Optimizing the medical equipment investment in primary care centres in rural China: evidence from a panel threshold model.

BACKGROUND: The previous "one-size-fits-all" practice in resource allocation can no longer adapt to the spatial variation in population and health needs. This study aimed to investigate the spatially heterogeneous effect of medical equipment investment in the township health centres in rural China to optimize the investment strategies. METHODS: Based on the national-scale stratified multistage cluster sampling, 319 township health centres from six provinces were included in the study. The retrospective data from 2013 to 2017 were collected for each sampled township health centres and the corresponding township community. The panel threshold regression model was applied to estimate the nonlinear effect of medical equipment increment on the service utilization due to the township communities' urbanization degree. The influence of township community remoteness on the effects of equipment increment was investigated through subgroup analysis. RESULTS: Among the township health centres in the neighbouring towns of the county seat (travel time to the county seat < 1 h), the significant effect of medical equipment increment was only found in the township health centres of the towns with high urbanization degrees (the proportion of the residents living in the built-up area > 69.89%), of which the effect size was 774.81 (95% CI 495.63, 1053.98, p < 0.05). Among the township health centres in the remote towns (travel time ≥ 1 h), the effect of medical equipment increment in the township health centres of the low urbanized towns (urban ≤ 5.99%, ß = 1052.54, p < 0.01) was around four times the size of that of the counterparts (urban > 5.99%, ß = 237.00, p < 0.01). CONCLUSION: This study demonstrated the spatially heterogeneous effect of medical equipment investment in the primary care centres in rural China. The priority of the equipment investment was suggested to be given to the township health centres in the remote towns with a low urbanization degree and those in the highly-urbanized neighbouring towns of the county seats.

Barriers and enablers to accessing perinatal health services for rural Australian women: A qualitative exploration of rural health care providers perspectives.

OBJECTIVE: To identify perceived barriers and enablers for rural women in accessing perinatal care within their own community from the perspective of perinatal health care providers. DESIGN: A qualitative descriptive study design utilising reflexive thematic analysis, using the socioecological framework to organise and articulate findings. SETTING: Victoria, Australia. PARTICIPANTS: Semi-structured interviews were conducted with nine perinatal health care providers who provide care to pregnant women or new mothers in rural communities. Participants were recruited across Victoria in 2023. RESULTS: Providers reported multi-level barriers and enablers that exist for rural women in accessing perinatal care within their communities. Barriers included women's personal circumstances, challenging professional relationships, inequitable service provision, ineffective collaboration between services and clinicians and government funding models and policies. Enablers included strength and resilience of rural women, social capital within rural communities, flexible care delivery and innovative practice, rural culture and continuity of care models. CONCLUSION: Rural perinatal health care providers perceived that rural women face multiple barriers that are created or sustained by complex interpersonal, organisational, community and policy factors that are intrinsic to rural health care delivery. Several addressable factors were identified that create unnecessary barriers for rural women in engaging with perinatal care. These included education regarding health systems, rights and expectations, equitable distribution of perinatal services, improved interprofessional relationships and collaborative approaches to care and equity-based funding models for perinatal services regardless of geographical location.

Investigating Patient Experience, Satisfaction, and Trust in an Integrated Virtual Care (IVC) Model: A Cross-Sectional Survey.

To improve access to primary care in underserved communities, we established a hybrid model of delivering team-based, comprehensive primary care using both in-person and virtual care options with family physician leadership. Using a cross-sectional online survey (n = 121), results showed high levels (90%) of patient satisfaction. Our findings suggest that a similar hybrid model for primary care delivery can provide levels of patient satisfaction comparable to traditional in-person models of primary care. This can be achieved regardless of whether patients had previously been attached to the same family physician before receiving care through the hybrid model.Annals "Online First" article.

Group Prenatal Care vs. Traditional Prenatal Care: A Parity-Matched Comparison of Perinatal Outcomes in a Rural Community.

