the recent equity-oriented policy attempts may accelerate the loss of rural doctors (coef. = - 0.517). Notably, the associations between PHC and community environments are affected inconsistently by this round of policy intervention. The town healthcare centers with higher inpatient service capacity (coef. = - 0.514) and more licensed doctors (coef. = - 0.587) and nurses (coef. = - 0.344) may indicate more detrimental policy effects that reduced the number of rural doctors, while the centers with more professional equipment (coef. = 0.504) and nurses (coef. = 0.184) are beneficial for the improvement of hardware setting in clinics. CONCLUSIONS: The findings suggest that the PHC inequalities are increasingly a result of joint social, economic, and institutional forces in recent years, underlining the increased complexity of the PHC resource allocation mechanism. Therefore, we claim the necessity to incorporate a broader understanding of community orientation in PHC delivery, particularly the interdisciplinary knowledge of the spatial lens of community, to support its sustainable development. Our findings also provide timely policy insights for ongoing primary healthcare reform in China.

Rural-urban differences in health service utilization in upper-middle and high-income countries: a scoping review.

PURPOSE: This scoping review aims to understand the extent and attributes of literature evaluating differences between rural and urban populations' utilization of health services in upper-middle and high-income countries. METHOD: The review was conducted in line with established scoping review methodology guidelines. We used the "Participants, Concept and Context" framework to guide the inclusion criteria and determination of the review's scope. Studies published over a 15-year period (2008-2022) were identified using Embase, Medine, PubMed, and Scopus databases. Study attributes, areas of focus and findings were reviewed and extracted. RESULTS: The search identified 179 studies. The number of studies published looking at rural-urban differences in health service utilization has increased over time. The focus of these studies is relatively evenly split between primary and secondary sectors. The majority of studies observed less service utilization by rural populations than urban-especially so in primary-sector services. When higher rural utilization of secondary services was observed this was frequently attributed to poor access to other services that would have had the potential to mitigate the secondary demand. Studies were not commonly grounded in principles of equity or fairness and rarely offered value judgements on observed differences in utilization. There were limited system-level studies - the vast majority being disease- or service-specific analyses. We consider this a notable gap in the literature. CONCLUSION: This scoping review identifies key parameters of studies on rural-urban variation in health service utilization. The finding that most studies observed rural populations utilized comparatively less services is concerning, in the context of general evidence about high levels of health need in rural communities. Future system-level research considering the combined variations in need and utilization appears a priority.

Perceived stakeholder benefits of continuously training general practitioners in the same rural or remote practice: interviews exploring the Remote Vocational Training Scheme.

OBJECTIVE: Explore stakeholder perspectives of the benefits of continuously training general practitioners in the same rural or remote practice in distributed locations via the Remote Vocational Training Scheme (RVTS). DESIGN, SETTING, PARTICIPANTS: Online one-hour semi-structured interviews were conducted with 27 RVTS staff, participants and supervisors from all states and territories between 16 October and 24 November 2023. Data were deductively and inductively coded by stakeholder type and the range of benefits, and the findings were informed by insights from a project reference group and a stakeholder advisory group. Questions explored the benefits of the RVTS - a program which supports doctors already working in rural, remote and First Nations communities to train towards general practice or rural generalist fellowship while remaining in the same practice. MAIN OUTCOMES MEASURES: Perspectives on the nature and spread of benefits. RESULTS: Broad benefits were perceived to flow to four system-level stakeholders: communities, health services, participants and policy makers. Perceived participant and community benefits were doctors staying longer in distributed locations with tailored place-based supports and training, doctors building relationships with patients, and doctors learning through longitudinal care. Health service benefits included reduced reliance on locums, improved continuity of accessible and appropriate services in areas otherwise facing major recruitment and retention issues, and the doctors having more time to contribute to improving service quality and upskilling local staff. Policy-maker benefits were sustaining safe and high quality services for distributed populations with high needs. CONCLUSION: The RVTS model was perceived to offer diverse benefits for different system stakeholders which could improve quality of learning, service delivery and community care. It also aligned with key policy directions for a distributed and sustainable generalist workforce under the goals of the National Medical Workforce Strategy 2021-2031 and the directions set by the independent review of overseas health practitioner regulatory settings led by Robyn Kruk. However, models like the RVTS largely rely on distribution levers to recruit more doctors to the locations it supports.

