A Qualitative Evaluation of a Home-based Palliative Care Program Utilizing Community Health Workers in India.

AIM: In India, the need for rural palliative care is increasing with the rising number of people diagnosed with late-stage cancers. Rural areas also have a shortage of trained medical personnel to deliver palliative care. To address these needs, a home-based palliative care program using community health workers (CHWs) to facilitate care delivery was developed to extend the reach of a cancer center's palliative care services outside of Kolkata, India. The research question guiding this qualitative study was, how feasible, useful, and acceptable was this program from the perspectives of the clinical team and CHWs who delivered the intervention? METHODS: This qualitative descriptive study used a grounded theory approach and the iterative constant comparative method to collect and analyze data from the key stakeholder interviews. Ten qualitative interviews took place at the Saroj Gupta Cancer Center and Research Institute and were conducted with the CHWs who delivered the home-based palliative care intervention (n = 3) and the clinical team who provided them with training, support, and supervision (n = 7). RESULTS: Three major themes emerged (a) CHWs' desire and need for more training, (b) the need for tailoring of existing intervention protocols and modifying expectations of stakeholders, and (c) the need for considerations for ensuring program sustainability. CONCLUSIONS: The study provided evidence that the utilization of CHWs to facilitate delivery of palliative care is a feasible model worthy of consideration and further research testing in low-resource settings.

Community boundary spanners as an addition to the health workforce to reach marginalised people: a scoping review of the literature.

BACKGROUND: Health services in high-income countries increasingly recognise the challenge of effectively serving and engaging with marginalised people. Effective engagement with marginalised people is essential to reduce health disparities these populations face. One solution is by tapping into the phenomenon of boundary-spanning people in the community-those who facilitate the flow of ideas, information, activities and relationships across organisation and socio-cultural boundaries. METHODS: A scoping review methodology was applied to peer-reviewed articles to answer the question: "How do health services identify, recruit and use boundary spanners and what are the outcomes?" The review was conducted in seven databases with search terms based on community-based boundary spanning, marginalised people and health services. FINDINGS: We identified 422 articles with the screening process resulting in a final set of 30 articles. We identified five types of community-based boundary spanning: navigators, community health workers, lay workers, peer supporters and community entities. These range from strong alignment to the organisation through to those embedded in the community. We found success in four domains for the organisation, the boundary spanner, the marginalised individuals and the broader community. Quantifiable outcomes related to cost-savings, improved disease management and high levels of clinical care. Outcomes for marginalised individuals related to improved health knowledge and behaviours, improved health, social benefits, reduced barriers to accessing services and increased participation in services. We identified potential organisational barriers to using boundary spanners based on organisational culture and staff beliefs. CONCLUSIONS: Community boundary spanners are a valuable adjunct to the health workforce. They enable access to hard to reach populations with beneficial health outcomes. Maintaining the balance of organisational and community alignment is key to ongoing success and diffusion of this approach.

Where There is No EMS: Lay Providers in Emergency Medical Services Care - EMS as a Public Health Priority.

By 2030, road traffic accidents are projected to be the fifth leading cause of death worldwide, with 90% of these deaths occurring in low- and middle-income countries (LMICs). While high-quality, prehospital trauma care is crucial to reduce the number of trauma-related deaths, effective Emergency Medical Systems (EMS) are limited or absent in many LMICs. Although lay providers have long been recognized as the front lines of informal trauma care in countries without formal EMS, few efforts have been made to capitalize on these networks. We suggest that lay providers can become a strong foundation for nascent EMS through a four-fold approach: strengthening and expanding existing lay provider training programs; incentivizing lay providers; strengthening locally available first aid supply chains; and using technology to link lay provider networks. Debenham S , Fuller M , Stewart M , Price RR . Where there is no EMS: lay providers in Emergency Medical Services care - EMS as a public health priority. Prehosp Disaster Med. 2017;32(6):593-595.

Practical recommendations for supporting medical students and faculty in learning about family violence.

