Experiences of family carers supporting older people within the last year of life in rural and remote areas in the UK.

BACKGROUND: In the UK, a large proportion of older adults live in rural/remote locations. More people are dying at home and require care from their families. Little is known about the experiences of family carers of older people in rural/remote areas in the last year of life. AIM: To explore the experiences of current and bereaved family carers who support/ed an older person in a rural area in the UK towards the end-of-life. DESIGN: Qualitative methodology using semi-structured interviews and reflexive thematic analysis methods. METHOD: Interviews were conducted with family carers of rural/remote-dwelling older people in the last year of life. Participants were recruited through national support services, third sector organisations and social media. RESULTS: Interviews were conducted with 20 family carers. Most were female (n = 17) and aged 52-80 years. Family carers experienced difficulties in accessing health and social care in rural/remote areas due to workforce and skills shortages within their regions. The wider community helped with practical tasks and made carers feel less alone. Community-based services, such as day care, helped to provide respite for carers and promoted meaningful activity and social inclusion for older people. Although internet access was problematic, family carers gained support remotely via social media and telehealth services. CONCLUSION: Family carers of older people in the last year of life in rural/remote areas value support from the wider community. Further work is required to understand how Public Health approaches to palliative care and workforce distribution can support rural/remote carers and older people.

Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis.

Guinea-Bissau has among the world's highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.

Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea.

BACKGROUND: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. METHODS: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. RESULTS: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. CONCLUSIONS: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Rural Emergency Medical Services Clinicians' Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment.

OBJECTIVE: Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians' perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. METHODS: This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. RESULTS: Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback's impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. CONCLUSION: Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.

The impact of provider-patient communication skills on primary healthcare quality and patient satisfaction in rural China: insights from a standardized patient study.

OBJECTIVES: In middle-income countries, poor physician-patient communication remains a recognized barrier to enhancing healthcare quality and patient satisfaction. This study investigates the influence of provider-patient communication skills on healthcare quality and patient satisfaction in the rural primary healthcare setting in China. METHODS: Data were collected from 504 interactions across 348 rural primary healthcare facilities spanning 21 counties in three provinces. Using the Standardized Patient method, this study measured physician-patient communication behaviors, healthcare quality, and patient satisfaction. Communication skills were assessed using the SEGUE questionnaire framework. Multivariate linear regression models and multivariate logistic regression models, accounting for fixed effects, were employed to evaluate the impact of physicians' communication skills on healthcare quality and patient satisfaction. RESULTS: The findings indicated generally low provider-patient communication skills, with an average total score of 12.2 ± 2.8 (out of 24). Multivariate regression models, which accounted for physicians' knowledge and other factors, demonstrated positive associations between physicians' communication skills and healthcare quality, as well as patient satisfaction (P < 0.05). Heterogeneity analysis revealed stronger correlations among primary physicians with lower levels of clinical knowledge or more frequent training. CONCLUSION: This study emphasizes the importance of prioritizing provider-patient communication skills to enhance healthcare quality and patient satisfaction in rural Chinese primary care settings. It recommends that the Chinese government prioritize the enhancement of provider-patient communication skills to improve healthcare quality and patient satisfaction.

Service quality: perspective of people with type 2 diabetes mellitus and hypertension in rural and urban public primary healthcare centers in Iran.

