Social learning, influence, and ethnomedicine: Individual, neighborhood and social network influences on attachment to an ethnomedical cultural model in rural Senegal.

The preference in many parts of the world for ethnomedical therapy over biomedical alternatives has long confounded scholars of medicine and public health. In the anthropological literature cultural and interactional contexts have been identified as fundamental mechanisms shaping adherence to ethnomedical beliefs and health seeking behaviors. In this paper, we examine the association between individual, neighborhood, and social network characteristics and the likelihood of attachment to an ethnomedical cultural model encompassing beliefs about etiology of disease, appropriate therapeutic and preventative measures, and more general beliefs about metaphysics and the efficacy of health systems in a rural population in Eastern Senegal. Using data from a unique social network survey, and supplemented by extensive qualitative research, we model attachment to the ethnomedical model at each of these levels as a function of demographic, economic and ideational characteristics, as well as perceived effectiveness of both biomedical and ethnomedical therapy. Individuals' attachment to the ethnomedical cultural model is found to be strongly associated with characteristics of their neighborhoods, and network alters. Experiences with ethnomedical care among neighbors, and both ethnomedical and biomedical care among network alters, are independently associated with attachment to the ethnomedical model, suggesting an important mechanism for cultural change. At the same time, we identify an independent association between network alters' cultural models and those of respondents, indicative of a direct cultural learning or influence mechanism, modified by the degree of global transitivity, or 'connectedness' of individuals' networks. This evidence supports the long held theoretical position that symbolic systems concerning illness and disease are shared, reproduced, and changed through mechanisms associated with social interaction. This has potentially important implications not only for public health programming, but for the understanding of the reproduction and evolution of cultural systems more generally.

Mobile Health, Information Preferences, and Surrogate Decision-Making Preferences of Family Caregivers of People With Dementia in Rural Hispanic Communities: Cross-Sectional Questionnaire Study.

BACKGROUND: Mobile health (mHealth) technology holds promise for promoting health education and reducing health disparities and inequalities in underserved populations. However, little research has been done to develop mHealth interventions for family caregivers of people with dementia, particularly those in rural Hispanic communities, who often serve as surrogate decision makers for their relatives with dementia. OBJECTIVE: As part of a larger project to develop and test a novel, affordable, and easy-to-use mHealth intervention to deliver individually tailored materials in rural Hispanic communities, in this pilot study, we aimed to examine (1) characteristics of people with dementia and their family caregivers in rural Hispanic communities, (2) caregivers' preferences for types and amounts of health information and participation in surrogate decision making, and (3) caregivers' mobile device usage and their desire for receiving information via mobile devices. METHODS: This was a cross-sectional survey. A convenience sample of 50 caregivers of people with dementia was recruited from rural health care facilities in Southwest Texas during 3 weeks of April 2017 to May 2017 via word-of-mouth and flyers posted at the facilities. RESULTS: More women than men were in the patient group (χ21=17.2, P<.001) and in the caregiver group (χ21=22.2, P<.001). More patients were on Medicare and Medicaid; more caregivers had private insurance (P<.001 in all cases). Overall, 42% of patients did not have a power of attorney for their health care; 40% did not have a living will or advance directive. Caregivers were interested in receiving all types of information and participating in all types of decisions, although on subscales for diagnosis, treatment, laboratory tests, self-care, and complementary and alternative medicine, their levels of interest for decision-making participation were significantly lower than those for receiving information. On the psychosocial subscale, caregivers' desire was greater for surrogate decision-making participation than for information. Caregivers did not differ in their interests in information and participation in decision making on the health care provider subscale. All but 1 caregiver (98%) owned a mobile phone and 84% had a smartphone. Two-thirds wanted to receive at least a little dementia-related information via a smartphone or tablet. The amount of dementia-related information caregivers wanted to receive via a mobile device was significantly greater for women than for men (U=84.50, P=.029). Caregivers who owned a tablet were more likely to want to receive dementia-related information via a mobile device than those who did not own a tablet (U=152.0, P=.006). CONCLUSIONS: Caregivers in rural Hispanic communities were interested in receiving a wide range of information as well as participating in making decisions for their relatives with dementia. There is much need for effective mHealth interventions that can provide information tailored to the needs and preferences of these caregivers.

Do Infant Feeding Practices Differ Between Grandmothers and Mothers in Rural China? Evidence From Rural Shaanxi Province.

The overall goal of this study is to examine whether infant feeding practices differ between mothers and grandmothers in rural China. We randomly sampled 1383 caregivers of infants aged 18 to 30 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas. Results show that a high fraction of caregivers of 18- to 30-month-old children living in low-income areas of rural China do not regularly engage in positive infant feeding practices. Only 30% of children in our sample achieved adequate dietary diversity. Only 49% of children in our sample were fed meat in the day prior to survey administration. Few caregivers reported giving any vitamin supplements (such as calcium or iron supplements) to their children. We find that 33% of the children were cared for by grandmothers rather than mothers, and that grandmothers feed a less diversified diet to children than do mothers. Most (84%) caregivers rely solely on their own experiences, friends, and family members in shaping their feeding behaviors. Overall infant feeding practices are poor in rural China. Grandmothers engage in poorer feeding practices than do mothers. Grandmothers have improved their feeding practices compared to when their own children were young. Our results suggest shortcomings in the quality of infant feeding practices, at least in part due to an absence of reliable information sources.