Family violence as a discipline of medical study and practice is now an integral component of medical education. Education about family violence should be spread among many courses and delivered by a variety of faculty throughout the four years of medical school. Medical faculty are just beginning to appreciate the complexities of teaching about family violence, in particular the issues involved in dealing with their own and their students' attitudes, feelings, and reactions to patients who have suffered from abuse. This article discusses the complex issues that need to be considered in preparing medical students and a broad range of medical faculty to teach and practice effectively in this area, and offers practical recommendations for approaching this complex issue. It notes the need for support services for both faculty and students, ranging from treatment for ongoing individual issues to an institutional plan or protocol for dealing with potential crises.

PIP: Family violence is an integral component of medical education and material on this topic should be spread among many courses throughout the 4 years of medical school. Medical faculty in the US are just beginning to recognize the complexities of teaching about family violence and the need for medical students to deal effectively with their own attitudes, feelings, and reactions toward abuse victims. Without adequate preparation and supervision, the stress of caring for abused patients can lead to countertransference, compassion fatigue, burnout, denial, and projection. Students with a personal background of exposure to family violence are especially in need of support. This paper presents 10 recommendations for family violence curriculum developers: 1) provide orientation to difficult issues in medicine, including physician impairment; 2) expose students to community and clinical experiences; 3) observe students interviewing abuse survivors; 4) legitimize all personal reactions to work in this area; 5) make available personal support, consultation, and treatment; 6) develop faculty discussion and support groups; 7) communicate a sense of urgency about the importance of family violence education; 8) provide a multimedia resource library for faculty and student use; 9) promote student and faculty scholars through attendance at local and national conferences; and 10) include family violence questions on board examinations.

Physician extender services in family planning agencies: issues in Medicaid reimbursement.

PIP: The US Social Security Amendments of 1972 mandated the inclusion of family planning services in state Medicaid plans, authorized 90% of reimbursements for family planning care, and imposed financial penalties for failure to provide these services to Medicaid-eligible clients. On the other hand, many states have retrictive policies regarding Medicaid reimbursements to family planning agencies for services provided by physician extenders (e.g.s nurse practitioners and physician assistants). There is concern that such restrictions greatly reduce accessibility to family planning services. Reasons that hae been suggested as causes of such restrictive policies include physician concern over loss of income, the uncertain status of physician extenders in some states, a fear that this step will lead to a demand for reiimbursement for the services of other allied health care providers such as social workers, and concern that care for the indigent will lead to an expensive increase in state reimbursement for family planning services. However, a review of relevant federal law and regulations indicates that Medicaid reimbursement for services provided to eligible patients by physician extenders has never been prohibited or discouraged. Physician supervision is required in reimbursement cases, but this does not mean that a physician must be on the premises while services are delivered. The Medicaid program actually allows significant latitude in establishing administrative policies and procedures. Rather, problems faced by family planning agencies in receiving Medicaid reimbursements for physician extenders' services are due to restrictions in state laws and staff misinterpretations of policy. Research has demonstrated that physcian extenders can contribute significantly to cost effectiveness, while providing types of care in localities such as rural areas that physicians tend to avoid. Given the importance of family planning services to Medicaid-eligible clients, unwarranted policy restrictions contrary to congressional intent should be eliminated.^ieng

Population uncertainty, social insurance, and actuarial bias.

PIP: The authors examine the relation between changes in the size of the working population and the value of a social insurance contract between unborn workers and future retirees. They develop a model suggesting that such a contract will benefit both of the generations concerned. The implied geographical focus is on developed countries.^ieng

Self-selection and intermunicipal migration in Canada.

"This paper investigates individual intermunicipal migration behaviour in Canada within the context of a human capital model that adjusts for the migrant's selectivity in computing expected income gains. In addition to the typical regional determinants of migration, housing and labour market characteristics are found to influence intermunicipal migration significantly, the effects differing with age. Structural coefficients remained more or less stable during the decade 1971-1981. It is shown that the failure to adjust income gains for selectivity bias results in an underestimation of the migration-impacts of income gains and municipal-specific factors."