PURPOSE: Prenatal care is important for positive outcomes for both mother and infant. The traditional one-on-one method remains the most common. This study aimed to compare perinatal outcomes of patients attending group prenatal care with traditional prenatal care. Most previously published comparisons did not match for parity, a key predictor of perinatal outcome. DESCRIPTION: We collected perinatal outcome data for 137 group prenatal care patients and 137 traditional prenatal care patients, matched for contemporaneous delivery and parity, who delivered at our small rural hospital during 2015-2016. We included key public health variables, including the initiation of breastfeeding, and smoking at the time of delivery. ASSESSMENT: There was no difference between the two groups for maternal age or infant ethnicity, induced or augmented labor, preterm deliveries, APGAR scores less than 7, low birth weight, NICU admissions, or cesarean deliveries. Group care patients had more prenatal visits and were more likely to initiate breastfeeding and were less likely to report smoking at the time of delivery. CONCLUSION: In our rural population matched for contemporaneous delivery and parity, we found no difference in traditional perinatal outcome measures and that group care was positively associated with the key public health variables of not smoking and initiating breastfeeding. If future studies in other populations have similar findings, it may be wise to provide group care more widely to rural populations.

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.

The impact of family physicians in rural maternity care.

BACKGROUND: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. METHODS: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. RESULTS: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. CONCLUSIONS: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Combining an experiential learning model and interprofessional peer-mentoring to improve maternal and neonatal health: Lessons learned from Indonesia.

Background: High maternal-neonatal mortality rate in the East Nusa Tenggara Timur Province, Indonesia, has raised a concern about improving quality health care and prevention. A task force team consisting of the district health office and the corresponding hospital implemented an interprofessional peer mentoring for improving maternal-neonatal health initiative involving various health professionals and community members. This study assesses the effectiveness of the interprofessional peer-mentoring program in improving health-care workers' capacity and community members' awareness of maternal-neonatal health in the primary care setting. Methods: A mixed-methods action research was conducted to measure the effectiveness of the peer-mentoring program. The task force appointed 15 personnel to be trained as peer mentors for 60 mentees from various professions. Peer mentors' perceptions of knowledge and skills improvement were measured before and after the training program. A reflective logbook was then developed to document mentoring activities. Surveys and logbook observations were performed to measure the effectiveness of the 8-month peer-mentoring program. Mentees' capacity and perception were measured before and after the mentoring program. Quantitative data were analyzed using the descriptive statistics and Wilcoxon's paired-rank test, whereas open-ended responses and log-book reflection were analyzed using the content analysis. Results: The peer-mentor training program improved peer mentors' knowledge and readiness from 3.64/5.00 to 4.23/5.00 (P < 0.001). Moreover, mentees viewed the program as effective in improving self-confidence and working capacity in maternal-neonatal health services from 3.47/5.00 to 3.98/5.00 (P < 0.001). Open-ended responses and a reflective logbook revealed that both mentees and peer mentors gained positive learning experiences. Seniority might become an obstacle to the mentoring process since peer mentors reported barriers in engaging elderly mentees due to seniority issues. Discussion: The interprofessional peer-mentoring program was effective in improving both mentors' and mentees' knowledge, self-confidence, and working capacity in maternal-neonatal primary health services and experiential learning. Further observation of the long-term outcomes of the program should be undertaken.

Overview of School-Based Telehealth Network Grant Program Services Delivered to Students in Rural Schools.

Telehealth can expand and enhance access to school-based health care, but its use has been relatively limited. Recognizing that school-based health care is still not reaching many students, the Health Resources and Services Administration (HRSA) funded the School Based Telehealth Network Grant Program to expand telehealth in rural school-based settings to help to increase the availability and use of these services. The 19 grantees delivered telehealth to over 200 schools across 17 states, choosing which services they would deliver and how. Looking across the services, these fell into three categories - primary/urgent care, behavioral health, and other more specialized services. The majority of grantees offered multiple telehealth services with the combination of behavioral health and primary/urgent care the most common. The current study adds to the literature by elucidating that telehealth in schools can address multiple clinical conditions through separate services even though doing so involves using various combinations of clinicians providing different services.

