Type 2 Myocardial Infarction Caused by Orthostatic Hypotension With Post-transcatheter Aortic Valve Implantation: A Case Report.

This case report delineates the occurrence and management of type 2 myocardial infarction (MI) in an 89-year-old woman following transcatheter aortic valve implantation (TAVI). The patient, with a history of severe aortic stenosis, hypertension, dyslipidemia, and colorectal cancer, presented with nausea and significant hypotension. Initial assessments revealed elevated troponin levels, atrial fibrillation, and ST-segment depression, leading to a diagnosis of type 2 MI. This condition was attributed to the interplay between left ventricular hypertrophy, hypotension-induced dehydration, and increased myocardial oxygen demand. The patient with post-TAVI exhibited dynamic changes in cardiac hemodynamics, with improvements in left ventricular function but persistent hypertrophy and diastolic dysfunction. This state, combined with hypotension due to diuretic-induced dehydration and atrial fibrillation, precipitated a mismatch in myocardial oxygen supply and demand. The cessation of diuretics and initiation of rehydration therapy stabilized her condition, with subsequent normalization of troponin levels and blood pressure. This case highlights the complexity of managing type 2 MI in elderly patients post-TAVI. It underscores the importance of holistic consideration of both myocardial oxygen supply and demand factors, particularly in left ventricular hypertrophy and diastolic dysfunction. The multifactorial nature of type 2 MI necessitates a tailored approach to diagnosis and management, emphasizing the need for comprehensive post-procedural care in patients undergoing TAVI.

Decision-Making in the Admission of Older Patients: A Thematic Analysis From Multiple-Stakeholder Perspectives.

Introduction As rural healthcare systems grapple with an aging population, understanding the factors influencing hospital admission decisions for elderly patients is crucial. This study explores the complex interplay of medical, social, and psychological factors that shape these decisions, as perceived by multiple stakeholders, including physicians, patients, and their families. Method This study was conducted in Unnan City Hospital, a rural community hospital in Unnan, Japan, using a qualitative thematic analysis approach. Participants included general physicians, patients admitted more than once, and their families. One-on-one semi-structured interviews were conducted in Japanese, recorded, transcribed, and analyzed. The analysis focused on identifying themes that influence decision-making processes regarding the admission of elderly patients. The research team, comprising family medicine, public health, and community health care experts, ensured a multi-perspective approach through collaborative coding and discussion. Results Three primary themes emerged from the analysis: "dilemma between medical indications and social admissions," "risks and benefits of hospitalization in response to unpredictable changes in the elderly," and "social factors intertwined with the multilayered nature of hospital admission decisions." Physicians reported a conflict between their medical training and the social needs of patients, often leading to stress and negative emotions. The unpredictable health trajectories of elderly patients necessitated a nuanced risk-benefit analysis for hospitalization. In addition, social factors, such as bed availability, patient's living environment, and psychosocial contexts, significantly influenced admission decisions. Conclusion The study highlights the need for a more holistic approach to medical education and practice, especially in rural healthcare settings. Recognizing the complexity of factors influencing hospitalization decisions, including medical, social, and individual patient circumstances, is vital. The findings underscore the importance of integrating biopsychosocial aspects into the decision-making process for the hospitalization of elderly patients, advocating for patient-centered care that respects the unique challenges in rural healthcare environments.

Responsiveness of a rural Aboriginal community controlled health organisation: A qualitative study.