Health personnel training in the Nicaraguan health system.

The "Unified National Health System" of Nicaragua was established in 1979, in an attempt to transform some of Latin America's worst health indices. This system, based on the stated principles of planning, regionalization, public participation, and primary care, has prioritized the development of health professions training programs appropriate to its special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of medical students by a factor of five. Formal residency training (never before available within the country) in primary care specialties has been established. Training for allied health personnel has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a tremendous need for educational resources both human and material. This article reviews the status of health personnel training in Nicaragua today, the integration of these programs into planning for the health system, and problems arising from their rapid appearance.

PIP: This article explores the policies and early experiences of the extensive changes in the preparation of health personnel in Nicaragua; massive changes in the health care system were launched after the victory of the Sandinista Revolution in 1979. It reviews the status of health personnel training in the country today, the integration of these programs into planning for the health system, and problems arising their rapid appearance. The Unified National Health System was established in 1979 in an attempt to transform some of Latin America's worst health indices. This system is based on the stated principles of planning, regionalization, public participation, and primary care. To implement these policies, high priority has been given to the development of health professions training programs appropriate to the system's special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of meidcal students by a factor of 5. Formal residency training in primary care specialties has been established. Training for allied health professions has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a trmendous need for educational resources, both human and material. The greatest constraint in expanding medical education was the lack of qualified teachers. As a solution, the new health system has made public sector employment much more available and attractive; most Nicaraguan physicians today divide their time between public and private practice, and the pressures on voluntary teaching time are heavy. The Health Ministry has developed strategies for making clinical teaching more attractive and prestigious in compensation. Medical curriculum reform since 1979 is designed to turn out doctors capable along 4 lines: clinical service, teaching, administration and research. Special importance is placed on integrated teaching and service. These multiple objectives are built into the teaching program from the very beginning. To date there are 6 schools of nursing in the country (4 before 1979), with 5 times the pre-1979 enrollment. Nicaragua has made a deliberate decision not to train mid-level medical workers. However, volunteer health personnel, the Brigadistas, have played a definite role in Nicaraguan communities. They concentrate on public education and mobilize the people for immunization and sanitation campaigns. Additionally, traditional birth attendants in rural areas have been recognised by the Health Ministry and been given training to upgrade their performance. Much in the new System has emulated policies of Cuba, especially the emphasis on public education, models for personnel training and community-oriented primary care.

The underemployment of American rural women: prevalence, trends and spatial inequality.

PIP: The growing numerical significance of women in the US nonmetropolitan labor force has not been matched by parallel efforts to document the changing quality of their employment. In this paper. Lichter uses the labor utilization framework of Clogg and Sullivan to examine the prevalence and spatial convergence of various forms of female underemployment during 1970-1985. Data from the March annual demographic files of the Current Population Survey reveal that underemployment has been a significant aspect of the employment experiences of nonmetropolitan women during this period. There has been little evidence of spatial or sex convergence in labor market outcomes. Roughly 1 of every 3 rural female workers today is a discouraged worker, jobless, employed part-time involuntarily, or working for poverty-level wages. Moreover, rural women continue to suffer substantially higher levels of economic underemployment than urban women and rural men. This study reinforces the view that rural women remain a seriously underutilized labor resource in the US.^ieng

Afro-Caribbean migrants in France: employment, state policy and the migration process.

"Afro-Caribbean labour in France plays a distinctive role relative to the French population as a whole and the foreign immigrant population. Using a variety of qualitative and quantitative sources, this paper demonstrates that the role of the state in the process of migration from the French Caribbean islands of Martinique and Guadeloupe from the early 1960s onwards was crucial.... Aggregate sources are used to describe detailed occupational distributions while records of individual migrants illustrate the process of migration and the influences on employment. At a time usually characterized by lack of direct involvement in migration by the French state, for Afro-Caribbeans state intervention in recruitment, training and settlement is shown to be very substantial."

Urbanization in a developing country: city size and population composition.

