The "Flying Intervention Team": A Novel Stroke Care Concept for Rural Areas.

BACKGROUND: Endovascular treatment of large vessel occlusion in acute ischemic stroke patients is difficult to establish in remote areas, and time dependency of treatment effect increases the urge to develop health care concepts for this population. SUMMARY: Current strategies include direct transportation of patients to a comprehensive stroke center (CSC) ("mothership model") or transportation to the nearest primary stroke center (PSC) and secondary transfer to the CSC ("drip-and-ship model"). Both have disadvantages. We propose the model "flying intervention team." Patients will be transported to the nearest PSC; if telemedically identified as eligible for thrombectomy, an intervention team will be acutely transported via helicopter to the PSC and endovascular treatment will be performed on site. Patients stay at the PSC for further stroke unit care. This model was implemented at a telestroke network in Germany. Fifteen remote hospitals participated in the project, covering 14,000 km2 and a population of 2 million. All have well established telemedically supported stroke units, an angiography suite, and a helicopter pad. Processes were defined individually for each hospital and training sessions were implemented for all stroke teams. An exclusive project helicopter was installed to be available from 8 a.m. to 10 p.m. during 26 weeks per year. Key Messages: The model of the flying intervention team is likely to reduce time delays since processes will be performed in parallel, rather than consecutively, and since it is quicker to move a medical team rather than a patient. This project is currently under evaluation (clinicaltrials NCT04270513).

Challenges experienced by midwives working in rural communities in the Upper East Region of Ghana: a qualitative study.

BACKGROUND: In 2017, a total of 295,000 women lost their lives due to pregnancy and childbirth across the globe, with sub-Saharan Africa and South Asia accounting for approximately 86 % of all maternal deaths. The maternal mortality ratio in Ghana is exceptionally high, with approximately 308 deaths/100,000 live births in 2017. Most of these maternal deaths occur in rural areas than in urban areas. Thus, we aimed to explore and gain insights into midwives' experiences of working and providing women-centred care in rural northern Ghana. METHODS: A qualitative descriptive exploratory design was used to explore the challenges midwives face in delivering women-centred midwifery care in low-resource, rural areas. A total of 30 midwives practicing in the Upper East Region of Ghana were purposefully selected. Data were collected using individual semistructured interviews and analysed through qualitative content analysis. RESULTS: Five main themes emerged from the data analysis. These themes included were: inadequate infrastructure (lack of bed and physical space), shortage of midwifery staff, logistical challenges, lack of motivation, and limited in-service training opportunities. CONCLUSIONS: Midwives experience myriad challenges in providing sufficient women-centred care in rural Ghana. To overcome these challenges, measures such as providing adequate beds and physical space, making more equipment available, and increasing midwifery staff strength to reduce individual workload, coupled with motivation from facility managers, are needed.

The Experience of Colombian Medical Students in a Pilot Cultural Safety Training Program: A Qualitative Study Using the Most Significant Change Technique.

Problem: The Colombian government provides health services grounded in the Western biomedical model, yet 40% of the population use cultural and traditional practices to maintain their health. Adversarial interactions between physicians and patients from other cultures hinder access to quality health services and reinforce health disparities. Cultural safety is an approach to medical training that encourages practitioners to examine how their own culture shapes their clinical practice and how to respect their patients' worldviews. This approach could help bridge the cultural divide in Colombian health services, improving multicultural access to health services and reducing health disparities. Intervention: In 2016, we conducted a pilot cultural safety training program in Cota, Colombia. A five-month training program for medical students included: (a) theoretical training on cultural safety and participatory research, and (b) a community-based intervention, co-designed by community leaders, training supervisors, and the medical students, with the aim of strengthening cultural practices related to health. Evaluation used the Most Significant Change narrative approach, which allows participants to communicate the changes most meaningful to them. Using an inductive thematic analysis, the authors analyzed the stories and discussed these findings in a debriefing session with the medical students. Context: Cota is located only 15 kilometers from Bogota, the national capital and biggest city of Colombia, so the small town has gone through rapid urbanization and cultural change. A few decades ago, inhabitants of Cota were mainly peasants with Indigenous and European traditions. Urbanization displaced agriculture with industrial and commercial occupations. One consequence of this change was loss of cultural health care practices and resources, for example, medicinal plants, that the community had used for centuries. Impact: A group of 13 final-year medical students (ten female and three male, age range 20-24) participated in the study. The medical students listed four areas of change after their experience: increased respect for traditional health practices to provide better healthcare; increased recognition of traditional practices as part of their cultural heritage and identity; a desire to deepen their knowledge about cultural practices; and openness to incorporate cultural practices in healthcare. Lessons Learned: Medical students reported positive perceptions of their patients' cultural practices after participating in this community-based training program. The training preceded a positive shift in perceptions and was accepted by Colombian medical students. To the best of our knowledge, this was the first documented cultural safety training initiative with medical students in Colombia and an early attempt to apply the cultural safety approach outside the Indigenous experience.

