Development of a rural strategy for an urban-based medical program: a pragmatic reality.

INTRODUCTION: Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce. METHODS: This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach. RESULTS: Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission. CONCLUSION: These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

National Rural Health Mission reforms in light of decentralised planning in Kerala, India: a realist analysis of data from three witness seminars.

BACKGROUND: The People's Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. METHODS: We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. RESULTS: Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM's frontline health workers, ASHAs, emerged as leaders in LSGs. CONCLUSION: The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation - these contradictions may vex progress going forward and warrant further study.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team.

BACKGROUND: Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS: We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS: The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION: Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review.

BACKGROUND: Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action. OBJECTIVE: This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building. METHODS: This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems). RESULTS: The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%). CONCLUSION: This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization.

BACKGROUND: Despite remarkable gains over the past decade, mounting evidence suggests that Ethiopia's rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia's rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level. METHODS: We employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists. FINDINGS: Despite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly. CONCLUSION: Despite significant gains over the last couple of months, Ethiopia's rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the "usual" tweaks to reap maximum benefits.

The effect of urban-rural health insurance integration on consumption of middle-aged and older adult households in rural areas: evidence from China.

Introduction: Rural consumption is crucial in promoting economic and social development in China's economic slowdown. Integrating urban-rural residents' health insurance has alleviated the financial burden of medical expenses for rural households and boosted rural household consumption. This study examines the effect of integrating urban-rural residents' health insurance on the consumption patterns of middle-aged and older adult households in rural China. Our research provides a reference basis for improving rural healthcare security and enhancing the sustainable consumption capacity in rural areas. Methods: We employed a Propensity Score Matching Difference-in-Differences model (PSM-DID) to estimate the association between health insurance integration and household consumption using panel data from the China Health and Retirement Longitudinal Study (CHARLS) from 2013 to 2018. Furthermore, we employed a mediation model to analyze the influencing mechanisms. Results: Our findings suggested a positive association between health insurance integration and survival consumption as well as total consumption among rural middle-aged and older adult households. The conclusion remained valid after endogeneity treatment, robustness and placebo tests. Furthermore, we found that the impact of health insurance integration is more pronounced for middle-aged, female, and high-income rural residents' households. Integrating urban-rural residents' health insurance raised consumption by reducing medical expenses and increasing health and life expectancy. Discussion: Policymakers should deepen the rural medical and health system reform, improve the convenience of medical services for middle-aged and older adult families in rural areas, and improve the medical and life assistance mechanism for vulnerable groups in rural areas. Additionally, the local government should continuously broaden rural household income channels to promote upgrading consumption structure while improving overall consumption levels.

Translating research into rural health practice: a qualitative study of perceived capability-building needs.

INTRODUCTION: The timely translation of research into practice and local policy is critical to improving healthcare delivery in rural and regional settings, and remains a concern for researchers, health professionals, health managers and policymakers alike. Successful and sustained research translation does not occur without concerted effort, support and strategies to build research translation capacity and capability. Research capacity comprises individual and organisational capabilities. This study is primarily focused on individual capabilities. Health professionals working in rural and regional settings, where research activity and infrastructure are generally less mature than that seen in metropolitan areas, need additional support and skills to build their capability to engage in translation-focused research. This study aimed to explore rural health research stakeholders' perspectives on capability-building needs for emerging researchers to enable the translation of research into health practice. METHODS: A qualitative description methodology was used to conduct three online focus groups to explore participants' understanding of research translation, and their perceptions of the supports that are needed to build capability for emerging health professional researchers to undertake translation-focused research. Emerging health professional researchers (emerging researchers hereafter) are health professionals who have little or no formal training or experience undertaking research. Data were analysed by a five-stage framework approach. RESULTS: Participants included emerging researchers (n=12), research mentors (n=3) and health managers (n=4) from six rural or regional organisations, including four health services, one university and one primary health network in Victoria, Australia. Participants' conceptualisation of research translation reflected previously documented definitions; that is, research grounded in health practice and characterised by adaptation of existing research evidence to local settings via implementation. Four key themes related to research translation support for rural and regional health researchers were identified: understanding the study and translation context is vital to enacting change; engaging with stakeholders identifies research and translation priorities and suitable approaches; mentor and managerial support assists navigation of research translation activities; and access to clinical and research networks promotes research translation partnerships and collaborations. Participants highlighted the need to identify and train appropriate research mentors and health leaders who can support translation-focused research at the emerging researcher level. The need for training that targets fundamental research translation skills, including systematic processes for engaging stakeholders and collaborative priority setting, and the processes to analyse both the research study and research translation contexts, were also identified as important. CONCLUSION: Given their understanding of the local community and health context, rural and regional health professionals are ideally placed to engage in translation-focused research; however, they require multiple types of research capability development through several levels of influence. This includes support and guidance to ensure their endeavours align with and leverage organisational and regional priorities for research translation. These findings can inform approaches to research capability building through training and resource provision, and organisational infrastructure development and capacity building, to support the rapid translation of research into clinical practice.