Holistic support framework for doctors training as rural and remote general practitioners: a realist evaluation of the RVTS model.

OBJECTIVE: To develop theory about how and why the supervision and support model used by the Remote Vocational Training Scheme (RVTS) addresses the professional and non-professional needs of doctors (including many international medical graduates) who are training towards general practice or rural generalist fellowship while based in the same rural or remote practice. DESIGN, SETTING, PARTICIPANTS: We conducted a realist evaluation based on the RAMESES II protocol. The initial theory was based on situated learning theory, networked ecological systems theory, cultural theory and geographical narcissism theory. The theory was developed by collecting empirical data through interviews with 27 RVTS stakeholders, including supervisors, participants and RVTS staff. The theory was refined using a project reference and a stakeholder advisory group and confirmed using individual meetings with experts. MAIN OUTCOMES MEASURES: Theory about how the contexts of person, place and program interacted to address professional and non-professional needs. RESULTS: The RVTS program offers remote access to knowledgeable and caring supervisors, real-time tailored advice, quality resources and regular professional networking opportunities, including breaks from the community. It worked well because it triggered five mechanisms: comfort, confidence, competence, belonging and bonding. These mechanisms collectively fostered resilience, skills, professional identity and improved status; they effectively counteracted the potential effects of complex and relatively isolated work settings. CONCLUSION: This theory depicts how a remotely delivered supervision and support model addresses the place and practice challenges faced by different doctors, meeting their professional and non-professional needs. The participants felt valued as part of a special professional group delivering essential primary health care services in challenging locations. The theory could be adapted and applied to support other rural and remote doctors.

The provision of general surgery in rural Australia: a narrative review.

Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia. The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes. Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes. To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural-facing generalist curriculum. Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres. Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

Recruitment and retention of new doctors in remote and Aboriginal medical services through the Remote Vocational Training Scheme's Targeted Recruitment Strategy: a focus group study.

OBJECTIVE: To explore the results of a targeted recruitment strategy designed to attract and retain new doctors in remote and Aboriginal medical services where they can access Remote Vocational Training Scheme (RVTS) training and support to qualify as general practitioners. STUDY DESIGN: Two 2-hour purposeful online focus groups on the RVTS' Targeted Recruitment Strategy. SETTING AND PARTICIPANTS: Five participants and nine stakeholders with knowledge and experience of the strategy. Data were transcribed and deductively and inductively coded for themes including insights from separate project reference and stakeholder advisory groups. MAIN OUTCOMES MEASURES: Perspectives of the strategy. RESULTS: The overarching theme was that the strategy is useful for attracting and retaining new general practitioners in areas of high need and is potentially scalable. Since 2018, 20 new doctors were recruited via the Targeted Recruitment Strategy and six of them completed the RVTS program. The strategy could better differentiate target locations because increasing communities are experiencing major general practice workforce shortages. The package of employment and training could also be more clearly defined for participants, nationally marketed and collaboratively implemented. Further, more site accreditation and ongoing risk and quality review is needed, along with intense early supports for participants who are new to both the community and general practice work. CONCLUSION: The Targeted Recruitment Strategy is still maturing but the early results suggest it is a unique and proactive model for attracting and improving access to general practitioners in places with high needs. It could be strengthened through formal agreements between communities and agencies, ensuring coordinated implementation, clarifying roles and responsibilities, and developing clear pathways for risk and quality management.