INTRODUCTION: Responsiveness of health care systems is a global concept defined as the ability of systems to function in a manner that meets the expectations of individuals, and is under-studied. In Australia, Aboriginal Community Controlled Health Organisations (ACCHOs) are valued by Aboriginal and Torres Strait Islander Peoples for the provision of holistic culturally safe primary health care and are well positioned to be responsive to community needs. OBJECTIVE: To develop a conceptual framework examining the responsiveness of a rural ACCHO to the health care needs of Aboriginal and Torres Strait Islander Peoples in their service region. DESIGN: A qualitative interview study using abductive reasoning was conducted. Interviews conducted with Aboriginal clients, key informants, and ACCHO health personnel from two evaluations undertaken in partnership with a rural ACCHO located in Victoria, Australia, were analysed through an iterative process of identifying key concepts from the data and evidence. Key concepts were used to develop a conceptual framework. FINDINGS: Across the two evaluations, 22 participants were involved in data collection and 28 interviews were undertaken. A conceptual framework examining the responsiveness of a rural ACCHO to the health care needs of Aboriginal Peoples within their service region was developed and encompassed three concepts: operating within a complex adaptive system, mechanisms of responsiveness used by the ACCHO, and challenges experienced by the ACCHO when being responsive. DISCUSSION: The developed conceptual framework expands on research supporting the value of ACCHOs in providing holistic culturally safe health care to their communities, particularly in rural settings. A key finding is the importance for ACCHOs to meet the health care needs of their community whilst navigating needs in the context of the broader health care system. When dissonance is encountered between external system components and community needs, challenges can be experienced such as adequately resourcing models of service delivery and maintaining the provision of services. CONCLUSION: Conceptualising the health care system as a complex adaptive system in which an ACCHO operates and is responsive, highlights the competing demands experienced. Findings expand on mechanisms of responsiveness used at the service-user interface. Future research should examine how the broader health care system can support the role and functions of ACCHOs in being responsive to the health care needs of their communities.

Challenges and strategies to improve the provision of end-of-life cancer care in rural and regional communities: Perspectives from Australian rural health professionals.

OBJECTIVE: To identify challenges and strategies to improve the provision of end-of-life (EOL) cancer care in an underserved rural and regional Australian local health district (LHD) from the perspective of general practitioners (GPs) and specialist clinicians while exploring the benefits of adopting a generalist health care approach to delivering EOL care in rural and regional communities. SETTING: Rural and regional Australia. PARTICIPANTS: General practitioners and palliative care and cancer care specialists (medical and nursing) involved in the provision of EOL care to people with advanced cancer in the rural and regional areas of an Australian LHD. DESIGN: Qualitative descriptive study involving 22 participants in four face-to-face and online focus groups. Thematic analysis of the transcripts identified key issues affecting EOL care for people with advanced cancer in rural and regional areas of the LHD. RESULTS: Four themes including geographical remoteness, system structures, medical management and expertise and training emerged from the focus groups. Key barriers to effective EOL care included insufficient remuneration for GPs and other clinicians (especially home visits), resource limitations, limited community awareness of palliative care and lack of confidence and training of clinicians. Continuity of care was identified as an important facilitator to effective EOL care. Participants suggested greater Medicare rebates for palliative care and home visits, adequate equipment and resources, technology-enabled clinician training and greater rural-based training for specialist PC clinicians may improve the provision of EOL care in regional and rural communities. CONCLUSIONS: Rural-based clinicians delivering EOL cancer care appear to be disproportionately affected by geographical challenges including resource and funding limitations. A multi-pronged strategy aimed at greater interdisciplinary collaboration, community awareness and greater resourcing and funding could help to improve the provision of EOL care in underserved rural and remote communities of Australia.

Osteopathy in rural and remote Australia: analysis of demographic, practice and clinical management characteristics from a nationally representative sample of 992 osteopaths.

INTRODUCTION: There is significant interest in allied health and the role it plays in health care for rural and remote populations. In Australia, osteopaths are allied health professionals who manage predominantly musculoskeletal complaints using manual therapy, exercise and patient education. Workforce distribution is a significant issue for osteopathy in Australia with most practitioners centred in the metropolitan regions of Victoria and New South Wales. There is limited evidence about the role osteopathy plays in the musculoskeletal health of Australian rural and remote populations. This research sought to profile the characteristics of Australian osteopaths who practise in rural and remote settings. METHODS: A secondary analysis of the Osteopathy Research and Innovation Network (ORION) data was undertaken to identify the demographic, practice and clinical management characteristics of Australian osteopaths in rural and remote settings. ORION is a practice-based research network for the Australian osteopathy profession. The ORION questionnaire comprised 27 items regarding osteopaths' characteristics. Inferential statistics were used to identify characteristics that were significantly different between Australian osteopaths practising in rural and remote settings compared to those practising in urban settings. Logistic regression was used to calculate adjusted odds ratios (AOR) relating to characteristics significantly associated with practising in a rural and remote setting. RESULTS: Of 992 osteopaths who responded to the ORION questionnaire, 18.3% (n=172) indicated practising in a rural and remote setting. Australian osteopaths in rural and remote settings were more likely to report receiving referrals from massage therapists (AOR 2.17), send referrals to other osteopaths (AOR 1.64), and often treat patients over the age of 65 years (AOR 2.25) compared to their urban counterparts. Osteopaths in rural and remote setting were less likely to report using private health insurance claim systems (AOR 0.36) and to treat non-English-speaking patients (AOR 0.09). CONCLUSION: This secondary analysis identified several practitioner and practice characteristics that differ between osteopaths practising in rural and remote settings and those practising in urban settings. These findings contribute to the emerging picture of the practice of rural and remote Australian osteopaths. Further research is required to understand the role osteopaths play in rural and remote health care, and how the current data can inform workforce and health policy development.