Enhancing early career professionals' representation and engagement at international conferences: WONCA "Rural Early Career Ambassador Integration" project.

INTRODUCTION: International conferences offer an excellent opportunity for career development and are global academic opportunities with the potential to foster educational and professional growth. However, equitable access to participation and meaningful involvement in such events remains an issue. In this article we describe the novel Rural Early Career Ambassador Integration project and its implications for the 2022 World Rural Health Conference, held at the University of Limerick, Ireland. METHODS: The project offered vertical and cross-country collaborative opportunities to early career professionals with a passion for rural medicine. Three ambassadors of diverse nationalities, ethnicities and professional backgrounds were selected. They bore no personal cost for travel, transport or accommodation relating to the conference. Each ambassador was matched to and clinically shadowed an expert rural GP for a week preceding the conference, who provided mentorship. Mentors and ambassadors collaborated on goal-setting and work-planning throughout the conference, and were offered one-on-one career and networking support. The ambassadors were welcomed and integrated within a larger working party, the WONCA Working Party for Rural Health. RESULTS: The project was well received by conference delegates and organisers, and achieved its stated goal of enhancing conference equity through the representation and meaningful involvement of diverse early career professionals. Vertical and cross-country collaboration generated actionable policy implications as is evidenced by the ambassadors' co-authorship on the Limerick Declaration on Rural Healthcare. CONCLUSION: Although sponsorship for these initiatives remains a challenge, this project highlights the importance of actively including early career professionals at international conferences.

Evaluating Rural Health Disparities in Colombia: Identifying Barriers and Strategies to Advancing Refugee Health.

Health disparities within rural communities, notably those affecting migrant and refugee populations, are well-documented. Refugees often grapple with high disease burdens and mortality rates due to limited access to primary healthcare and their vulnerable socio-economic and political situations. This issue is particularly acute in the rural areas around Medellin, Colombia, where the refugee influx exacerbates the existing public health challenges. Studies highlight a substantial gap between community needs and public health policies, resulting in inadequate healthcare access. Our study, utilizing the Delphi technique, aimed to identify common barriers and strategies to enhance rural healthcare for refugees. Through consensus-building with community leaders, we identified six primary barriers to healthcare access and five barriers to healthcare quality. Community leaders endorsed five strategies to address the access barriers and eight strategies to improve healthcare quality. This research provides valuable insights for optimizing resource allocation and designing effective support programs for these vulnerable populations.

A new one-stop interdisciplinary cognitive clinic model tackles rural health inequality and halves the time to diagnosis: Benchmarked against a national dementia registry.

OBJECTIVES: Unequal access to cognitive assessments is a major barrier to timely diagnosis, especially for those living in rural or remote areas. 'One-stop' cognitive clinic models are a proposed solution, but few such clinics exist. We evaluate the implementation of a new one-stop State-wide clinic model in Tasmania, Australia, where 27% of people live in rural/remote areas. METHODS: A novel single-visit protocol has been developed, comprising interdisciplinary medical and cognitive assessments, research participation, consensus diagnosis and management plan. A cross-sectional evaluation was undertaken using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework and results benchmarked against the national Australian Dementia Network Registry. RESULTS: Over the first 52 consecutive weekly clinics: Reach: 130 adults were assessed (mean age [SD] 70.12 years [10.31]; 59.2% female) with 40 (36.8%) from rural/remote areas. EFFECTIVENESS: 98.5% (128/130) received a same-day diagnosis: 30.1% (n = 40) Subjective Cognitive Decline, 35.4% (46) Mild Cognitive Impairment, 33.1% (43) dementia and one case inconclusive. Adoption: 22.9% (156) of General Practitioners referred patients. IMPLEMENTATION: Nearly all 'ideal' diagnostic clinical practices were met and >90% of surveyed patients reported 'good/very good' clinic experience. The wait from referral to diagnosis was 2 months shorter than other national Registry clinics (78 vs. 133 days). CONCLUSIONS: This 'one-stop' model provides an interdisciplinary consensus cognitive diagnosis quickly and is well accepted; this may reduce health inequities especially for people living in rural/remote areas. This cognitive clinic model may be of relevance to other centres worldwide and also provides a rich data source for research studies.

