Addressing Rural Health Challenges Head On.

Providing health care to patients and families living in rural America presents significant challenges, but comes with unique rewards. The physician who chooses a rural life typically cares for an underserved and aging population, which is often less healthy and affluent than its urban and suburban counterparts. At the same time, rural clinicians feel deeply connected to their patients and their communities. Physicians cite strong doctor-patient relationships as a primary motivator to practice in a rural setting, in addition to lower cost of living and slower pace of life1. Those who choose primary care specialties also enjoy the challenge of caring for multiple, interrelated aspects of health for their patients and community. During Kansas City University of Medicine and Biosciences' (KCU) century-long history, we have offered our osteopathic medical students the opportunity to learn in rural areas during the third and fourth years. As our new, state-of-the-art medical school campus opens in Joplin, Missouri, we will build on our commitment to rural health by offering first- and second-year KCU-Joplin students training opportunities in rural settings, and expanding third- and fourth-year rural clinical rotations. The rich experience to learn rural medicine offers the potential to connect medical students, patients and community in new and exciting ways, building on the firm foundation of osteopathic medical training grounded in strong patient-centered primary care.

Neurosurgery in India: an overview.

This overview of neurosurgery in India during the last six decades gives a holistic perspective of the phenomenal advances made. Neurosurgical education, the change in clinical spectrum of diseases and their presentation, evolution of various subspecialties and societies, the state of research, the issues peculiar to India, including the urban-rural health divide, the increasing role of information and communication technology in neurosurgery, and the gradual but definite global recognition of Indian neurosurgery will be addressed.

Cardiovascular risk levels in general practice patients with type 2 diabetes in rural and urban areas.

OBJECTIVE: To investigate the change of cardiovascular risk factor from 2000 to 2002 in general practice patients with type 2 diabetes in urban and rural areas, and the association between cardiovascular risk (both single risk factors and coronary heart disease absolute risk (CHDAR)) and rurality in three years. METHODS: In total, 6305 patients were extracted from 16 Divisions (250 practices). Multivariate regression at Division, practice and patient levels was conducted with adjustment for age and gender. RESULTS: In each of the three years, most single individual risk factors and CHDAR were high. Comparing 2002 with 2000: for urban patients in 2002 total cholesterol (OR 0.85) and low-density lipoprotein (OR 0.81) significantly decreased, and high-density lipoprotein (HDL) (OR 1.16) significantly increased; for rural patients in 2002 HbA1c (OR 0.85) significantly decreased and HDL (OR 1.22) significantly increased; and CHDAR significantly improved only in urban patients (OR 0.93) in 2002. In 2002 rural patients were still more likely to be overweight/obese (OR 1.16), be current smokers (OR 1.36), and have worse HDL (OR 0.84) and triglycerides (OR 1.23) than their urban counterparts. CONCLUSION: Some key individual risk factors and CHDAR did not improve in rural patients with type 2 diabetes despite a number of programs designed to provide comprehensive care to rural patients with diabetes. More emphasis is needed on supporting access to lifestyle changes (such as smoking, diet and physical activity) in rural primary health care.

Trends in the distribution of body mass index among Chinese adults, aged 20-45 years (1989-2000).

OBJECTIVE: To describe body mass index (BMI, in kg/m(2)) distribution patterns and trends among Chinese adults, aged 20-45 years (1989-2000). DESIGN: A descriptive, population-based study of BMI change. SETTING: Chinese provinces (eight in 1989 and 1997; nine in 2000), representative of the household-based surveys (the China Health and Nutrition Survey, 1989-2000) using multistage, random cluster sampling, supplemented with annual household consumption survey data of the State Statistical Bureau (SSB). SUBJECTS: A total of 4527, 4507 and 4046 adults, aged 20-45 years, in 1989, 1997 and 2000, respectively. MEASUREMENTS: BMI (underweight: BMI<18.5 kg/m(2) and overweight: BMI>/=25 kg/m(2)). Percentile curves for BMI in 1989 and 2000 were constructed by gender and age using the LMS (lambda, mu, sigma) method. RESULTS: Compared with 1989, the 2000 BMI distribution curves flattened at higher levels of BMI (men and women). There was a 13.7% increase in the proportion of men and a 7.9% increase of women who were overweight or obese with a resulting greater change in the annualized prevalence rate for men. This increase in the prevalence of overweight and obesity was far greater than the decrease (2.1% for men; 2.2% for women) in that of underweight. Age-gender-specific percentile curves showed BMI increases mainly among women, aged 35-45 years, and among men at all age groups. CONCLUSIONS: Chinese BMI dynamics show much greater rates of change among men, aged 20-45 years, than among women, with the increase among women concentrated between ages 35 and 45 years. These changes portend large shifts in other diet-related non-communicable diseases in China over the following decades. Controlling the increasing trends of BMI, especially in men, is an important public health problem facing China.