Integrating Clinical and Socio-Environmental Approaches in Managing Rheumatoid Arthritis With Social Determinants of Health: A Case Study of an Elderly Patient in Rural Japan.

Rheumatoid arthritis (RA) poses significant management challenges, especially in elderly patients living in rural areas with limited access to health care. This case report illustrates an integrative approach to managing RA, emphasizing the interplay of clinical, social, and environmental factors. A 72-year-old woman in a rural Japanese setting presented with progressive, widespread joint pain, initially self-managed with over-the-counter medications. Her condition, complicated by socioeconomic constraints and limited access to health care, necessitated a comprehensive management strategy. Clinical examination revealed bilateral joint tenderness, swelling, and high titers of rheumatoid factor and anti-citrullinated protein antibodies, confirming RA. Treatment included methotrexate and prednisolone, complemented by lifestyle modifications. Interdisciplinary collaboration among healthcare professionals, including nutritionists and physiotherapists, facilitated her management. The patient's care was guided by the chronic care model and the ecological model, addressing her clinical needs and socio-environmental context. This holistic approach resulted in improved clinical outcomes and enhanced quality of life. This case highlights the importance of a patient-centered, multidisciplinary approach in managing RA in rural settings. Integrating clinical management with an understanding of social determinants and patient empowerment is crucial for effective treatment. The case underscores the need for adaptable healthcare strategies that are sensitive to the unique challenges faced by elderly patients in rural communities.

Perceptions, Motivations, and Empowerment Strategies of Midwives in Rural and Remote Areas of Northern Morocco.

The shortage of midwives is a problem in rural and remote areas. This is mainly the consequence of job insecurity and difficult living conditions. The present study aimed to identify and analyse the perceptions and motivations of midwives in rural and remote areas of northern Morocco on the quality of their working life and the motivational factors and empowerment strategies they use to maintain and develop their work. It is a qualitative study that follows Van Manen's hermeneutic phenomenology approach. Three focus groups and in-depth interviews were conducted with 15 midwives from rural and remote areas. The results indicate that midwives in rural and remote areas have a negative perception of the quality of the work and their personal life because of the scarcity of basic resources, unfavourable working conditions, and the personal sacrifices they have to make to support themselves. However, some factors favour their efforts. Therefore, there is a need to promote intersectoral policies that focus on improving material and human resources, as well as the working and personal conditions of midwives and the factors that support and empower them.

A Preliminary Study of Clinical Practice and Prenatal Nutrition in Rural Kansas.

Introduction: The primary purpose of this study was to determine if new recommendations for prenatal supplements of docosahexaenoic acid (DHA) and choline have been implemented into care by physicians who care for pregnant women in rural Kansas communities. Both nutrients are inadequate in the diet of most pregnant women in the U.S., and not all prenatal supplements provide DHA and choline. Methods: A cross sectional web-based survey was developed and provided by the University of Kansas Medical Center (KUMC) students to 44 rural Kansas clinics believed to have physicians who provide obstetrical care. Questions about DHA and choline were embedded in a larger survey focused on prenatal care. A total of 29 surveys were returned, however, only 21 were completed by physicians who provided obstetrical care. Results: DHA (3/21) and choline (0/21) rarely were singled out for recommendation in contrast to folic acid (16/21) and iron (14/21). Participants stated that most women sought prenatal care during the first trimester of their pregnancy and indicated that they recommended prenatal vitamins at the first visit. Eleven gave patients a prescription for prenatal vitamins. The remaining patients either chose traditional over the counter prenatal vitamin capsules or less traditional chewable (gummy) vitamins, which provided lower concentrations of nutrients. Common barriers to nutritional counseling were limited resources and time constraints. Clinicians assessed their confidence and ability to provide nutritional counseling as moderate and competent, respectively. Conclusions: New nutritional recommendations for DHA and choline have not been implemented into standard of care in rural Kansas.