Teaching psychomotor skills online: exploring the implications of novel coronavirus on health professions education.

CONTEXT: The safe and effective application of psychomotor skills in the clinical environment is a central pillar of the health professions. The current global coronavirus pandemic has significantly impacted health professions education (HPE) and has been of particular consequence for routine face-to-face (F2F) skill education for health professionals and clinical students worldwide. What is being experienced on an unprecedented scale parallels a problem familiar to regional, rural and remote health professionals and students: the learners are willing, and the educational expertise exists, but the two are separated by the tyranny of distance. This article considers how the problem of physical distance might be overcome, so that quality skill education might continue. ISSUES: Psychomotor skills are undeniably easier to teach and learn F2F, and training schedules in tertiary, in-service and accredited professional courses reflect this. This aspect of HPE is therefore at significant risk in the context of social distancing and physical isolation. Psychomotor skills are much more complex than the physical motor outputs alone might suggest, and an F2F skill session is only one way to build the complementary aspects of new skill performance. This article argues that educators and course designers can progress with psychomotor skill education from a physical distance. LESSONS LEARNED: Videos can be used to either passively present content to learners or actively engage them. It is the design of the educational activity, rather than the resource medium itself, that enables active engagement. Furthermore, while many training schedules have been adapted to accommodate intensive F2F skill training once it is safe to do so, distributed practice and the need for reflection during the acquisition and development of new skills may challenge the pedagogical effectiveness of this approach. Skill development can be fostered in the absence of F2F teaching, and in the absence of a shared physical space. Embracing the creative licence to do so will improve equitable access to regional, rural and remote clinicians and students well beyond the resolution of the current pandemic.

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study.

BACKGROUND: Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya. METHODS: The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods. RESULTS: The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3. CONCLUSIONS: The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Landscapes of care and despair for rural youth - a qualitative study in the northern Swedish 'periphery'.

BACKGROUND: This study emerges as a response to the lack of youth perspectives when it comes to discussions about access to and experiences of health and social services in rural areas. It subsequently contributes to the literature by positioning young people at the centre of this debate, and by taking a more holistic approach to the topic than is typically the case. Specifically, based on the idea that a good life in proper health for young people may be contingent on notions of care that are bounded up in multi-layered social and spatial environments, the aim of this study was to explore what characterises 'landscapes of care' for rural youth. METHODS: In this qualitative study, the participants included young people and professionals residing in five diverse areas across the northern Swedish 'peripheral' inland. Individual interviews (16 in total) and focus group discussions (26 in total) were conducted with 63 youth aged 14-27 years and with 44 professionals operating across sectors such as health centres, school health, integration units, youth clinics and youth clubs. Following an emergent design and using thematic analysis, we developed one main theme, 'landscapes of care and despair', comprising the two themes: '(dis)connectedness' and 'extended support or troubling gaps'. RESULTS: The findings illustrate how various health-promoting and potentially harmful aspects acting at structural, organisational and interpersonal levels contributed to dynamic landscapes characterised simultaneously by care and despair. In particular, our study shows how rural youths' feelings of belongingness to people and places coupled with opportunities to participate in society and access practical and emotional support appear to facilitate their care within rural settings. However, although the results indicate that some in the diverse group of rural youth were cared for and about, a negative picture was painted in parallel. These aspects of despair included youths' senses of exclusion and marginalisation, degrading attitudes towards them and their problems, as well as recurrent gaps in the provision and practices of care. CONCLUSIONS: To gain a more comprehensive understanding about the health of rural youth, this study highlights the benefits investigating 'care-ful' and 'uncaring' aspects bounded up in dynamic and multi-layered landscapes.

Maternity connect: Evaluation of an education program for rural midwives and nurses.