Saúde como prática da liberdade: as práticas de famílias em um acampamento do MST e o desenvolvimento de estratégias de educação popular em saúde / Health as practice of the freedom: the practices of families in a camping of the Landless Movement MST and the development of strategies of popular education in health

As famílias do Acampamento Padre Gino (Frei Inocêncio – MG), participantes do MST, lutam por saúde e qualidade de vida através da adoção de algumas práticas complementares afim de alcançarem a (saúde para todos), preconizada pela OMS. O objetivo deste trabalho foi conhecer e discutir tais práticas de saúde, bem como seu contexto e relação com os serviços oficiais de saúde, a fim de desenvolver estratégias de educação popular e motivar a discussão das políticas públicas. Esta pesquisa envolveu os métodos da educação popular e utilizou observação participante, questionário e entrevista. Durante a vivência no Acampamento, 38 famílias responderam a um questionário e 12 informantes-chave foram entrevistados. Entre as famílias, além da utilização dos serviços públicos de saúde, é comum o uso de práticas complementares (plantas medicinais, bioenergética, argila, orações, benzeções e alimentação adequada), havendo um sincretismo harmonioso entre diferentes racionalidades em saúde.Esta utilização é ora uma opção pessoal (resolução dos problemas simples, preferência, praticidade, tradição familiar, etc.) e ora uma imposição social (dificuldade financeira e/ou de acesso aos serviços oficiais), variando com a especificidade do momento ou do problema. Cem plantas foram apontadas como utilizadas para a busca e manutenção da saúde e, destas, 70 foram identificadas. Dentre as 70, 42 estão em consonância com a literatura sobre os usos populares e apenas 8 estão com ação cientificamente comprovadas. Plantas e receitas são trocadas na comunidade, ajudando a reforçar os laços sociais e a rede de apoio social. Fatores como a fé religiosa e a associação de saúde como capacidade para trabalhar também se fizeram presentes. A conquista definitiva da terra é percebida pelas famílias como capaz de melhorar a atual situação de saúde. Após a vivência, dois materiais educativos foram elaborados na tentativa de estimular um diálogo entre os saberes popular e científico.

Saúde como prática da liberdade: as práticas de famílias em um acampamento do MST e o desenvolvimento de estratégias de educação popular em saúde

As famílias do Acampamento Padre Gino (Frei Inocêncio – MG), participantes do MST, lutam por saúde e qualidade de vida através da adoção de algumas práticas complementares afim de alcançarem a (saúde para todos), preconizada pela OMS. O objetivo deste trabalho foi conhecer e discutir tais práticas de saúde, bem como seu contexto e relação com os serviços oficiais de saúde, a fim de desenvolver estratégias de educação popular e motivar a discussão das políticas públicas. Esta pesquisa envolveu os métodos da educação popular e utilizou observação participante, questionário e entrevista. Durante a vivência no Acampamento, 38 famílias responderam a um questionário e 12 informantes-chave foram entrevistados. Entre as famílias, além da utilização dos serviços públicos de saúde, é comum o uso de práticas complementares (plantas medicinais, bioenergética, argila, orações, benzeções e alimentação adequada), havendo um sincretismo harmonioso entre diferentes racionalidades em saúde.Esta utilização é ora uma opção pessoal (resolução dos problemas simples, preferência, praticidade, tradição familiar, etc.) e ora uma imposição social (dificuldade financeira e/ou de acesso aos serviços oficiais), variando com a especificidade do momento ou do problema. Cem plantas foram apontadas como utilizadas para a busca e manutenção da saúde e, destas, 70 foram identificadas. Dentre as 70, 42 estão em consonância com a literatura sobre os usos populares e apenas 8 estão com ação cientificamente comprovadas. Plantas e receitas são trocadas na comunidade, ajudando a reforçar os laços sociais e a rede de apoio social. Fatores como a fé religiosa e a associação de saúde como capacidade para trabalhar também se fizeram presentes. A conquista definitiva da terra é percebida pelas famílias como capaz de melhorar a atual situação de saúde. Após a vivência, dois materiais educativos foram elaborados na tentativa de estimular um diálogo entre os saberes popular e científico