Healthcare consumers' and professionals' perceived acceptability of evidence-based interventions for rural transitional care.

BACKGROUND: There is a pressing need for high quality hospital-to-home transitional care in rural communities. Four evidence-based interventions (discharge planning, treatments, warning signs, and physical activity) have the potential to improve rural transitional care. However, there is limited understanding of how the perceptions of healthcare consumers and professionals compare on the acceptability of the interventions. Convergent views on intervention acceptability support implementation, whereas divergent views highlight areas requiring reconciliation prior to implementation. AIMS: This study compared the acceptability of four evidence-based interventions proposed for rural transitional care, as perceived by healthcare consumers and professionals. METHODS: A cross-sectional, comparative design was used. The convenience sample included 36 healthcare consumers (20 patients and 16 family caregivers) who had experienced a hospital-to-home transition in the past month and 30 healthcare professionals (29 registered nurses and one nurse practitioner) who provided transitional care in rural Ontario, Canada. Participants were presented with descriptions of the four interventions and completed an established intervention acceptability measure. Presentation of the four intervention descriptions and respective acceptability measures was randomized to control for possible order effects. The perceived overall acceptability of the interventions and their attributes (i.e., effectiveness, appropriateness, risk, and convenience) were compared using independent samples t-tests. RESULTS: Consumer ratings were consistently higher across all four interventions in terms of overall acceptability as well as effectiveness, appropriateness, and convenience (all p's < .01; effect sizes 0.70-1.13). No significant between-group differences in perceived risk were found. LINKING EVIDENCE TO ACTION: Contextual and methodological differences may account for variability in ratings, but further research is needed to explore these propositions. The results support future qualitative inquiry targeting professionals to better understand their perspectives on the effectiveness, appropriateness, and convenience of the four interventions.

A framework for nursing practice in rural and remote Canada.

INTRODUCTION: Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. METHODS: Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. RESULTS: The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. CONCLUSION: It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process.

Promotores de Salud in Montana: An Analysis of a Rural Health Care Intervention Rooted in Catholic Social Teaching and its Place in Medical Curricula.

The Latino population in the United States faces significant health disparities compared to their White counterparts. Community-based processes in Gallatin County, Montana, through academic-community partnerships have identified strategies to overcome these barriers. One such strategy includes the utilization of community health workers (CHWs) in the Latino population-in Spanish, "Promotores de Salud." CHWs are often selected to target community health problems because they share the cultural, social, and demographic features of the population they serve. This paper explores the inherent ties between Catholic Social Teaching and the CHW health care model while focusing on a community-academic partnership in Montana that is implementing a CHW program. Catholic health care providers are called to apply CST principles to their health care systems and communities in order to achieve health equity for their patients. This paper proposes that community organizing and advocacy should be taught in medical school curricula across the country in order to promote physician involvement in solving public health disparities. Additionally, the authors suggest that practicing Catholic health care providers immediately incorporate community organizing through the use of CHWs to attain health equity for their patient panels.

Impact of Rural Hospital Closures on Health-Care Access.

BACKGROUND: Access to health care is an important issue, particularly in remote areas. Since 2010, 106 rural hospital have closed in the United States, potentially limiting geographic access to health care. The aim of this study was to evaluate the impact of these hospital closures on the proportion of the population who can reach a secondary care facility, by road, within 15, 30, 45, or 60 min. METHODS: Geographical information system analysis, using population data obtained from the 2010 U.S. Census Bureau and hospital data between 2010 and 2019 from the Center for Medicare and Medicaid Services, created 15-, 30-, 45-, and 60-min drive time isochrones (areas from which a central location can be reached within a set time). RESULTS: Rural hospital closures resulted in 0%-0.97% of the population no longer being able to access a hospital within 15 min. The most marked changes were in the East South Central (0.97%, 178,478 residents) and West South Central (0.54%, 197,660 residents) divisions. Lesser degrees of change were noted for longer drive times. The changes were more marked when the rural population was analyzed exclusively. CONCLUSIONS: Recent closures of rural hospitals in the United States have impacted population access to hospital care, although the extent varies. There are regions, such as the Southern and Southeastern United States, which demonstrate greater and potentially more concerning losses in population coverage, probably because of the greater number of closures. Future work should evaluate clinical implications of hospital closures and loss of population coverage.