The Power in Rural Place Stigma.

The phenomenon and implications of stigma have been recognized across many contexts and in relation to many discrete issues or conditions. The notion of spatial stigma has been developed within stigma literature, although the importance and relevance of spatial stigma for rural places and rural people have been largely neglected. This is the case even within fields of inquiry like public and rural health, which are expansively tasked with addressing the socio-structural drivers of health inequalities. In this paper, we argue that developing a better understanding of rural place stigma is critical for addressing contemporary patterns of spatial injustice and health inequalities affecting rural communities globally. Drawing on international literature and examples from the reported experiences of rurally living Australians and news and other media, we present an analysis highlighting the power in rural place stigma. In doing so, we build a case for the relevance and importance of interrogating rural place stigma, especially in the fields of public and rural health, for changing the conditions within-and the broader positioning of-the rural in the public and political landscapes.

Effective health and wellness systems for rural and remote Indigenous communities: a rapid review.

Background: The Canadian healthcare system bares a long legacy of colonisation and assimilation of Indigenous values and approaches to health and wellness. This system often perpetuates social and health inequities through systemic racism, underfunding, lack of culturally appropriate care and barriers to access care. Current funding legislation policies enacted across federal, provincialand territorial governments do not necessarily uphold Indigenous Peoples' rights to self-determination, health and wellness. We summarise literature on promising Indigenous health systems and practices that prioritise and/or improve rural Indigenous Peoples' health and wellness. Objective: The impetus for this review was to provide information on promising health systems, while Dehcho First Nations developed a health and wellness vision. Methods: Documents were gathered from indexed and non-indexed databases to obtain literature from peer-reviewed and non-peer reviewed sources. Two reviewers independently 1) screened titles, abstracts and full texts to ensure they met the inclusion criteria, 2) gathered relevant data from all included documents and 3) identified major themes and sub-themes. Reviewers then discussed and reached consensus on the themes. Results: Thematic analysis revealed six themes for effective health systems for rural and remote Indigenous communities: 1) access to primary care, 2) multi-directional knowledge exchange, 3) culturally appropriate care, 4) training and building community capacity, 5) integrated care and 6) health system funding. Conclusion: Effective health and wellness systems must support Indigenous ways of knowing and doing in healthcare models based on collaborative partnerships with community members, health providers and government agencies.

Sustainable health and wellness funding plans must be provided through federal, provincial, territorial and state partnerships.Indigenous core values, culture and knowledge must be integrated within mainstream health systems.Indigenous Rightsholders must inform all plans for altering or implementing Indigenous health systems.Non-Indigenous cultural safety and competency training can improve care.

Barriers to rural health care from the provider perspective.

INTRODUCTION: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. METHODS: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. RESULTS: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. CONCLUSION: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

Association of Urban-Rural Health Insurance Integration With Health Outcomes Among Middle-aged and Older Adults in Rural China.

This cohort study examines the association of urban-rural health insurance integration with health outcomes among middle-aged and older adults in rural China.

Climate-Related Natural Disasters: Reflections on an Agenda for Rural Health Research.

The increasing frequency and severity of climate-related disasters will exacerbate the health inequities that already exist between people living in rural communities and those living in urban areas. There is a need to improve understanding of the differences in the impacts on and needs of rural communities, in order that policy, adaptation, mitigation, response and recovery efforts meet the needs of those who are most affected by flooding and who have the fewest resources to mitigate the impact and adapt to the increased flood risk. This paper is a reflection by a rural-based academic on the significance and experience of community-based flood-related research, with a discussion of the challenges and opportunities for research on rural health and climate change. From an equity perspective, there is a need for all analyses of national and regional datasets on climate and health to, wherever possible, examine the differential impacts and policy and practice implications for regional, remote and urban communities. At the same time, there is a need to build local capacity in rural communities for community-based participatory action research, and to enhance this capacity through building networks and collaborations between different researchers based in rural areas, and between rural- and urban-based researchers. We should also encourage the documentation, evaluation and sharing of experience and lessons from local and regional efforts to adapt to and mitigate the impacts of climate change on health in rural communities.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States.

INTRODUCTION: The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based). METHODS: We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type. RESULTS: Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic. DISCUSSION: The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.