Rural Integrated Primary Care Psychiatry Programme: a systems approach to education, training and service integration.

OBJECTIVE: To describe the development of a rural primary care psychiatry programme, within a stepped collaborative care model. CONCLUSION: Development of a system-wide approach to the provision of mental health services offers the opportunity to increase the proportion of people with mental health problems who receive effective treatment. In addition, it enables allocation of resources and matching of interventions to patient preference and clinical need. This is particularly important in rural areas where there is a shortage of specialist mental health services and practitioners.

Social differentials in the decline of infant mortality in Sweden in the twentieth century: the impact of politics and policy.

This article describes some of the policies behind the decline of infant mortality in Sweden during the 20th century, from very high levels and large social differentials at the turn of the 19th century to one of the lowest levels in the world by 1950. Political commitment to reducing infant mortality and disparities between groups, a more equitable distribution of economic resources, and a successful combination of universal social and health policies most benefiting the least advantaged families and their children contributed to this favorable development.

Nutritional status of Libyan children in 2000 compared with 1979.

This cross-sectional study examined the growth and nutritional status of Libyan preschool children and the socioeconomic status of their parents in 2000 and compared the results with those of a similar study conducted in 1979. The investigation involved 1614 healthy children of both sexes under 5 years of age in two regions of the Libyan Arab Jamahiriya. Simple random sampling and cluster sampling techniques were used to enlist participants. Body weight, height, and head and arm circumference of the children were recorded and mothers were interviewed about their child's health and the socioeconomic status of the family. Significant improvements in nutritional status since 1979 were found that could be attributable to factors such as socioeconomic development, longer breastfeeding, greater availability of high energy foods, supplementation with semi-solid or solid foods and heavy government subsidy of basic foods.

Conocimientos y expectativas sobre la hospitalización en escolares de Córdoba, en el ámbito rural # / Knowledges and hopes about hospitalization in a rural area of Cordoba schoolchildren´s population

Fundamento: La edad pediátrica constituye un grupo de población especialmente vulnerable al estrés de la hospitalización. Al niño hospitalizado es necesario proporcionarle junto a los cuidados sanitarios, atención psicológica y educativa.Método: Se realiza un estudio de corte transversal de conocimientos y expectativas sobre la hospitalización en escolares de la provincia de Córdoba, en medio rural, mediante cuestionario.Resultados: Participaron niños de 8 a 13 años, de 4 colegios (n =279). El análisis de los datos obtenidos muestra que el nivel de conocimientos de los escolares resultó insuficiente, con puntuación media de 4,4 sobre 10. Dan gran importancia a los cuidados y la atención (44,8 por ciento de los niños) y a la visita de familiares y amigos (44,08 por ciento). Consideraron lo mejor del Hospital el mimo y los cuidados (37,99 por ciento) y la curación más rápida (17,92 por ciento); lo peor, el dolor y la enfermedad (17,56 por ciento) y las comidas-instalaciones-ruidos (17,20 por ciento). Para la mayoría de los niños el hospital es "aburrido" (54,48 por ciento) y "no se juega" (30,11 por ciento).Conclusiones: necesidad de incrementar y estructurar la actividad ludopedagógica y reforzar el aspecto psico-social de la atención hospitalaria en la edad pediátrica, necesidad de adaptar el hospital a las necesidades del niño (AU)

Changing patterns of corneal disease and associated vision loss at a rural African hospital following a training programme for traditional healers.