Participatory research with a rural Aboriginal Community Controlled Health Organisation: lessons learned using the CONSIDER statement.

CONTEXT: In Australia, Aboriginal Community Controlled Health Organisations (ACCHOs) are geographically proximal to where Aboriginal and Torres Strait Islander People reside and are valued for providing holistic and culturally safe primary health care. Partnering with ACCHOs in research is appropriate for redressing health inequities experienced by Aboriginal and Torres Strait Islander People, which includes a high burden of chronic disease. Historically, some approaches to Aboriginal and Torres Strait Islander health research have been unethical. Greater accountability in the research process, transparency in reporting, and use of culturally appropriate research methodologies are key recommendations to improving the ethical integrity of research. The need for strengthening the reporting of health research involving Aboriginal and Torres Strait Islander People and Indigenous peoples globally led to the development of the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples (CONSIDER statement), which is a synthesis of international ethical guidelines. This project report uses the CONSIDER statement to critically reflect on participatory research undertaken in partnership with an ACCHO in the rural context and to identify lessons of value for future research. ISSUE: By using the CONSIDER statement as a tool for critical reflection, it was identified that processes used to establish a research partnership with an ACCHO were key to setting the research agenda, including identifying ethical issues, the needs of local Aboriginal and Torres Strait Islander People, and expectations from the research. The participation of Aboriginal community members throughout the entire research process was not only methodologically important but was also ethically appropriate. Research activities in this project included opportunities for Aboriginal community members to directly share their perspectives and experiences and develop local solutions to issues affecting them. Outcomes included evidence to support future funding applications, community-derived priorities that assisted with government reporting, and locally identified methods for addressing chronic disease management. Key to this was building the research capacity and capability of local Aboriginal community members, which also reflected the ethical principles of reciprocity and equity. This also provided opportunities for non-Indigenous researchers to learn from local Aboriginal community members and develop skills in culturally appropriate research. LESSONS LEARNED: Using the CONSIDER statement was beneficial in enabling researchers to critically reflect on a participatory research project undertaken in partnership with a rural ACCHO. Researchers identified that participatory approaches can be used to generate research of relevance to local Aboriginal community members and their ACCHOs, and to support health service reporting, and future funding applications. Research timelines and activities needed to be flexible and adaptable, to allow for staff turnover and unforeseen events of cultural significance. Similarly, it is important for researchers to be receptive to change and open to learning. Although research partnerships are established on trust and mutual respect, it is recommended that greater formal provisions are required to protect the intellectual property of Aboriginal and Torres Strait Islander communities involved in research. These lessons are likely to be transferrable to other settings and are of value to researchers seeking to partner with ACCHOs in research.

Provision of specialized care in remote rural municipalities of the Brazilian semi-arid region.

INTRODUCTION: Specialized care barriers are widespread and multifactorial, with consequences for timely access, health outcomes, and equity, especially in rural contexts. This article aims to identify and analyze arrangements for providing specialized care in the Brazilian remote rural municipalities (RRMs). METHODS: This is a multiple-case qualitative case study developed in seven RRMs located in the Brazilian semi-arid region. Twenty-two semi-structured interviews were conducted with the public health system managers, complemented by analysis of secondary data from national health information systems. Thematic content analysis was guided by the Integrated Health Service Network attributes related to the provision of specialized care. RESULTS: Socioeconomic indicators and indicators of availability and accessibility to health services express the context of greater vulnerability of RRM and their respective health regions when compared to states and the country. The analyzed cases do not come close to the RISS constitutive attributes. Various arrangements for the provision and financing of specialized care in the RRM were identified: public provision through an agreement between managers in the health region, health consortia, public provision in the municipality itself or neighboring municipalities, provision in private health services through direct purchase (out-of-pocket), and telehealth (very incipient). Such arrangements were unable to respond quantitatively and qualitatively to the demand for specialized care. Providing timely specialized care in an adequate place is not achieved, resulting in a fragmented, low-resolution model. The fragility of regionalized networks, aggravated by underfunding of the Brazilian Unified Health System, insufficient logistical support, and computerization of health services, contributes to care gaps and unacceptably long travel times for common specialized procedures, with more severe effects for people residing in the rural areas of the municipalities. CONCLUSION: Brazil's disorganization or lack of a systemic response based on regionalized health networks generates several care improvisations. The less structured the RISS, the more informal arrangements are made, with gains for the private sector to the detriment of public health system users.