OBJECTIVE: This study aimed to assess the service quality (SQ) for Type 2 diabetes mellitus (T2DM) and hypertension in primary healthcare settings from the perspective of service users in Iran. METHODS: The Cross-sectional study was conducted from January to March 2020 in urban and rural public health centers in the East Azerbaijan province of Iran. A total of 561 individuals aged 18 or above with either or both conditions of T2DM and hypertension were eligible to participate in the study. The study employed a two-step stratified sampling method in East Azerbaijan province, Iran. A validated questionnaire assessed SQ. Data were analyzed using One-way ANOVA and multiple linear regression statistical models in STATA-17. RESULTS: Among the 561 individuals who participated in the study 176 (31.3%) were individuals with hypertension, 165 (29.4%) with T2DM, and 220 (39.2%) with both hypertension and T2DM mutually. The participants' anthropometric indicators and biochemical characteristics showed that the mean Fasting Blood Glucose (FBG) in individuals with T2DM was 174.4 (Standard deviation (SD) = 73.57) in patients with T2DM without hypertension and 159.4 (SD = 65.46) in patients with both T2DM and hypertension. The total SQ scores were 82.37 (SD = 12.19), 82.48 (SD = 12.45), and 81.69 (SD = 11.75) for hypertension, T2DM, and both conditions, respectively. Among people with hypertension and without diabetes, those who had specific service providers had higher SQ scores (b = 7.03; p = 0.001) compared to their peers who did not have specific service providers. Those who resided in rural areas had lower SQ scores (b = -6.07; p = 0.020) compared to their counterparts in urban areas. In the group of patients with T2DM and without hypertension, those who were living in non-metropolitan cities reported greater SQ scores compared to patients in metropolitan areas (b = 5.09; p = 0.038). Additionally, a one-point increase in self-management total score was related with a 0.13-point decrease in SQ score (P = 0.018). In the group of people with both hypertension and T2DM, those who had specific service providers had higher SQ scores (b = 8.32; p < 0.001) compared to the group without specific service providers. CONCLUSION: Study reveals gaps in T2DM and hypertension care quality despite routine check-ups. Higher SQ correlates with better self-care. Improving service quality in primary healthcare settings necessitates a comprehensive approach that prioritizes patient empowerment, continuity of care, and equitable access to services, particularly for vulnerable populations in rural areas.

Rural healthcare professionals' participation in Medical Assistance in Dying (MAiD): beyond a binary decision.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016 and amended in 2021. At the time that this study was conducted, the federal government was considering expanding the eligibility criteria to include patients whose death was not reasonably foreseeable. The purpose of this study was to better understand rural healthcare professionals' experiences with assisted dying set against the backdrop of legislative expansion. METHODS: A qualitative exploratory study was undertaken with general rural practice physicians, nurse practitioners, registered nurses, ethicists, patients, and patient families in rural Southern Alberta, Canada. For this paper, data from 18 audio-recorded and transcribed semi-structured interviews with healthcare professionals were analyzed using thematic analysis. Categories and patterns of shared meaning that linked to an overarching theme were identified. RESULTS: Between the binary positions of full support for and conscientious objection to assisted dying, rural healthcare professionals' decisions to participate in MAiD was based on their moral convictions, various contextual factors, and their participation thresholds. Factors including patient suffering; personal and professional values and beliefs; relationships with colleagues, patients and family, and community; and changing MAiD policy and legislation created nuances that informed their decision-making. CONCLUSIONS: The interplay of multiple factors and their degree of influence on healthcare professionals' decision-making create multiple decision points between full support for and participation in MAiD processes and complete opposition and/or abstention. Moreover, our findings suggest evolving policy and legislation have the potential to increase rural healthcare professionals' uncertainty and level of discomfort in providing services. We propose that the binary language typically used in the MAiD discourse be reframed to reflect that decision-making processes and actions are often fluid and situational.

Consensus Guidelines for Assessment and Comprehensive Outcomes Evaluation in Rural Pain Clinics.