Use of Self-management Interventions for Chronic Pain Management: A Comparison between Rural and Nonrural Residents.

Individuals with chronic pain who live in rural communities often lack access to pain specialists and rely on primary care providers who may be less prepared. Research has indicated that rural residents with chronic pain are more likely to receive an opioid prescription than nonrural residents. Although self-management approaches are available for chronic pain management, it is unclear to what extent rural residents use these interventions. This study compares usage of self-management interventions and opioid-based analgesics for chronic pain management between rural and nonrural residents. This study is a secondary analysis of baseline data from a randomized controlled trial evaluating a telehealth intervention for chronic pain management. Participants, recruited from primary care clinics, were 65 rural residents and 144 nonrural residents with similar demographic characteristics. Differences in the use of self-management interventions, pain intensity, and opioid dose were evaluated between rural and nonrural residents. Rural residents (n = 50, 77%) were less likely to use self-management interventions compared with nonrural residents (n = 133, 92%) (p = .019). Opioids were taken for pain relief by 76% of the rural residents compared with 52% of the nonrural residents. A disparity exists in the use of self-management interventions for chronic pain management by rural residents compared with nonrural residents. Further study is needed to determine if this is related to the lack of access to specialists and/or pain management training of primary care providers. Nurses can play an essential role in addressing this disparity by educating patients about self-management interventions.

Achieving universal coverage: Understanding barriers to rural placement for final year midwifery students.

OBJECTIVE: the objective of this study is to understand the barriers final year midwifery students face when deciding to practice in a rural, deprived area. DESIGN: a cross-sectional study design using a computer based structured survey. SETTING: 15 of the 16 publicly funded midwifery colleges across all ten regions in Ghana. PARTICIPANTS: a national sample of final-year midwifery students from publically funded midwifery colleges in Ghana. MEASUREMENTS: basic frequencies and percentages were calculated for the variables cited as the top three factors motivating participants to study midwifery stratified by student type (post-basic verses diploma) and program location (urban, peri-urban, and rural). Odds ratios were calculated using separate logistic regression models to analyze the relationship between students' experience with rural communities and how it affected their willingness to work in a rural area following graduation. FINDINGS: eight hundred and fifty-six midwifery students (N = 856) completed a computerised survey for a response rate of 91.8%. The top motivation to study midwifery was a 'desire to help others'. Over half (55%) of participants reported they will 'definitely work' (11%) or 'were likely to work' (44%) in a deprived area. When examined by student type and location of school, the top reason cited by participants was 'to serve humanity'. Those born in a rural area, currently living in a rural area, or under obligation to return to a rural or peri-urban area had greater odds of being willing to work in a deprived area after graduation. KEY CONCLUSIONS: findings from our study are unique in that they examine the distinct motivational factors from a national sample of midwifery students about to join the workforce. Regardless of the type of student or the location of the school, midwifery students in Ghana were highly motivated by altruistic values. Strategies to address the rural shortage of midwifery providers in Ghana is presented. IMPLICATION FOR PRACTICE: understanding the factors that motivate midwifery students to work in rural, deprived areas will help develop effective policy interventions affecting practice.

Integration of Mental and Behavioral Health in Pediatric Health Care Clinics.

OBJECTIVE: Integrating behavioral health services into primary and pediatric health care settings is important to increase availability and access to quality mental and behavioral health care for children and adolescents. The Mental and Behavioral Health Capacity Project implemented models of pediatric integrated health care at Federally Qualified Health Clinics covering largely rural communities in Louisiana and impacted communities on the Florida Panhandle. The objectives of this article are to describe the programs and demonstrate sustainability and effectiveness of services provided. DESIGN: A subsample from the Louisiana clinics collected data at intake and follow-up at 1, 3, and 6-month intervals. The hypotheses were that child behavior problems and parenting stress would significantly decrease over the course of treatment. SETTING: This study was conducted at 2 Federally Qualified Health Clinics in rural southeast Louisiana that provide pediatric primary health care. PARTICIPANTS: Sample parameters were child patients younger than 18 years presenting at primary health care clinics in Southeast Louisiana (N = 177); the mean age was 9.8 years (standard deviation = 4.3 years). INTERVENTION: Brief behavioral health services included parental education, medication management, stress management, empowerment, and psychodynamic interventions. MAIN OUTCOME MEASURE: The main outcome measures were the Pediatric Symptom Checklist and the Parenting Stress Index. RESULTS: Statistically significant decreases in child behavior problems and parenting stress were revealed, with 87% reporting satisfaction with services. CONCLUSIONS: Utilizing community-based and culturally sensitive approaches, mental and behavioral health integrated into pediatric health care clinics can be sustainable and effective at improving child behavior problems, parenting stress, and overall family functioning.