Informal and popular healthcare subsystems in a remote rural municipality in the Brazilian Amazon region.

INTRODUCTION: While Brazil has achieved a significantly higher coverage through primary care and improved health outcomes through the Family Health Strategy, rural areas still have worse indicators and several barriers to access primary healthcare units, which sometimes condition users to seek alternative answers outside the formal circuit. From the framework of medical anthropology, Arthur Kleinman indicates that the sociohistorical-cultural context also determines the search for health care, and not only by the conditions of access and availability of formal services. From this perspective, each health system would consist of three interrelated subsystems: the informal, the popular, and the professional subsystem, widely used in an overlapping and non-exclusive way, interacting according to an individual's needs. This study analyzes how informal and popular health subsystems are featured in a remote rural municipality in the Brazilian Amazon region. METHODS: This is a single, exploratory, qualitative case study conducted in the remote rural municipality of Assis Brasil, in the state of Acre, Brazil. Data were collected with onsite visits to the municipality through semi-structured interviews with users, managers, and health professionals. Data thematic analysis was guided by categories inspired by Arthur Kleinman's framework and emerging in the field, focusing on the dimensions of the informal and popular subsystems. RESULTS: In the informal system, family, friends, and community seem to have broader roles in the field of care, underpinning the social support network to allow using health services. Also included in the informal system are NGOs, armed forces, and the church, acting complementarily to the Unified Health System (Sistema Único de Saúde). Two patterns of relationship with the popular system were identified: in complementarity with the formal system, with the specific or longitudinal use of its resources, and replacing formal practices. In the popular system, secular healing agents such as shamans, healers, prayers, and midwives, and the use of medicinal herbs and other natural resources, are part of the care scenario, especially among the traditional populations of the territory. Popular resources are sometimes activated mainly due to geographic and economic barriers, which prevent timely access to health services and contribute to the deterioration of conditions. The level of resistance of health professionals varied according to the substitutive or complementary nature that such care assumes in users' therapeutic trajectories. CONCLUSION: Complex policies and processes such as health care have been implemented nationwide, in general, with a poor understanding of the context and culture of rural communities. In this sense, understanding the dynamics between the subsystems can help identify more appropriate and sensitive strategies for the organization of health services, which respond to the population's needs from a broader perspective, especially in the context of rurality.

A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest.

PURPOSE: Rural communities have unique economic and social structures, different disease burdens, and a more patchworked healthcare delivery system compared to urban counterparts. Yet research into addressing social determinants of health has focused on larger, urban, integrated health systems. Our study sought to understand capacities, facilitators, and barriers related to addressing social health needs across a collaborative of independent provider organizations in rural Northeastern Minnesota and Northwestern Wisconsin. METHODS: We conducted qualitative, semi-structured interviews with a purposive sample of 37 key informants from collaborative members including 4 stand-alone critical access hospitals, 3 critical access hospitals affiliated with primary care, 1 multi-clinic system, and 1 integrated regional health system. FINDINGS: Barriers were abundant and occurred at the organizational, community and policy levels. Rural providers described a lack of financial, labor, Internet, and community-based social services resources, a limited capacity to partner with other organizations, and workflows that were less than optimal for addressing SDOH. State Medicaid and other payer policies posed challenges that made it more difficult to use available resources, as did misaligned incentives between partners. While specific payer programs and organizational innovations helped facilitate their work, nothing was systemic. Relationships within the collaborative that allowed sharing of innovations and information were helpful, as was the role leadership played in promoting value-based care. CONCLUSIONS: Policy change is needed to support rural providers in this work. Collaboration among rural health systems should be fostered to develop common protocols, promote value-based care, and offer economies of scale to leverage value-based payment. States can help align incentives and performance metrics across rural health care entities, engage payers in promoting value-based care, and bolster social service capacity.