Recent advancements in nurse anesthesiology fellowship training programs have helped to establish advanced pain management services for rural communities. Consensus guidelines to direct the rural provider toward the most valid and reliable measures for pain assessment and functional outcomes evaluation are not presently available. The primary aim of this initiative was to establish consensus guidelines for a comprehensive outcome evaluation program with specific time intervals for assessments that can be utilized by all rural pain clinics. The American Association of Nurse Anesthesiology Nonsurgical Pain Management Advisory Panel members provided formative and expert feedback for this initiative. The Delphi model was utilized to achieve consensus through multiple rounds of surveys. Items achieving >70% agree/strongly agree were kept; items with >70% disagree/strongly disagree were rejected; items meeting neither advanced to the following round for evaluation until consensus was met. During round I, consensus was reached for: (1) the use of the Numerical Rating Scale for pain severity; and (2) timing of pain severity & functional pain outcomes on each office visit and before/after each intervention. Round II, consensus was achieved for: (1) the use of Wong-Baker FACES Pain Rating Scale as a suitable instrument when literacy or communication pose a barrier but not as a primary assessment; and (2) the use of the Brief Pain Index-Short Form for functional outcome measures. During round III, consensus was reached for: (1) the use of the Oswestry Disability Index as a functional outcome measure; and (2) pain reassessment being performed within 14 days of intervention. This initiative provides rural pain clinics with a comprehensive outcome evaluation program with specific time intervals for assessments.

Development and psychometric testing of a scale to measure effective rural emergency transfer (RET).

BACKGROUND: The process of transferring patients from small rural primary care facilities to referral facilities impacts the quality of care and effectiveness of the referral healthcare system. The study aimed to develop and evaluate the psychometric properties of a scale measuring requirements for effective rural emergency transfer. METHODS: An exploratory sequential design was utilized to develop a scale designed to measure requirements for effective emergency transport. Phase one included a qualitative, interview study with 26 nursing transport providers. These transcripts were coded, and items developed for the proposed scale. Phase two included a content validity review by these 16 transport providers of the domains and items developed. Phase three included development and evaluation of psychometric properties of a scale designed to measure requirements for effective emergency transport. This scale was then tested initially with 84 items and later reduced to a final set of 58 items after completion by 302 transport nurses. The final scale demonstrated three factors (technology & tools; knowledge & skills; and organization). Each factor and the total score reported excellent scale reliability. RESULTS: The initial item pool consisted of 84 items, generated, and synthesized from an extensive literature review and the qualitative descriptive study exploring nurses' experiences in rural emergency patient transportation. A two-round modified Delphi method with experts generated a scale consisting of 58 items. A cross-sectional study design was used with 302 nurses in rural clinics and health in four rural health districts. A categorical principal components analysis identified three components explaining 63.35% of the total variance. The three factors, technology, tools, personal knowledge and skills, and organization, accounted for 27.32%, 18.15 and 17.88% of the total variance, respectively. The reliability of the three factors, as determined by the Categorical Principal Component Analysis (CATPCA)'s default calculation of the Cronbach Alpha, was 0.960, 0.946, and 0.956, respectively. The RET Cronbach alpha was 0.980. CONCLUSIONS: The study offers a three-factor scale to measure the effectiveness of emergency patient transport in rural facilities to better understand and improve care during emergency patient transport.

The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina.

OBJECTIVE: To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. MATERIALS AND METHODS: Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality. RESULTS: Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. CONCLUSIONS: Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

Implementation of a quality improvement strategy to optimise the management of community acquired pneumonia in a rural health setting.

PROBLEM: In Australia, inappropriate prescribing of antimicrobials is higher in rural and regional areas than in major city hospitals. Inappropriate prescribing is defined as the prescription of antimicrobial agents that do not adhere to guidelines in terms of type of antimicrobial chosen, dose and/or duration or are deemed unnecessary. A review of antimicrobial prescribing in a Queensland rural Hospital and Health Service (HHS) identified that respiratory infections were an area for potential improvement. SETTING: The study was performed in a rural HHS in Queensland. KEY MEASURES FOR IMPROVEMENT: Appropriateness of antimicrobial prescribing for baseline and post-implementation phases of the study was evaluated according to Therapeutic Guidelines: antibiotic recommendations for community acquired pneumonia (CAP). STRATEGIES FOR CHANGE: Quality improvement strategy to implement a multifaceted package of interventions for CAP. EFFECTS OF CHANGE: Post-implementation, overall appropriateness of antimicrobial prescribing improved and there was a decrease in duration of antimicrobial therapy. LESSONS LEARNT: A quality improvement strategy to implement a multifaceted package of interventions for CAP has shown to be acceptable and effective in improving the antimicrobial prescribing in a rural setting. Our findings highlight the importance of utilising a multifaceted package of interventions which can be tailored to the prescribers and the patients at hand. It is also valuable to engage with local clinicians to promote the optimal management of common infections in the rural setting.