Growth parameters and childhood epilepsy in Hai District, Tanzania: a community-based study.

AIM: This cross-sectional study examined whether growth parameters were associated with epilepsy in children living in a rural community in sub-Saharan Africa (SSA). MATERIALS AND METHODS: A cross-sectional study was performed in the Hai District Demographic Surveillance Site (HDSS), Tanzania in which 6-14 year old children with epilepsy (CWE) were identified. Age matched controls were randomly selected from the Hai census database for comparison. Anthropometric measurements were used to assess the nutritional status of the children and body mass index (BMI) calculated. Associations between social, demographic and nutritional factors and epilepsy were assessed using multivariable logistic regression. RESULTS: 112 CWE were identified and were compared with 113 controls. There was no significant difference in the BMI between cases and controls (T-test, p-value of 0.117). Amongst cases, there were no significant associations between BMI and motor difficulties, antiepileptic drug use, cognitive or behavioural problems, early-onset epilepsy or seizure frequency. In the whole group, BMI was significantly associated with socio-economic status (p=0.037) and age. DISCUSSION: There was no significant difference found between CWE and matched controls with respect to nutritional status. This suggests that there is no causal association between under nutrition and epilepsy in this community. Nutritional assessment is still important as part of the comprehensive care of CWE.

Learning from HIV: exploring migration and health in South Africa.

Southern Africa is associated with high HIV prevalence and diverse population movements, including temporary, circular movements between rural and urban areas within countries (internal migration), and movements across borders (international migration). Whilst most migration in southern Africa is associated with the search for improved livelihood opportunities in urban areas a small--but significant--number of people are forced to migrate to escape persecution or civil war. This paper utilises recent empirical studies conducted in South Africa to explore linkages between migration into urban areas and health, focusing on HIV. It is shown that the relationship between migration and HIV is complex; that both internal and international migrants move to urban areas for reasons other than healthcare seeking; and that most migratory movements into urban areas involve the positive selection of healthy individuals. Whilst healthy migration has economic benefits for rural sending households, the data uncovers an important process of return migration (internally or across borders) in times of sickness, with the burden of care placed on the rural, sending household. There is an urgent need for a comprehensive response that maintains the health of migrants in urban areas, and provides support to rural areas in times of sickness.

From mainstream to marginal? Trends in the use of Chinese medicine in China from 1991 to 2004.

In many Western societies, alternative healing options, including Chinese medicine, have started to move from the marginal to mainstream. In China, Chinese medicine has been an established component in the official health care system, but its relevance and effectiveness have often been challenged in a society committed to modernization. Despite abundant speculation, little research has established empirical facts regarding the use of Chinese medicine in China. This paper uses a longitudinal dataset to examine the trends from 1991 to 2004, and explore the extent to which changing population demographic and socioeconomic characteristics contributed to the observed trends. It finds that in the formal medical sector, the use of Chinese medicine has contracted, particularly in cities. Changing population demographic and socioeconomic characteristics cannot entirely account for the contraction. Rather, shifts in cultural values and structural changes in the health care system may have led to the observed decline.

Stroke in rural areas and small communities.

The management of stroke in rural and regional areas is variable in both the developed and developing world. Informed by best-practice guidelines and recommendations for systems of stroke care, adaptable models of care that are appropriate for local needs should be devised for rural and regional settings. This review addresses the issue of the provision of appropriate services in rural and regional settings, with particular attention to the barriers involved, according to the classification of Low Human Development Country (LHDC), Medium Human Development Country (MHDC) and High Human Development Country (HHDC). We discuss the need and feasibility of developing implementing stroke care in rural settings according to best-practice recommendations, within models of care adapted to local conditions.

"They're too smart for that": predicting what children would do in the presence of guns.

OBJECTIVES: We examined parents' beliefs about how children would react to finding guns, with particular emphasis on how parents reasoned about children's actions. METHODS: Based on a randomized telephone survey of Northeast Ohio residents, we focused on the 317 urban and 311 rural respondents who had children 5 to 15 years old in their homes. Respondents were asked about gun ownership and their expectations of how children would react to finding guns. Analysis examined responses in relation to various demographic and socioeconomic variables. RESULTS: All respondents--regardless of gun ownership, geography, race, gender, education level, income, or child age--were equally likely (approximately 87%) to believe that their children would not touch guns they found. Fifty-two percent of those reasoned that children were "too smart" or "knew better." Only 40% based their predictions on specific instructions they had given their children. Only 12% (15/122) of owners stored guns locked and unloaded. Only 3 of 13 variables tested were positively associated with safe storage: having a child 5 to 9 years old, having at least a 4-year college education, and having an income >or=65,000 dollars per year. CONCLUSION: Results indicate that parental beliefs may effectively relieve adults of responsibility and place the burden on children to protect themselves. The implication for injury prevention is that caregivers' unrealistic expectations of children's developmental levels and impulse control may influence storage decisions or the inclination to address gun safety issues with children or other adults with whom children spend time (relatives, playmates' parents).