Continuity of service and longer term retention of doctors training as general practitioners in the Remote Vocational Training Scheme.

OBJECTIVE: To explore continuity of service and longer term retention outcomes of participants of the Remote Vocational Training Scheme (RVTS). DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study of all doctors who participated in the RVTS from 2000 to 2023, many of whom are international medical graduates and are expected to work in the same community for three to four years in remote (Modified Monash Model [MMM] categories 4-7) or rural Aboriginal Medical Services (AMS) streams while undertaking training towards general practice fellowship. MAIN OUTCOME MEASURES: Continuity of service was measured in the pre-program period (period working in same practice before commencing) and during-program period (period completing the RVTS program in same practice as worked in before commencing the program). Retention was measured firstly within two years, and secondly beyond two years (up to 20 post-completion years) based on: working in the same community (relevant to both streams); working in the same region (Remote Stream only); working in any MMM4-7 community (Remote Stream only); or working anywhere rurally (both streams). RESULTS: From 506 enrolled participants, 373 (73.7%) were international medical graduates. The approximate mean service continuity in the same practice was 1.6 years (standard deviation [SD], 2.2 years) for the pre-program period and 3.6 years (SD, 1.4 years) for the during-program period (mean total, 5.2 years). Two years after completion, 21 out of 43 Remote Stream doctors (49%) and four out of five AMS Stream doctors (80%) remained in the same community. Over the long term, retention in the same community stabilised to 44 out of 242 Remote Stream doctors (18.2%) and seven out of 27 AMS Stream doctors (26%); 72 Remote Stream doctors (29.8%) remained in the same region, 70 Remote Stream doctors (28.9%) were in an MMM4-7 community, and 11 AMS Stream doctors (41%) were in a rural (MMM2-7) community. CONCLUSION: Strong service continuity outcomes have been achieved by the RVTS, which supports mostly international medical graduates in locations typified by the highest workforce turnover. This suggests that continuity of service could be improved for remote and First Nations communities through place-based retention-focused programs like the RVTS.

Growing up without health insurance: Evidence from rural China.

This paper examines the long-term effects of health insurance on children's educational attainment in a developing country. Utilizing the county-by-county rollout of the New Rural Cooperative Medical Scheme in rural China, we find that exposure to the health insurance program in early life leads to improved educational attainment in adulthood. Empirical tests suggest that a short-term increase in health care utilization is unlikely to be a potential channel. We provide some evidence for the channel that health insurance reduces household financial burdens and increases household expenditure on children's nutrition.

Clinician perspectives on delivering primary and specialty palliative care in community oncology practices.

PURPOSE: Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. METHODS: Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. RESULTS: Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). CONCLUSION: Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

Experiences of family carers supporting older people within the last year of life in rural and remote areas in the UK.

BACKGROUND: In the UK, a large proportion of older adults live in rural/remote locations. More people are dying at home and require care from their families. Little is known about the experiences of family carers of older people in rural/remote areas in the last year of life. AIM: To explore the experiences of current and bereaved family carers who support/ed an older person in a rural area in the UK towards the end-of-life. DESIGN: Qualitative methodology using semi-structured interviews and reflexive thematic analysis methods. METHOD: Interviews were conducted with family carers of rural/remote-dwelling older people in the last year of life. Participants were recruited through national support services, third sector organisations and social media. RESULTS: Interviews were conducted with 20 family carers. Most were female (n = 17) and aged 52-80 years. Family carers experienced difficulties in accessing health and social care in rural/remote areas due to workforce and skills shortages within their regions. The wider community helped with practical tasks and made carers feel less alone. Community-based services, such as day care, helped to provide respite for carers and promoted meaningful activity and social inclusion for older people. Although internet access was problematic, family carers gained support remotely via social media and telehealth services. CONCLUSION: Family carers of older people in the last year of life in rural/remote areas value support from the wider community. Further work is required to understand how Public Health approaches to palliative care and workforce distribution can support rural/remote carers and older people.