Thank You for Being Here: Insights From Rural Oncology Practice.

Rural oncologist reflects on 20 years of providing vital cancer care in underserved areas.

A mixed-methods descriptive study on the role of continuous quality improvement in rural surgical and obstetrical stability: Considering enablers, challenges and impact.

INTRODUCTION: The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers' experiences with CQI and the implications for service stability. BACKGROUND: Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings. METHODS: Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023. FINDINGS: Qualitative findings revealed participants' perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships). CONCLUSION: Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care.

Can digital innovation transform rural primary health care? A systematic review protocol.

INTRODUCTION: Digital technology is increasingly being adopted within primary healthcare services to improve service delivery and health outcomes; however, the scope for digital innovation within primary care services in rural areas is currently unknown. This systematic review aims to synthesise existing research on the use and integration of digital health technology within primary care services for rural populations across the world. METHODS AND ANALYSIS: A systematic approach to the search strategy will be conducted. Relevant medical and healthcare-focused electronic databases will be searched using key search terms between January 2013 and December 2023. Searches will be conducted using specific inclusion and exclusion criteria. A systematic study selection and data extraction process will be implemented, using standardised templates. Outcomes will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses- Protocol statement guidelines. Quality assessment and risk of bias appraisal will be conducted using the Mixed Methods Appraisal Tool. ETHICS AND DISSEMINATION: Ethical approval will not be required because there is no individual patient data collected or reviewed. The finding of this review will be disseminated through peer-reviewed publications and conference presentations. Outcomes will help to understand existing knowledge and identify gaps in delivering digital healthcare services, while also providing potential future practice and policy recommendations. PROSPERO REGISTRATION NUMBER: CRD42023477233.

Exploring factors associated with failure of totally implanted vascular access devices in a regional and rural health service: a retrospective case-control study.

BACKGROUND: The assessment and management of totally implanted vascular access devices (TIVAD) prior to the administration of medications/fluids are vital to ensuring the risk of harm is mitigated. While numerous guidelines exist for the insertion and management of TIVAD, the level of evidence and external validity to support these guidelines is lacking. OBJECTIVES: The purpose of this study was to identify factors associated with suboptimal TIVAD placement and with failure of TIVAD. METHODS: A retrospective case-control study (n=80) was conducted at a regional hospital and health service in Australia. Binomial logistic regression analysis was performed using a backward selection approach to establish variables associated suboptimal TIVAD placement and with TIVAD failure. FINDINGS: Significant associations were identified between the patient's primary diagnosis and suboptimal TIVAD insertion. Specifically, a prior diagnosis of breast cancer was associated with a decreased probability of optimal TIVAD tip placement (OR=0.236 (95% CI 0.058 to 0.960), p=0.044). A statistically significant association between TIVAD failure and the log of the heparinised saline flush rate and rate of undocumented flushes was also established. Further research is needed to identify and assess whether modification of these variables improves initial totally implantable venous access ports placement and risk of subsequent failure.

'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India.