BACKGROUND: Rural and regional health services often find it difficult to maintain their maternity service and skills of their maternity workforce and enable women to give birth close to home. The Maternity Connect Program is a professional development initiative aimed at supporting and upskilling rural and regional maternity workforces to meet their maternity population care needs. AIM: To evaluate the Maternity Connect Program from the perspectives and experiences of participating midwives/nurses and health services. METHODS: A retrospective audit of data routinely collected as part of the Maternity Connect Program: initial needs assessments (baseline survey), and one month and six months post-placement surveys completed by participants, placement health services and base health services. The main outcome measures were: participants' (midwives and health services) level of satisfaction with the Program; and changes in midwives'/nurses' perceived level of confidence in performing key midwifery skills after participating in the program. RESULTS: Respondents (n = 97 midwives/nurses; n = 23 base health services; n = 4 placement health services) were satisfied with the program and there was an increase in midwives/nurses' confidence when providing specific aspects of maternity care (birthing, neonatal and postnatal). Midwives/nurses report transferring skills learnt back to their base health service. CONCLUSION: The Maternity Connect Program appears to be a successful educational model for maintaining and increasing clinician confidence in rural and regional areas.

Improving maternal and newborn care: cost-effectiveness of an innovation to rebrand traditional birth attendants in Sierra Leone.

OBJECTIVES: This paper evaluates the cost-effectiveness of rebranding former traditional birth attendants (TBAs) to conduct health promotion activities and refer women to health facilities. METHODS: The project used 200 former TBAs, 100 of whom were also enrolled in a small income generating business. The evaluation had a three-arm, quasiexperimental design with baseline and endline household surveys. The three arms were: (a) Health promotion (HP) only; (b) Health promotion plus business (HP+); and (c) the comparison group. The Lives Saved Tool is used to estimate the number of lives saved. RESULTS: The HP+ intervention had a statistically significant impact on health facility delivery and four or more antenatal care (ANC) visits during pregnancy. The cost-effectiveness ratio was estimated at US$4130 per life year saved in the HP only arm, and US$1539 in the HP+ arm. Therefore, only the HP+ intervention is considered to be cost-effective. CONCLUSIONS: It is critical to prioritize cost-effective interventions such as, in the case of rural Sierra Leone, community-based strategies involving rebranding TBAs as health promoters and enrolling them in health-related income generating activities.

'Being a midwife is being prepared to help women in very difficult conditions': midwives' experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo.

INTRODUCTION: Maternal and neonatal health are core focus areas in fragile and conflict-affected areas, and hence midwives are key actors. But there is currently very little evidence on midwives' experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri Province in the north-eastern part of the Democratic Republic of Congo (DRC). This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives' work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, north-eastern DRC. METHODS: As part of a qualitative approach, life history interviews with 26 midwives and 6 ex-midwives, and three focus group discussions with 22 midwives in three health districts of Ituri Province (Bunia, Aru and Adja), were conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo software. A timeline framework was deployed in the analytical process. RESULTS: Problem solving, childhood aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses, resulting in different levels and training experiences. Midwives faced many work challenges: serious shortages of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation was worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives wanted to continue working as midwives or follow further midwifery studies. Family-related reasons were the main reasons for most ex-midwives to leave the profession. CONCLUSION: Midwives play a critical role in supporting women to deliver babies safely in rural Ituri Province. They face immense challenges and demonstrate bravery and resilience as they navigate the interface between underresourced health systems and poor, marginalized rural communities. This situation requires a call to action: donors need to prioritize these contexts; and the government and other stakeholders in DRC need to invest more in improving security conditions as well as working conditions and professional support for midwives in rural Ituri Province. Only then will midwives be able to provide the critical services that women and their families need, and therefore contribute to achieving universal health coverage.

Staff and Organizational Capacity in the Implementation of Coordinated Care: an Examination of 10 Behavioral Health Agencies in Rural Communities.

Providing primary care services in behavioral health settings has become more common and necessary given the needs of individuals with serious mental illness (SMI). In this exploratory study, we developed a survey to assess agency and professional staff and practitioner capacity for coordinated care. The survey provides a feedback mechanism for agencies to target staff and organizational needs related to building capacity to provide coordinated care. Logistic regressions compared differences in 24 dimensions of coordinated care specifically comparing capacity based on professional role (behavioral health and medical), model of coordination (co-located and fully integrated), and time of model adoption (early and late adopters). Findings indicated that all three were significant predictors of capacity in multiple dimensions suggesting the need for training and planning around inter-professional and inter-agency coordination.