The 2018 Japan Floods Increased the Frequency of Yokukansan Prescriptions Among Elderly: A Retrospective Cohort Study.

OBJECTIVE: The impact of the 2018 Japan Floods on prescriptions of Yokukansan was evaluated. METHODS: This was a retrospective cohort study based on the National Database of Health Insurance Claims which covers all the prescriptions issued in Japan. Participants were patients aged 65 or older who received any medical care at medical institutions located in the three most-severely affected prefectures between 1 year before and after the disaster. We analyzed the number of new prescriptions of Yokukansan and other Kampo drugs among those who had not been prescribed any Kampo for 1 year before the disaster. Kaplan-Meier analysis and a Cox proportional hazards model were used to evaluate the risk of the disaster for a new prescription. RESULTS: Subjects comprised 1,372,417 people (including 12,787 victims, 0.93%). The hazard ratio (HR) of the disaster for Yokukansan prescriptions was 1.49 [95% confidence intervals (CI): 1.25-1.78], and 1.54 (95% CI: 1.29-1.84) in the crude and age-sex adjusted model, respectively. The HR of the disaster for prescription of other Kampo drugs in the crude and adjusted model was 1.33 (95% CI: 1.27-1.39), and 1.32 (95% CI: 1.27-1.38), respectively. The magnitude of increase of victims prescribed Yokukansan (31.4%) was statistically higher than for those prescribed other Kampo drugs (19.3%) (p < 0.001). CONCLUSION: The disaster increased prescriptions of both Yokukansan and other Kampo drugs among elderly victims. The increase was more remarkable in Yokukansan than other Kampo drugs. Clinicians and policymakers should be aware of the increased need for Yokukansan in times of natural disaster.

Urban-rural disparity of preventive healthcare utilisation among children under the universal health insurance coverage in Taiwan: a national birth cohort analysis.

OBJECTIVE: In the context of universal health insurance coverage, this study aimed to determine whether urban-rural inequality still exists in preventive health care (PHC) amongst children in Taiwan. STUDY DESIGN: Prospective cohort study. METHODS: A total of 184,117 mothers and their children born in 2009 were identified as the study cohort. The number of children born in urban, satellite and rural areas was 40,176, 57,565 and 86,805, respectively. All children were followed for 7 years, before which a total of seven times PHC were provided by Taiwan's National Health Insurance (NHI) programme. Ordinal logistic regression models were used to associate urbanisation level with the frequency of PHC utilisation. Stratified analyses were further performed in accordance with the children's birth weight and the mothers' birthplace. RESULTS: Children from satellite areas had higher utilisation for the first four scheduled PHC visits. Children living in urban areas received more PHC for the fifth and sixth scheduled visits. Compared with those from rural areas, children in satellite areas exhibited a small but significant increase in odds in PHC utilisation, with a covariate-adjusted odds ratio (aOR) of 1.04 and 95% confidence interval (CI) of 1.02-1.06. By contrast, no significant difference was observed between rural and urban areas (aOR = 1.01). Further stratified analyses suggest more evident urban-rural difference in PHC utilisation amongst children with low birth weight and foreign-born mothers. CONCLUSIONS: Given a universal health insurance coverage and embedded mechanisms in increasing the availability of healthcare resources in Taiwan, a slight urban-rural difference is observed in PHC utilisation amongst children. Hence, sociodemographic inequality in utilisation of PHC still exists. This issue should be addressed through policy intervention.