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

Diferencias en la nota del ENAM y el promedio ponderado universitario en postulantes al servicio rural peruano, 2008-2015 / Differences in the ENAM grade and the university weighted average in applicants to the Peruvian Rural Health Service, 2008-2015

INTRODUCCIÓN: El Servicio Rural y Urbano Marginal de Salud (SERUMS) es un programa obligatorio al finalizar la carrera médica en el Perú, para la adjudicación de una plaza se toma en cuenta la nota del promedio ponderado promocional (PPP) y del Examen Nacional de Medicina (ENAM). MATERIALES Y MÉTODOS: Estudio analítico, retrospectivo, se empleó el registro de inscritos al SERUMS en el período 2008-2015. Se evaluó la diferencial entre la nota de calificación del ENAM y el PPP, por proceso de adjudicación y según procedencia de la universidad. Se obtuvo estadísticos de asociación. RESULTADOS: De los 21.296 evaluados, el rango de notas del promedio final en las universidades peruanas fue de 10,3-12,7 (PPP: 12,7-14,0 y ENAM: 9,3-12,3), en las de Cuba fue 5,5-12,9 (PPP: 16,9-18,3 y ENAM: 0,0-10,1), en las de Bolivia fue 3,6-11,2 (PPP: 12,0-13,2 y ENAM: 0,0-10,3) y en otras universidades del extranjero fue 4,2-11,7 (PPP: 13,6-17,1 y ENAM: 0,0-10,6). Al realizar el cálculo de la diferencial del ENAM-PPP se halló discrepancia estadísticamente significativa (p < 0,001) en todos los casos, según el tipo de universidad. CONCLUSIONES: Existen diferencias estadísticamente significativas entre las notas finales, los PPP y el ENAM según la procedencia de la universidad. Esto podría generar inequidad al elegir una plaza en el SERUMS y podría indicar que los modelos de adquisición de conocimientos fueron distintos, lo que debe evaluarse para estudiar su repercusión durante el SERUMS

INTRODUCTION: The Rural and Urban Marginal Health Service (SERUMS) is a mandatory program at the end of the medical career in Peru. The promotional grade point average (PPP) and the national medical examination (ENAM) grades are used when awarding places. MATERIALS AND METHODS: An analytical, retrospective study was conducted using the registration of SERUMS in the processes between 2008 and 2015. The differential between the ENAM and PPP grades was evaluated, by an adjudication process and according to the origin of the university. Association statistics were obtained. RESULTS: From the 21,296 evaluated, the range of grades of the final average in the Peruvian universities was 10.3-12.7 (PPP: 12.7-14.0 and ENAM: 9.3-12.3). In Cubans it was 5.5-12.9 (PPP: 16.9-18.3 and ENAM: 0.0-10.1), in Bolivians it was 3.6-11.2 (PPP: 12.0-13.2 and ENAM: 0.0-10.3), and in other foreign universities it was 4.2-11.7 (PPP: 13.6-17.1 and ENAM: 0.0-10, 6). When calculating the ENAM-PPP differential, a statistically significant discrepancy (P < .001) was found in all cases, and depending on the type of university. CONCLUSIONS: There are statistically significant differences between the final grades of the PPPs and the ENAM according to the origin of the university. This could create inequity in choosing a place in the SERUMS, and could suggest that the acquisition of knowledge models are different, which should be evaluated in order to study their impact during the SERUMS

Percepciones de utilidad y preparación para el Examen Nacional de Medicina en 10 facultades peruanas, 2017 / Perceptions of usefulness and preparation for the national examination in medicine in ten faculties of medicine, Peru-2017

INTRODUCCIÓN: El Examen Nacional de Medicina (ENAM) es una prueba obligatoria que rinden los estudiantes al finalizar el internado médico; con los cambios de ley ahora sirve como requisito para realizar el Servicio Rural y Urbano-Marginal en Salud. OBJETIVO: Determinar las percepciones de utilidad y preparación para el ENAM en 10 facultades de medicina peruanas. METODOLOGÍA: Estudio transversal analítico que se basó en 11 preguntas de una encuesta autoaplicada, con un alfa de Cronbach de 0,65. Se cruzó dichas variables según el tipo de universidad, año de estudios y si ha repetido cursos; esto con los modelos lineales generalizados. RESULTADOS: El 92% sabía que es el ENAM, el 82% para qué servía, el 74% pensaba que lo aprobaría y el 27% percibía que los conocimientos que le daban en su universidad eran suficientes para rendirlo. El año de estudios fue la variable que más se relacionó con los conocimientos y percepciones acerca del ENAM, pero también se encontraron algunas diferencias según el tipo de universidad y el haber reprobado un curso anteriormente. DISCUSIÓN: El ENAM sigue siendo el más importante examen de medicina a nivel nacional, ya que compara el nivel de enseñanza entre universidades y ahora sirve para poder realizar el Servicio Rural y Urbano-Marginal en Salud. La mayoría sabía qué era y para qué servía, pero la minoría pensaba que lo podría aprobar o que los conocimientos que recibían eran suficientes; siendo ocasionalmente influido por el año de estudios y en menor medida por otras variables