Collaborative international partnership: Enabling the development of a state-of-the-art minimally invasive surgical center in rural Uganda through telementoring.

BACKGROUND: Access to minimally invasive surgery (MIS) is limited in Sub-Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self-sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in-person training and supervised telementoring. We present the results of our initial MIS telementoring experience. METHODS: We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar-powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high-speed Internet. The local Ugandan general surgeon (JOD) underwent a mini-fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in-person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR. RESULTS: From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra-operative complications. Postoperatively, field medical workers visited patients at home to collect follow-up information. Two superficial wound infections (3.3%) were reported in the short-term follow-up. CONCLUSION: Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population.

An inverted U-shaped relationship between work-family conflict and job burnout among village clinic doctors: the moderating effect of information and communication technology use.

BACKGROUND: Village clinic doctors are an integral part of the rural healthcare workforce. With the advancement of science and technology and the coronavirus disease 2019 (COVID-19) pandemic, the prevalence of remote work and the use of information and communication technologies (ICT) have increased significantly. However, these developments have also had an impact on the work family balance and mental well-being of village clinic doctors. The study aimed to explore how work-family conflict affected job burnout and what the role of ICT use was in this relationship. METHODS: This was a cross-sectional study. Data were collected collected through an anonymous self-administered questionnaire survey conducted in December 2021 in Shandong Province, China. A total of 1,093 village clinic doctors participated in the survey. The data were analyzed using multiple linear regression and the PROCESS macro in SPSS. RESULTS: The results showed that an inverted U-shaped relationship between work-family conflict and job burnout among village clinic doctors. Specifically, the squared term of work-family conflict had a negative coefficient (-0.324). The slope was positive (SL=2.291) at the low end of the X-range and negative (SH=-0.379) at the high end. The turning point occurred at X = 1.227(-2.309 ≤ X ≤ 1.812). Additionally, ICT use positively moderated between work-family conflict and job burnout (ß1ß4-ß2ß3 = 0.217, ß4 > 0). CONCLUSIONS: The work-family conflict has an inverted U-shaped effect on job burnout, while the use of ICT positively moderates this relationship between work-family conflict and job burnout. Policymakers should pay attention to the effects of ICT use and work-family conflict on job burnout among village clinic doctors.

Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis.

BACKGROUND: Almost half the world's population lives in rural areas. How best to provide palliative care to rural populations is unclear. Privileging rural patient and family voices about their experiences of receiving care delivered via rural palliative care models is necessary. AIM: To identify the key palliative care elements that rural patients with palliative care needs and their families perceive to be critical to receiving the care and support they need to live well. DESIGN AND DATA SOURCES: A systematic review and meta-synthesis registered with Prospero (CRD42020154273). Three databases were searched in June 2024. Raw qualitative data were extracted and analysed using Thomas and Harden's three-stage thematic synthesis methodology. Findings reported according to the PRISMA statement. RESULTS: Of the 10,834 identified papers, 11 met the inclusion criteria. Meta-synthesis of extracted, raw quotes (n = 209) revealed three major themes: (1) Honouring the patient's existing relationship with their General Practitioner (GP); (2) strategically timed access to specialist services, clinicians and equipment is critical; and (3) a need to feel safe, prepared and supported. CONCLUSION: The strategic inclusion of specialists alongside primary care providers is integral to optimising rural palliative care models. General Practioners are central to these models, through being embedded in their communities and as the conduit to specialist palliative care services. Rural palliative care patients and families value responsive care, trajectory signposting, effective communication, 24/7 support and recognise the value of virtual health. Globally, positive public policy and funding is critical to ensuring access to GP-led, specialist-supported, rural palliative care models.

Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea.

BACKGROUND: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. METHODS: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. RESULTS: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. CONCLUSIONS: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis.

Guinea-Bissau has among the world's highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.