Reasons for the high correlation between city size and educational attainment in developing countries are explored. "Two explanations are examined. First, the types of goods produced in larger cities require relatively high skill labor inputs. Second, public and perhaps private services demanded by higher skill people are only offered in larger cities. The paper econometrically tests these hypotheses for Brazil, estimating the elasticities of substitution (or typically complementarity) between high and low skill labor and the 'bright lights' effect for high versus low skill labor."

The earnings of Mexican immigrants in the United States.

"This paper documents the trends in the earnings of Mexican immigrants during the 1970-1990 period. The empirical evidence indicates that there has been a decline in the relative wage of successive Mexican immigrant waves in the past three decades and that little wage convergence occurs between the typical Mexican immigrant and the typical native worker. The data also suggest that the increasing importance of Mexican immigration is partly responsible for the deterioration in relative skills observed in the aggregate immigrant population, but that there has also been a decline in relative skills even among non-Mexican immigrants."

Migration to the United States and Mexican rural development: a case study.

An analysis of the impact of migration to the United States on the sending community and on the labor market in the receiving country is presented based on a case study of Las Animas, Mexico. "As the community becomes increasingly involved in migration, tendencies can be identified regarding changing migration patterns, class differentiation among villagers, impact of migration on village economy, and the changing role of Mexican workers in California labor markets. Results indicate the importance of social networks in determining the outcome of migration; while migration is individually rational, it is a factor of stagnation for village economy, and it helps reproduce segmented California labor markets."

Immigration from poor to wealthy countries: experience of the United States.

PIP: The U.S. experience with immigration from poor countries is examined using the results of two projects carried out by the National Bureau of Economic Research. Questions considered include what determines the supply of immigrants, how such immigrants fare in the U.S. job market, and how this immigration affects the prospects of native-born workers.^ieng

The determinants of East-West German migration: some first results.

Determinants of the propensity to migrate are explored using data collected in a survey of East German residents following German reunification in 1991. The author notes that in the period 1989-1992, some 870,000 individuals migrated to West Germany, representing about 5% of the total East German population and 10% of the work force. He suggests that "recent developments in the literature on the option value of waiting may yield important insights into these determinants."

Why do rich countries prefer free trade over free migration? The role of the modern welfare state.

"According to traditional trade theory (Heckscher-Ohlin), free trade and free migration are equivalent measures of economic integration leading both to an equalization of factor prices. This prediction is in sharp opposition to the observed preference of rich countries for free trade over free migration. We provide an explanation for this inconsistency: the redistribution policies in the countries. Social welfare in countries with a relatively small number of low-skilled native workers is higher with free trade than with free migration due to redistribution of income towards immigrating workers."

Income, self-selection, and return and onward interprovincial migration in Canada.

"Estimated returns to migration based on comparison of individual migrants may be biased owing to self-selection in the migration process. Using data derived from the 1986 Canadian census, I will study the effects of expected wage differentials in determining the return or onward migration decision of nonnative adults aged 20 to 64 years. Evidence was found that return migrations were in the 'right' direction, as they are observed to respond to provincial economic variables (that is, average employment growth and income levels) in a rational manner. After accounting for self-selectivity, I found that...return migrants...are negatively selected, and experience lower income levels, following the return migration, than onward migrants would have, had they chosen the return migration option. This drop in expected wages decreases the propensity associated with making a return migration. Despite this drop in income, the large proportion selecting the return migration option suggests the importance of the province of birth in the mental map of nonnative migrants."

Reciprocal link between exit from unemployment and geographical mobility.

"Is geographical migration a consequence of the end of unemployment or does it help in finding a job? This question is approached within the general framework of human capital theory.... A model is introduced in the form of a system of two simultaneous equations with qualitative endogenous variables. The test is based on a 1993 survey of 1,176 young rural people of seven areas of France. A main finding is that migrations of young rural people are essentially the result of professional preoccupations. However, migration is not a factor which always helps in finding a job, when people are unemployed. When a young person has a good initial training, he or she has to migrate (and leave a rural area) to get a job. Yet, migration does not seem to be necessary for less trained people."