INTRODUCTION: The National Medical Examination (ENAM) is a mandatory test that students are given to complete after their medical internship. With the changes in law, it now serves as a requirement for the Rural and Urban-Marginal Health Service (SERUMS). OBJECTIVE: To determine perceptions of usefulness and preparation for ENAM in ten Peruvian medical faculties. METHODOLOGY: An analytical cross-sectional study was based on 11 questions from a self-administered questionnaire, with a Cronbach Alpha of 0.65. The variables were crossed according to the type of university, year of studies, and if courses were repeated, with the generalised linear models. RESULTS: Almost all of them (92%) knew what the ENAM is, 82% for what it served, 74% thought they would pass it, and 27% perceived that the knowledge gained in their university was sufficient to pass it. The year of studies was the variable that was most related to the knowledge and perceptions about the ENAM, but some differences were also found according to the type of university and to have failed a previous course. DISCUSSION: The ENAM is still the most important national medical examination, as it compares the level of teaching between universities, and now serves to work in SERUMS. Most students knew what it was and what it was for, but the minority thought they could pass it or that the knowledge they received was sufficient, being occasionally influenced by the year of studies and to a lesser extent by other variables

Feasibility of a multifaceted educational strategy for strengthening rural primary health care / Factibilidad de una estrategia educativa multifacética para fortalecer la atención primaria rural

Abstract: Objective: To evaluate the feasibility and acceptability of a comprehensive educational strategy designed to improve care quality in rural areas of Mexico. Materials and methods: A demonstration study was performed in 18 public rural health centers in Mexico, including an educational intervention that consists of the following steps: Development of the strategy; Selection and training of instructors (specialist physicians from the referral hospital and multidisciplinary field teams); Implementation of the strategy among health care teams for six priority causes of visit, through workshops, individual tutorials, and round-table case-review sessions. Feasibility and acceptability were evaluated using checklists, direct observation, questionnaires and in-depth interviews with key players. Results: Despite some organizational barriers, the strategy was perceived as worthy by the participants because of the personalized tutorials and the improved integration of health teams within their usual professional practice. Conclusion: The educational strategy proved to be acceptable; its feasibility for usual care conditions will depend on the improvement of organizational processes at rural facilities.

Resumen: Objetivo: Evaluar la factibilidad y aceptabilidad de una estrategia educativa multifacética de mejora de calidad de atención en áreas rurales de México. Material y métodos: Se realizó un estudio de demostración con una intervención educativa a equipos de salud en 18 centros de salud rurales en México, que incluyó desarrollo de la estrategia; selección y capacitación de instructores (especialistas del hospital de referencia y equipos asesores multidisciplinarios); implementación de la estrategia educativa para seis motivos prioritarios de atención, mediante talleres, asesorías individualizadas y sesiones de revisión de casos. Se evaluaron factibilidad y aceptabilidad mediante listas de cotejo, observación directa, cuestionarios y entrevistas a profundidad con actores clave. Resultados: A pesar de algunas barreras organizacionales, la estrategia fue percibida como valiosa por los participantes, por la asesoría personalizada y la integración de los equipos de salud en su práctica profesional. Conclusión: La estrategia educativa es aceptable para áreas rurales; su factibilidad en la operación usual dependerá de mejoras organizacionales de los servicios.