The daily routine of nurses in rural areas in the Family Health Strategy / El cotidiano de enfermeros en áreas rurales en la Estrategia Salud de la Familia / O cotidiano de enfermeiros em áreas rurais na estratégia saúde da família

ABSTRACT Objective: to analyze the daily work of rural Family Health Strategy (FHS) nurses. Method: a qualitative, descriptive and exploratory research. The data were collected with eleven rural nurses of the city of Campina Grande, Paraíba State, through semi-structured interviews, between January and March of 2017, using Content Analysis. Results: rural nurses have a strong relationship with the population. However, they reveal a daily work with various organizational barriers that range from the team displacement to the workplace to the operationalization of health actions, which are mediated by the characteristics of rurality. Some of these barriers can be remedied by a more proactive action from the management. Final considerations: conditioned by the characteristics of rurality, the differentiated dynamics work reveal weaknesses in the quality of nursing care and lower effectiveness of the FHS.

RESUMEN Objetivo: analizar el cotidiano de trabajo de enfermeros de la Estrategia Salud de la Familia (ESF) que actúan en áreas rurales. Método: investigación cualitativa, descriptiva-exploratoria. Los datos fueron recolectados con once enfermeros del área rural del municipio de Campina Grande-PB, a través de entrevistas semiestructuradas, entre enero y marzo de 2017, con análisis a partir del Análisis de Contenido. Resultados: los enfermeros de las áreas rurales tienen relación de vínculo intensa con la población. Sin embargo, revelan un cotidiano de trabajo con varias barreras organizacionales que van desde el desplazamiento del equipo al lugar de trabajo a la operacionalización de las acciones de salud, siendo estas mediadas por las características de la ruralidad. Algunas de esas barreras pueden ser sanadas por la acción más propositiva de la gestión. Consideraciones finales: la dinámica de trabajo diferenciada, condicionada por las características propias de la ruralidad, revelan fragilidades en la calidad de la asistencia de enfermería y menor efectividad de la ESF.

RESUMO Objetivo: analisar o cotidiano de trabalho de enfermeiros da Estratégia Saúde da Família (ESF) que atuam em áreas rurais. Método: pesquisa qualitativa, descritiva-exploratória. Os dados foram coletados com onze enfermeiros da área rural do município de Campina Grande-PB, por meio de entrevistas semiestruturadas, entre janeiro e março de 2017, com análise a partir da técnica de Análise de Conteúdo. Resultados: os enfermeiros das áreas rurais têm relação de vínculo intensa com a população, no entanto, revelam um cotidiano de trabalho com várias barreiras organizacionais que vão desde o deslocamento da equipe ao local de trabalho à operacionalização das ações de saúde, sendo essas mediadas pelas características da ruralidade. Algumas dessas barreiras podem ser sanadas pela ação mais propositiva da gestão. Considerações finais: a dinâmica de trabalho diferenciada, condicionada pelas características próprias da ruralidade, revelam fragilidades na qualidade da assistência de enfermagem e menor efetividade da ESF.

Design of the Rural LEAP randomized trial: An evaluation of extended-care programs for weight management delivered via group or individual telephone counseling.

Obesity is a major contributor to the greater prevalence of chronic disease morbidity and mortality observed in rural versus nonrural areas of the U.S. Nonetheless, little research attention has been given to modifying this important driver of rural/urban disparities in health outcomes. Although lifestyle treatments produce weight reductions of sufficient magnitude to improve health, the existing research is limited with respect to the long-term maintenance of treatment effects and the dissemination of services to underserved populations. Recent studies have demonstrated the feasibility of delivering lifestyle programs through the infrastructure of the U.S. Cooperative Extension Service (CES), which has >2900 offices nationwide and whose mission includes nutrition education and health promotion. In addition, several randomized trials have shown that supplementing lifestyle treatment with extended-care programs consisting of either face-to-face sessions or individual telephone counseling can improve the maintenance of weight loss. However, both options entail relatively high costs that inhibit adoption in rural communities. The delivery of extended care via group-based telephone intervention may represent a promising, cost-effective alternative that is well suited to rural residents who tend to be isolated, have heightened concerns about privacy, and report lower quality of life. The Rural Lifestyle Eating and Activity Program (Rural LEAP) is a randomized trial, conducted via CES offices in rural communities, targeted to adults with obesity (n = 528), and designed to evaluate the effectiveness and cost-effectiveness of extended-care programs delivered via group or individual telephone counseling compared to an education control condition on long-term changes in body weight.