Immigration--mismatches in labour, housing and space: the effects of immigration of several nationalities with regard to the Netherlands.

"In the Netherlands, the sharp recent increase of the number of refugee immigrants (asylum seekers) runs parallel to increased numbers of immigrants of other types. Therefore, at least five types of immigrants should still be distinguished (labour migrants, migrants from former colonies, from EU countries, from other rich countries, and asylum seekers). Their spatial orientation in the Netherlands (urban, suburban, rural), by choice or by constraint, is the main focus of this study. The outcomes of the immigration processes have been confronted with general and spatial characteristics of the labour market and housing market. Matches and mismatches are discussed."

Influence of demographics and profitability on physician selection of family practice procedures.

BACKGROUND: Family physicians must make complex decisions regarding which procedures to learn in training and which to perform in practice. Factors that influence these decisions include community needs, the potential profitability of a procedure, and the desires and skills of the individual physician. METHODS: To further clarify some of these influences, we surveyed members of the Wisconsin Academy of Family Physicians. The survey instrument included questions about 27 different procedures, including the perceived profitability of the procedure, which procedures they had discontinued, and which they planned to learn. RESULTS: More than 40% of family physicians reported doing skin surgery, flexible sigmoidoscopy, nonstress obstetrical testing, breast-cyst aspiration, multiple joint arthrocentesis, and Norplant insertion, whereas fewer than 6% perform colonoscopy, esophagogastroduodenoscopy, and nasolaryngoscopy. Fifty-seven percent of physicians had discontinued at least one procedure, and 34% planned to learn one or more procedures. Being younger, male, and practicing in smaller communities correlated with performing a greater number of procedures (P < .001), but female physicians performed more gynecologic procedures (P < .05). There was a statistically significant correlation (r = -.478, P < .05) between perceived low profitability of a procedure and family physicians discontinuing a learned procedure, and a marginal correlation between perceived profitability and planning to learn a procedure (r = .338, P < .1). CONCLUSIONS: Family physicians in Wisconsin vary greatly in the number and types of procedures performed. Community size, sex, and age are important variables associated with the number and type of procedures performed. The performance of procedures is dynamic: physicians both discontinue learned procedures and learn new procedures. The profitability of the procedure influences the learning and discontinuation of procedures.

PIP: Physicians during their period of residency training have the opportunity to learn many procedures. Often, however, there is insufficient information to guide faculty and resident decisions about which procedures merit training emphasis. A study in general internal medicine has shown that the procedures taught during residency are not necessarily those most needed in practice. Family physicians must therefore decide which procedures to learn in training and which to perform in practice. Community needs, the potential profitability of a procedure, and the desires and skills of individual physicians influence the decision-making process. The authors surveyed 500 physicians by mail questionnaire in March 1993 in an effort to learn more about these factors. The subjects all belonged to the Wisconsin Academy of Family Practice. Despite three mailings to nonrespondents, only 65% of the family physicians responded to the survey, with only 297 actually supplying all of the demographic information requested. The survey listed 27 different procedures with regard to the perceived profitability of the procedure, which procedures they had discontinued, and which procedures they planned to learn. 76% of the sample was male and 59% younger than age 40. The doctors were evenly distributed across different community size, with family practice groups being the most common mode of practice; only 8% of surveyed doctors were in solo practices. The mean number of different procedures performed was 6.9, with a range of 0-18. More than 40% of family physicians reported doing skin surgery, flexible sigmoidoscopy, nonstress obstetrical testing, breast-cyst aspiration, multiple joint arthrocentesis, and Norplant insertion, while fewer than 6% perform colonoscopy, esophagogastroduodenoscopy, and nasolaryngoscopy. 57% of physicians had discontinued at least one procedure and 34% planned to learn one or more procedures. Being younger, male, and practicing in smaller communities correlated with performing a greater number of procedures, but female physicians performed more gynecologic procedures. There was a statistically significant correlation between perceived low profitability of a procedure and family physician discontinuing a learned procedure, and a marginal correlation between perceived profitability and planning to learn a procedure.