AIMS/BACKGROUND: Use of African traditional eye medicines (TEM) is associated with the presence of corneal disease, delay in presentation, and vision loss. An interactive training programme was conducted with traditional healers in Chikwawa District, Malawi and changes in the pattern of corneal disease assessed in patients presenting to the district hospital after the training. METHODS: All patients presenting to the district hospital with corneal disease for a 15 month period before intervention and a 12 month period after intervention were enrolled in the study. Interviews and examinations were carried out by the same person using a standardised, pretested form. RESULTS: Among the 175 pre-intervention and 97 post-intervention patients, delay in presentation improved only slightly. Blindness among patients reporting the use of TEM decreased from 44% to 21%; bilateral corneal disease in patients using TEM decreased from 31% to 10%. Multivariate analysis demonstrates that poor vision in corneal disease patients continues to be associated with TEM use and distance from the district hospital. CONCLUSION: As there were no other relevant eye health programmes in the district it is believed that this collaborative eye care programme with the traditional healers was likely to have been responsible for many of the changes in the pattern of corneal disease in the district. Although the changing patterns are encouraging and are likely to improve with additional collaboration, distance to a district hospital will continue to be a barrier to timely use of Western eye care services.

Rural psychiatric services.

OBJECTIVE: The objective was to describe and evaluate a community mental health service developed during 1991-1992 in an attempt to meet the mental illness needs of an isolated rural community. The setting was the Grampians health region in Western Victoria: this region has an area of 45,000 square kilometers and a population of 182,000. METHOD: The method involved firstly describing the evolution of the service delivery model. This comprised a team of travelling psychiatrists and community psychiatric nurses which succeeded in providing a combined inpatient and outpatient service which was integrated with general practitioners. Secondly, diagnostic and case load descriptions of patients receiving service were compared for both the inpatient and outpatient settings. RESULTS: The results were that reduced reliance on inpatient beds and increased consumer satisfaction were achieved. CONCLUSION: It was concluded that on initial evaluation of the service it was seen to be meeting its objective of treating the seriously mentally ill in an isolated rural community-based setting.

Primary health care and donor dependency: a case study of nongovernment assistance in Burkina Faso.

Primary health care assistance has become prominent in the rural development programs of many nongovernment organizations throughout sub-Saharan Africa. By emphasizing education and the promotion of new participatory health systems, most such programs aim to enhance the conditions of women as principal community care givers. Yet village-level health assistance in Africa is not without shortcomings. This is exemplified in a case study of two nongovernment programs in Burkina Faso's Namentenga Province. Although both programs have contributed to maternal health and infant survival, they have also induced new ties of donor dependency. This appears to present a conundrum for the sponsoring agencies which espouse self-reliance as a development assistance goal. In fact, however, where the intervention of nongovernment organizations helps to improve rural health, new dimensions of dependency may prove to be a positive first stage in the mobilization of women and the development of locally managed health systems. For this to be so, much is contingent on the capacity of these organizations to integrate local participation in their own planning and management processes, and to augment the professional status of indigenous health workers.

PIP: The relative effectiveness of foreign-funded nongovernmental organization (NGO) development programs in the province of Namentenga in east-central Burkina Faso was evaluated by studying two NGO programs. In 1971 the resident Catholic mission initiated a neighborhood women's health assistance program in Boulsa township entitled Sante Maternelle et Infantile (SMI), which by 1991 extended assistance to 14 villages. In 1978 a second NGO program started, the Plan de Parrainage International de Boulsa (PPIB), which provided village assistance, school construction, bore-hole well drilling, and agricultural extension. By 1991, 18 extension agents were working in 26 villages. The two NGOs provided infrastructure (first aid clinics, maternities, and midwife lodgings); education and consultation assisted by village health workers in growth monitoring and education (GME), nutrition, and prenatal care; and community health development (health committees and women's development committees to foster female participation in community affairs). The impact of the primary health care (PHC) programs was assessed during a 16-month period from late 1985 to early 1987 in 4 villages by visiting 873 households and conducting interviews with 99 married women 18-45 years old (7% of all married women). Most women had attended GME clinics and 73% of the households had charts to prove it. 145 (43%) of 334 children born to 79 women who had attended GME clinics had been delivered in village maternities; only 8 of 103 children born to 20 women who had not attended clinics had been delivered in maternities. Only 11 of 128 deceased infants under 5 years of age had been examined at these clinics. The maternities and clinics improved maternal health and child survival. People's knowledge about the causes of disease and community hygiene had improved, however, the treatment of diarrhea and malnutrition did not change much, and the new knowledge did not lead to behavioral change. In addition, the ineffectiveness of the village committees to support indigenous paraprofessionals indicates the dependency that has emerged from NGO intervention.