Maternal and neonatal service delivery by traditional birth attendants in rural Benin: A case for integration?

The Republic of Benin faces high maternal, newborn and child (MNCH) morbidity and mortality. Traditional birth attendants (TBAs) continue to operate on the margins of the health system yet provide critical services to women and children. This study aims to further the understanding of TBA's scope of practice for developing appropriate strategies to strengthen MNCH services at the community-level. TBAs were identified and surveyed on education, training, system support and scope of practice including management of obstetric and newborn emergencies. TBAs were found to perform diverse preventive and health promotion activities, including antenatal and newborn care counselling, promotion of family planning and immunizations. Among 109 TBAs, 11,102 births were documented in the prior year with a maternal mortality ratio (MMR) of 790/100,000 and neonatal mortality rate (NMR) 12.2/1000. The scope of TBA practices is broad and rural communities rely on this cadre for services. However, TBAs report higher rates of adverse maternal events compared to national statistics. Better understanding is needed on community preferences, training and methods of participation of TBAs within the health system. This could improve identification and referral for emergencies, reinforce safer practices and increase preventive and promotive health activities at the community level.

Determining the feasibility and effectiveness of brief online mindfulness training for rural medical students: a pilot study.

BACKGROUND: We sought to determine the feasibility and effectiveness of a mindfulness training program, delivered online to medical students at a Rural Clinical School. METHODS: An 8-week online training program was delivered to penultimate-year medical students at an Australian Rural Clinical School during 2016. Using a mixed methods approach, we measured the frequency and duration of participants' mindfulness meditation practice, and assessed changes in their perceived stress, self-compassion and compassion levels, as well as personal and professional attitudes and behaviours. RESULTS: Forty-seven participants were recruited to the study. 50% of participants were practising mindfulness meditation at least weekly by the end of the 8-week program, and 32% reported practising at least weekly 4 months following completion of the intervention. There was a statistically significant reduction in participants' perceived stress levels and a significant increase in self-compassion at 4-month follow-up. Participants reported insights about the personal and professional impact of mindfulness meditation training as well as barriers to practice. CONCLUSIONS: The results provide preliminary evidence that online training in mindfulness meditation can be associated with reduced stress and increased self-compassion in rural medical students. More rigorous research is required to establish concrete measures of feasibility of a mindfulness meditation program.

Integrating Behavioral and Primary Health Care in Rural Clinics: What Does Culture Have to Do with It?

Successful integration of health care in rural and underserved communities requires attention to power structures, trust, and disciplinary boundaries that inhibit team-based integration of behavioral and primary health care. This paper reports on perceived successes and ongoing challenges of integrating primary and behavioral health care from the perspectives of providers, community leaders, and community members. Data collection consisted of semi-structured qualitative interviews and focus groups conducted as part of a regional health equity assessment in northern Arizona. The authors explore barriers and successes in integrating health care in rural clinics using the perspective of a social ecological framework and the mediating role of culture. Differing expectations, differing professional areas, and interpersonal interactions were primary factors challenging movement toward integrated health care. Results suggest that providers and policymakers working toward health care integration should consider culture and interpersonal interaction as dynamic mediators, particularly in underserved and rural health care contexts.

Engaging the capacity of comadronas as HIV prevention providers in rural Guatemala.

In this study the author address rural Guatemala's poor maternal health and HIV status by integrating an effective evidence-based HIV intervention (SEPA), with local implementing health partners to extend the capacity of comadronas (traditional Mayan birth attendants) to encompass HIV prevention. I employed a multi-method design consisting of a focus group, an interview, and participant observation to identify important factors surrounding comadrona receptivity towards expanding their capacity to HIV prevention. I analyzed data using thematic analysis and identified four categories: Project logistics, HIV knowledge and risk assessment, condom perceptions, and HIV testing perceptions. I affirm comadrona receptivity toward HIV prevention, and that will guide future cultural adaptation and tailoring of SEPA for comadrona training. I will use my results to create a prototype intervention that could be applied to other similarly underserved indigenous communities.

Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics.

OBJECTIVE: Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. INTERVENTIONS: Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. METHODS: Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. RESULTS: A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. DISCUSSION: We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.