Does increasing health care access reduce disability insurance caseloads? Evidence from the rural United States.

This paper leverages the expansion of the United States' Community Health Center program over the 21st century to investigate whether improved access to health care reduces disability insurance (DI) participation at the county level. I find that the introduction of a health center that specializes in mental health and substance abuse services is associated with a 0.09 to 0.40 percentage point reduction in working-age DI enrollment in rural counties. A cost-benefit analysis indicates that the money saved from reduced program participation can account for more than a third of the cost the federal government faces in funding well-targeted health care access initiatives.

Older people and rural eHealth: perceptions of caring relations and their effects on engagement in digital primary health care.

BACKGROUND: The aim of this article is to describe older people's perceptions of caring relations in the context of rural eHealth, as well as to explore how such relations can facilitate engagement in digital primary health care. There is an ongoing implementation of eHealth in Western health care, and rural areas and older people are specifically targeted. eHealth is said to be a solution to emergent problems and a technology that will facilitate people's opportunities to achieve good and equal health. From this perspective, it is crucial that older people engage in eHealth services, but there are barriers for use, and care providers need to adapt to the preferences of older people. METHODS: Semi-structured interviews with 19 individuals aged 61-85 were conducted. The participants were using digital services at two primary healthcare centres located in northern Sweden. Qualitative content analysis was used. An important theoretical tenet was that older people's perceptions of and engagements in eHealth are affected by the specific rural conditions. Ethical approval for the study has been obtained. RESULTS: The analysis rendered a total of three themes: in-person interaction was central to people's perceptions of good caring relations; patient-nurse relations were particularly emphasised; and caring relations in rural eHealth appeared to be multi-directional and fuelled by a shared sense of rural community. Altogether, this facilitated participants' engagement in local eHealth initiatives. CONCLUSIONS: eHealth is an opportunity for primary health care and for rural communities. However, the results provide insight into matters that can affect the quality, access, and equality of rural primary health care. Participants' engagement in eHealth was almost always facilitated by close caring relations with local Registered Nurses. Digital care needs to be approached as a combination of digital and in-person presence. Separating digital and physical task assignments among different personnel could make older people refrain from seeking health care.

Developing interprofessional collaborative practice competencies in rural primary health care teams.

BACKGROUND: Leaders from a university, Area Health Education Center, and primary care centers (PCCs) collaborated to integrate Interprofessional Collaborative Practice (IPCP) in PCCs. PURPOSE: Describe the facilitators and barriers of IPCP implementation in rural clinics and the impact on decision-making and safety culture. METHODS: The implementation team used engagement strategies to support the development of IPCP. PCC team participants completed surveys measuring collaboration and satisfaction with care decisions and safety culture. Qualitative data were analyzed to describe facilitators and barriers to IPCP. FINDINGS: Significant improvement (p < .035) in the Global Amount of Collaboration made over time. Barriers to IPCP included high turnover, hierarchical culture, lack of role clarity, competing time demands, limited readiness for change, and physical space limitations. Facilitators included structured huddles, alignment of IPCP with organizational goals, and academic-practice partnership. DISCUSSION: Partnering with academic-practice partnerships may facilitate collaboration and team learning as PCCs incorporate IPCP into practice.

"The Noblest Roman of them all?" Professional versus Popular Views of America's Country Doctors.

This essay studies the images, perceptions, and values of the professional medical journals, as well as popular sources such as magazine and films, to show that the country doctor was a contested figure in the late nineteenth and early twentieth centuries. The country doctor's image embodied competing ideals of a racialized professional and masculine identity that included both place as well as visions of science. Medical professionals pressed an image in their journals and professional advice books that mapped a celebration of science and its predictive value onto urban places that were enshrined in hospitals and laboratory facilities. The public, while embracing this image, also embraced a second one shown in popular media that glorified the self-sacrificing rural solo practitioner. This practitioner's wisdom came from long contact with patients, he was dedicated to seeing patients in their homes, and his identity was based in the larger needs of the entire community.