Improved maternal and child health care access in a rural community.

Few studies have measured the extent to which expansion of health services for pregnant women and children in poor rural communities improves access to care and health status. This paper describes an underserved rural community in which health care initiatives increased access to comprehensive care. Over a three-year period, use of preventive services increased, whereas emergency room visits and hospitalizations at the community hospital decreased. Low birthweight, risk of congenital syphilis and childhood tuberculosis, and child mortality all decreased. Provision of comprehensive services was met with increased use of preventive health care and improved health outcomes in this rural community.

Expanded programme on immunization. Programme review.

PIP: In Bangladesh an evaluation of the Expanded Programme on Immunization (EPI) was conducted in February 1993. Data, including immunization coverage based on random surveys, were collected from all 4 divisions, 8 rural districts, 25 sub-districts (thanas) and from the cities of Dhaka and Chittagong. The Review Team assessed and made several recommendations concerning immunization coverage, surveillance for the EPI target diseases, immunization in urban areas, the cold chain and logistics, training, communication and social mobilization, other primary health care (PHC) interventions, vaccine supply, and the sustainability of EPI achievements. The population of Bangladesh is 110 million, with an estimated 3.6 million newborns during 1993. More than 90% of the 108,000 routine monthly immunization services are being conducted as scheduled. Nationally, among children 0-11 months of age, BCG coverage is 89%, as measured by evaluation surveys, coverage with 3 doses of diphtheria/pertussis/tetanus (DPT3) and oral polio vaccine (OPV3) is 63%, and measles coverage is 59%. Coverage with a second dose of tetanus toxoid (TT2) for pregnant women is 80%. In urban areas, BCG coverage for infants is 92%, DPT3/OPV3 76%, measles 68%, and TT2 for pregnant women 82%. In 2/3 of the sites visited, immunization was combined with vitamin A supplementation, oral rehydration treatment, or family planning. The coverage for both BCG and DPT3/OPV3 increased from only 2% in 1985 to almost 90% of infants having BCG immunization services in 1992. Yet only 50% of children are reached before their first birthday, and at least 20% of newborns are not protected against neonatal tetanus at birth. DPT1 and DPT3 drop-out is 29% nationally and 17% in urban areas. In 1992, an estimated 117,000 cases of neonatal tetanus and 6700 cases of poliomyelitis were prevented by immunization. Surveys of neonatal tetanus in selected districts have confirmed a reduction in incidence from 40/1000 live births in 1986 to 10/1000 in 1991.^ieng

Investigacion de creencias comunes sobre cinco enfermedades en el altiplano boliviano: un ejemplo Carabuco / Common believes research about five deseases in the bolivian altiplano: Carabuco, an example

Una investigacion etnografica realizada con grupos focales aymaras en el Altiplano Norte boliviano, Provincia Camacho, sobre creencias y costumbres relacionadas con enfermedades relevantes a la mortalidad evitable: Diarrea en niños y adultos, Neumonia, Tuberculosis, Sepsis puerperal. Comparacion de terminos aymaras con terminos tecnicos castellanos en cuanto a la etiologia, semiologia prevencion y tratamiento de entidades nosologicas percibidas por la poblacion. Recomendaciones concretas de traduccion del castellano al aymara requeridas en la educacion para la salud que concientizan sobre connotaciones especificamente ligadas al contexto cultural

Alteraciones de la biometria hematica en pacientes infectados por Leishmaniasis-cutaneo-mucosa y tratados por antileishmaniasicos / Hematological variations in treted patients with mucocutaneous leishmaniasis

Si la leishmaniasis cutaneo-mucosa en si no afecta mucho la biometria hematica de los pacientes infectados, a la inversa los efectos de los agentes antileishmaniasicos sobre la biometria hematica son bien conocidos a traves de estudios, investigaciones y ensayos terapeuticos. Los resultados de nuestros estudios demuestran cierta concordancia con lo reportado en la literatura mundial, aunque llama la atencion algunas diferencias que mencionamos en el documento.