A mixed-method study of chiropractic student clinical immersion placements in nonmetropolitan Western Australia: Influence on student experience, professional attributes, and practice destination.

OBJECTIVE:: To explore the influence of nonmetropolitan clinical immersion placements (CIPs) on undergraduate chiropractic student experience, professional attributes, and practice destination. METHODS:: Students enrolled in an Australian undergraduate chiropractic program were invited to complete a service experience questionnaire and an open-ended reflective feedback form following a nonmetropolitan CIP (Part A). Online searches were performed to gather data on graduate practice location (Part B). RESULTS:: Sixty-four students participated in Part A. All agreed that the placement was educational and should be retained in the program. Students agreed that the placement enhanced respect for individuals and awareness of others in need, highlighted the importance of respect for all people, improved empathy for the disadvantaged, and provided an opportunity to improve communication skills. Most indicated that they were more likely to practice in a country setting as a result of their placement, with those participating in a country placement more likely to practice in nonmetropolitan regions after graduation. CONCLUSION:: Many chiropractic programs around the world are adopting CIPs. This study is the 1st to investigate the possible influence of nonmetropolitan CIPs on the development of desirable attributes in Australian chiropractic students. It also discusses the potential influence of nonmetropolitan CIPs on future practice location decisions. These results support the utility of CIPs to help meet the educational objectives of chiropractic programs and possibly address the maldistribution of the chiropractic workforce in Australia.

Maternity services for rural and remote Australia: barriers to operationalising national policy.

INTRODUCTION: In Australia, many small birthing units have closed in recent years, correlating with adverse outcomes including a rise in the number of babies born before arrival to hospital. Concurrently, a raft of national policy and planning documents promote continued provision of rural and remote maternity services, articulating a strategic intent for services to provide responsive, woman-centred care as close as possible to a woman's home. The aims of this paper are to contribute to an explanation of why this strategic intent is not realised, and to investigate the utility of an evidence based planning tool (the Toolkit) to assist with planning services to realise this intent. METHODS: Interviews, focus groups and a group information session were conducted involving 141 participants in four Australian jurisdictions. Field notes and reports were thematically analysed. RESULTS: We identified barriers that helped explain the gap between strategic intent and services on the ground. These were absence of informed leadership; lack of knowledge of contemporary models of care and inadequate clinical governance; poor workforce planning and use of resources; fallacious perceptions of risk; and a dearth of community consultation. In this context, the implementation of policy is problematic without tools or guidance. CONCLUSIONS: Barriers to operationalising strategic intent in planning maternity services may be alleviated by using evidence based planning tools such as the Toolkit.

The distribution of maternity services across rural and remote Australia: does it reflect population need?

BACKGROUND: Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need. METHODS: Health facilities in Australia were identified and a service catchment was determined around each using a one-hour road travel time from that facility. Catchment exclusions: metropolitan areas, populations above 25,000 or below 1,000, and a non-birthing facility within the catchment of one with birthing. Catchments were attributed with population-based characteristics representing need: population size, births, demographic factors, socio-economic status, and a proxy for isolation - the time to the nearest facility providing a caesarean section (C-section). Facilities were dichotomised by service level - those providing birthing services (birthing) or not (no birthing). Birthing services were then divided by C-section provision (C-section vs no C-section birthing). Analysis used two-stage univariable and multivariable logistic regression. RESULTS: There were 259 health facilities identified after exclusions. Comparing services with birthing to no birthing, a population is more likely to have a birthing service if they have more births, (adjusted Odds Ratio (aOR): 1.50 for every 10 births, 95% Confidence Interval (CI) [1.33-1.69]), and a service offering C-sections 1 to 2 h drive away (aOR: 28.7, 95% CI [5.59-148]). Comparing the birthing services categorised by C-section vs no C-section, the likelihood of a facility having a C-section was again positively associated with increasing catchment births and with travel time to another service offering C-sections. Both models demonstrated significant associations with jurisdiction but not socio-economic status. CONCLUSIONS: Our investigation of current birthing services in rural and remote Australia identified disparities in their distribution. Population factors relating to vulnerability and isolation did not increase the likelihood of a local birthing facility, and very remote communities were less likely to have any service. In addition, services are influenced by jurisdictions.