Nurse home visitation with vulnerable families in rural areas: A qualitative case file review.

OBJECTIVE: Nurse home visiting may address challenges and resource disparities that threaten maternal and infant well-being in rural areas, but little is known about United States' program implementation. This qualitative study explored how family and community characteristics affected rural nurse home visiting. SAMPLE: The sample for content analysis included families beginning services in 2010-2011 living in the rural counties with the highest caseloads (433 families). DESIGN: Electronic nurse home visiting case files from three rural counties were analyzed using a content analysis approach. The partner agency provided input on key constructs of interest but independent coding was also done to capture additional themes. Quantitative county level data and comments from member checking informed interpretation. Member checking included individual nurses serving the selected counties (n = 3) and input from an agency level supervisory meeting for validation. RESULTS: Concerns of families served (e.g., mental health) may not be unique to rural areas, but challenges to accessing resources and constellation of needs were. Nurses adapted engagement and service strategies to meet these needs. CONCLUSION: Agencies serving rural areas should allocate resources and adapt training to support nurses based on unique community profiles. More research on rural nurse home visiting practice and outcomes is needed.

Antenatal care in rural Bangladesh: current state of costs, content and recommendations for effective service delivery.

BACKGROUND: Measurement of antenatal care (ANC) service coverage is often limited to the number of contacts or type of providers, reflecting a gap in the assessment of quality as well as cost estimations and health impact. The study aims to determine service subcomponents and provider and patient costs of ANC services and compares them between community (i.e. satellite clinics) and facility care (i.e. primary and secondary health centers) settings in rural Bangladesh. METHODS: Service contents and cost data were collected by one researcher and four interviewers in various community and facility health care settings in Gaibandha district between September and December 2016. We conducted structured interviews with organization managers, observational studies of ANC service provision (n = 70) for service contents and provider costs (service and drug costs) and exit interviews with pregnant women (n = 70) for patient costs (direct and indirect costs) in health clinics at community and facility levels. Fisher's exact tests were used to determine any different patient characteristics between community and facility settings. ANC service contents were assessed by 63 subitems categorized into 11 groups and compared within and across community and facility settings. Provider and patient costs were collected in Bangladesh taka and analyzed as 2016 US Dollars (0.013 exchange rate). RESULTS: We found generally similar provider and patient characteristics between the community and facility settings except in clients' gestational age. High compliance (> 50%) of service subcomponents were observed in blood pressure monitoring, weight measurement, iron and folate supplementation given, and tetanus vaccine, while lower compliance of service subcomponents (< 50%) were observed in some physical examinations such as edema and ultrasonogram and routine tests such as blood test and urine test. Average unit costs of ANC service provision were about double at the facility level ($2.75) compared with community-based care ($1.62). ANC patient costs at facilities ($2.66) were about three times higher than in the community ($0.78). CONCLUSION: The study reveals a delay in pregnant women's initial ANC care seeking, gaps in compliance of ANC subcomponents and difference of provider and patient costs between facility and community settings.

Palliative care made visible: Developing a rural model for the Western Cape Province, South Africa.

INTRODUCTION: Caring for people with life-threatening illnesses is a key part of working in health care. While South Africa launched the National Policy Framework and Strategy for Palliative Care 2017-2022, integrating palliative care into existing public health care is in its infancy. Most patients in the Western Cape have poor access to palliative care, an inequality felt hardest by those living in rural areas.Building the model: In 2018, with district wide institutional managerial support, a palliative care model for rural areas was initiated in the Western Cape. The process involved setting up hospital- and community-based multi-professional palliative care teams, initiating weekly palliative care ward rounds, training champions in palliative care and raising awareness of palliative care and its principles. DISCUSSION: Establishing regular ward rounds has changed the way patients needing palliative care are managed, particularly in challenging the mindsets of specialist departments. The emergence of the multi-professional team listening and planning together at the patient's bedside has restored some of the dignity and ethos of patient-centred care, which is a core principle of the provincial Health Care 2030 vision. CONCLUSION: In a short time period, we have managed to build a service that aims to improve care for palliative patients in rural areas. Its strength lies in a multi-professional patient-centred approach and improved communication between different components of the health system, providing a more seamless service that supports patients when they need it most.

Psychosocial care provision for terminally ill clients in rural Australian communities: the role of social work.