[COVID-19 as a catalyst of development of telemedicine services to rural population].

The paper presents a review of publications concerning issues of development of telemedicine in rural health care of the USA during in conditions of COVID-19 pandemic and expediency of extensive application of telemedicine technologies during "post-COVID" period. The issues, aspects, prospects and required conditions for extensive diffusion of telemedicine services to the rural population are considered.

Challenges of delivering evidence-based stroke services for rural areas in Australia.

OBJECTIVE: The aim of this paper was to use current stroke care guidelines to identify and discuss current stroke care challenges in rural Australian health care and potential solutions for delivery of evidence-based practice. DESIGN AND SETTING: A review of national guidelines since 2002 for organised stroke care was undertaken to determine best practice for delivering primary stroke care. We then employed a narrative literature review strategy looking at relevant articles, based on keywords, outlining current stroke service availability in Australia, highlighting the challenges of implementing evidence-based stroke care in rural areas in Australia based on the current guidelines. RESULTS: Delivery of evidence-based stroke care in rural Australia is fraught with challenges. Although national best-practice guidelines for stroke care are well established, the recommendations made in these guidelines do not always reflect the resource availability in rural Australia. Redesigning processes and utilising available resources, such as telemedicine or local clinical pathways, can achieve an evidence-based standard; however, ultimately better resourcing of these areas is required. CONCLUSION: Evidence-based stroke care, aligned with current national standards is the key to providing adequate stroke services in rural Australia. Improved health service resourcing and better utilisation of currently available resources are options for achieving elements of evidence-based stroke care. IMPLICATIONS FOR PUBLIC HEALTH: Availability of adequate services for stroke patients directly impacts public health as it determines health outcomes for these patients. Indirect implications for public health include the effects on health professionals and the general public.

Treating perinatal opioid use disorder in rural settings: Challenges and opportunities.

Perinatal opioid use disorder (OUD) is a life-threatening condition that significantly impacts women in rural areas. Medication assisted treatment (MAT) is the recommended treatment but can be difficult to access. Pregnant women may initially present for treatment of OUD in the emergency department, on labor and delivery units, or in an office setting, each of which presents unique challenges. Initiation of MAT in the appropriate setting, based on accurate assessment of gestational age, is a centrally important component of care for perinatal OUD. However, initiating treatment may present challenges to providers who lack experience treating this disorder. Vermont and New Hampshire are predominantly rural states which have focused on expanding MAT access for pregnant women using two different approaches to integrating treatment with maternity care.

[The motivation of participants of the "Zemstvo doctor" program in the Tyumen oblast and evaluation of their satisfaction with conditions of work and life in rural territory].

The article presents the results of the second stage of the study of the motivation of participants of the "Zemstvo Doctor" program, working in medical organizations in rural municipal districts of the Tyumen region (without okrugs) and the evaluation of their satisfaction with labor and living conditions. The sociological questionnaire survey was carried out in 2016-2017 with purpose of evaluating effectiveness of the "Zemstvo Doctor" program and the risks of medical personnel support of rural health care system. During the first stage of study, participants of the program in Tyumen municipal district were interviewed and the results were published. While analyzing the reasons of dismissal from previous job and moving to countryside for employment, the main motives of participating in the "Zemstvo Doctor" program were identified. The analysis of satisfaction with conditions of program implementation, as well as social, labor and living conditions in rural areas was implemented. The results made possible to assess the risks associated with medical personnel support of health organizations, both in process of implementing the program, and after completion of a five-year period, which the specialist must work for. The implemented analysis permitted to reveal factors of labor motivation and satisfaction with living conditions in rural areas. In general, the participants of program are satisfied both with its availability and conditions of its implementation. The results of the research can be used by the authorities in managerial decision making related to organization of conditions for attraction and keeping specialists in rural areas.