INTRODUCTION: Despite being one of the most avoided topics of all time, death is a guaranteed eventuality for us all. However, quality psychosocial care as death approaches is not a guarantee. Where people reside is likely to impact a person's accessibility to quality psychological, emotional, social, spiritual and cultural support. Structural forces such as funding and resourcing will also be a contributing factor. Social workers have specific expertise in the psychosocial domain, yet enablers and inhibitors to social work referrals to support terminally ill clients in rural and remote communities have not been well explored. This study had two primary aims: to investigate the provision of psychosocial care for palliative clients in rural Australian communities and to identify barriers and facilitators of social work referrals to address psychosocial concerns for palliative care clients. METHODS: Qualitative interviews were conducted with 38 rural participants across 24 rural and remote communities in the state of Queensland, Australia. The researcher travelled 7500 km to conduct these interviews over a 5-week period. The Rural, Remote, Metropolitan Areas classifications provided guidance on determining which communities would be considered regional, rural or remote communities. To explore the aims of the study, four participant groups were selected to participate in semi-structured qualitative interviews: group 1, social workers; group 2, community health nurses; group 3, community workers; and group 4, palliative clients/carers. For a comprehensive analysis, it was important to not only hear the views of those addressing psychosocial needs, but also include the voices of those receiving psychosocial care, resulting in all perspectives being captured. A thematic analysis was utilised, from which prominent, recurring themes were identified to form the basis for recommendations for future psychosocial care provision. RESULTS: Findings revealed that psychosocial needs for terminally ill clients were addressed in an ad-hoc, inconsistent manner across rural and remote Queensland. Eligibility and access for palliative care program funding impacted service delivery and what support could be provided. Furthermore, social workers were limited in what they could offer due to the vast geographical distances, which inhibited quality face-to-face interventions and the capacity to address urgent psychosocial concerns. This resulted in community nurses assuming the role that social workers would usually undertake in more urban settings. In communities where a generalist social worker was employed, referrals were often impacted by the perceptions of other professionals of social work competencies. Finally, the results highlighted that a disparity exists between the perspectives of palliative care clients and their caregivers and understanding of healthcare professionals of what were identified as important psychosocial concerns. CONCLUSIONS: Palliative care funding in Queensland is insufficient to effectively address the existing demand. Resourcing for rural and remote palliative care in Queensland is inadequate to ensure holistic and quality approaches to psychosocial care in the end stages of life. Increased resourcing would result in better care, for longer time frames throughout a disease trajectory. Education and training for health practitioners to address skills and competencies in psychosocial care for terminally ill clients is a recommendation for professional development. Furthermore, there is a need for social work to develop national standards and competencies to enhance practitioner confidence to efficiently address psychosocial concerns for terminally ill clients. Whilst this study was undertaken in Queensland, Australia, the findings are echoed in other international rural communities.

Combining Resource, Structure and Institutional Environment: A Configurational Approach to the Mode Selection of the Integrated Healthcare in County.

Integrated healthcare has received considerable attention and has developed into the highly important health policy known as Integrated Healthcare in County (IHC) against the background of the Grading Diagnosis and Treatment System (GDTS) in rural China. However, the causal conditions under which different integrated health-care modes might be selected are poorly understood, particularly in the context of China's authoritarian regime. This study aims to identify these causal conditions, and how they shape the mode selection mechanism for Integrated Healthcare in County (IHC). A theoretical framework consisting of resource heterogeneity, governance structure, and institutional normalization was proposed, and a sample of fifteen IHCs was selected, with data for each IHC being collected from news reports, work reports, government documents and field research for Fuzzy-sets Qualitative Comparative Analysis (fsQCA). This study firstly pointed out that strong governmental control and centralization are necessary conditions for the administration-oriented organization mode (MOA). Additionally, this research found three critical configured paths in the selection of organizational modes. Specifically, we found that the combination of low resource heterogeneity, weak governmental control, centralization, and normalization was sufficient to explain the selection path of the insurance-driven organization mode (MOI); the combination of low resource heterogeneity, strong governmental control, centralization, and normalization was sufficient for selecting MOA; and the combination of weak governmental control, weak centralization, and weak normalization was sufficient for selecting the contractual organization mode (MOC). Our study highlighted the necessity and feasibility of constructing different IHC modes separately and promoting their development gradually, as a result of the complex relationships among the causal conditions described above, thus helping to optimize the distribution of health resources and integrate the healthcare system.