Co-designing a cardiac rehabilitation program with knowledge users for patients with cardiovascular disease from a remote area.

BACKGROUND: Cardiovascular disease is the leading cause of death worldwide. Cardiac rehabilitation (CR) programs are recognized as effective in reducing the burden of cardiovascular disease. However, CR programs are offered inequitably across regions and are available in less than 15% of remote areas worldwide. The main goal of this study was to design a CR program adapted to the contexts of remote areas to improve the service offered to patients. METHODS: We used an iterative user-centered design approach to understand the user context and services offered in cardiac rehabilitation in remote areas. We conducted two co-design processes with knowledge users in two remote regions. Two advisory committees were created in each of these regions, comprising managers (n = 6), healthcare professionals (n = 12) and patients (n = 2). We utilized the BACPR guidelines and the Hautes Autorités de santé operational model to support data collection in coding sessions to develop the CR program. We conducted four cycles of co-design with each of the committees to develop the cardiac rehabilitation program. Qualitative data were analyzed iteratively after each cycle. RESULTS: The co-design process resulted in developing a prototype cardiac rehabilitation program similar in both regions. It is based on a contextualized six-phase pathway of care designed for remote regions. For each phase 0 to 6 of the care pathway, knowledge users were asked to describe how to offer these phases in remote areas. Participants made structural changes to phases 0, 2, 3 and 4 in order to overcome staffing shortages in remote areas. These changes make it possible to decentralize cardiac rehabilitation expertise away from specialized centers, to ensure equity of service across the territory. Therapeutic patient education was integrated into phase 4 to meet patients' needs. Participants suggested that three follow-up offerings could come from nursing services to increase access to the cardiac rehabilitation program (primary care, home care, special chronic disease programs) in patients' home communities. CONCLUSION: The co-design process enables us to meet the needs of remote regions in program development. This final program can be the subject of future implementation research.

Barriers to Childhood Immunization in Rural and Remote Areas: A Qualitative Exploration From the Perspectives of Community Leaders in Sindh, Pakistan.

Despite overall improvements observed at the national level, there is a significant disparity in childhood vaccination coverage rates between urban and rural regions, particularly within tribal and remote areas in Pakistan. Our study aimed to explore the views of community/tribal leaders concerning barriers and their local solutions for improving vaccine uptake, with a specific focus on remote settings. An exploratory qualitative research study was conducted from July to September 2019 in Shikarpur, Sindh, Pakistan. We interviewed 11 community leaders, after developing a semi-structured interview guide based on the health belief model. Following validation, the collected data was transcribed and subsequently translated into the English language. A stepwise process of manual familiarization, coding, theme generation, and theme review using an inductive approach was followed. While most of the rural community leaders expressed a willingness to support vaccinations, numerous unexplored barriers were identified. These barriers included an unsustainable communication system heavily dependent on polio mobile teams, discourteous behavior of healthcare personnel, cultural restrictions that limited women's involvement, economic hardships, limited transportation options, insufficient collaboration with the education sector, poor knowledge among community leaders, and security concerns. Additionally, they proposed some innovative solutions of information dissemination methods through the Ottaque system, ethics-based training, subsidized transportation services or voucher system, and addressing security concerns in collaboration with community leaders. Our findings suggest policymakers take both community leaders and members for an inclusive policy-making process to redraft the special policy for these remote and rural areas.

Old-age mental telehealth services at primary healthcare centers in low- resource areas in Greece: design, iterative development and single-site pilot study findings.

BACKGROUND: Even though communities in low-resource areas across the globe are aging, older adult mental and cognitive health services remain mainly embedded in tertiary- or secondary hospital settings, and thus not easily accessible by older adults living in such communities. Here, the iterative development of INTegRated InterveNtion of pSychogerIatric Care (INTRINSIC) services addressing the mental and cognitive healthcare needs of older adults residing in low-resource areas of Greece is depicted. METHODS: INTRINSIC was developed and piloted in three iterative phases: (i) INTRINSIC initial version conceptualization; (ii) A 5-year field testing in Andros island; and (iii) Extending the services. The INTRINSIC initial version relied on a digital platform enabling videoconferencing, a flexible battery of diagnostic tools, pharmacological treatment and psychosocial support and the active involvement of local communities in service shaping. RESULTS: Ιn 61% of the 119 participants of the pilot study, new diagnoses of mental and/or neurocognitive disorders were established. INTRINSIC resulted in a significant reduction in the distance travelled and time spent to visit mental and cognitive healthcare services. Participation was prematurely terminated due to dissatisfaction, lack of interest or insight in 13 cases (11%). Based on feedback and gained experiences, a new digital platform, facilitating e-training of healthcare professionals and public awareness raising, and a risk factor surveillance system were created, while INTRINSIC services were extended to incorporate a standardized sensory assessment and the modified problem adaptation therapy. CONCLUSION: The INTRINSIC model may be a pragmatic strategy to improve access of older adults with mental and cognitive disorders living in low-resource areas to healthcare services.

The perceived need for evidence-based COVID-19 management and Tele-education in the North-East region of India: a cross-sectional survey.

Due to the sudden rise in the cases of COVID-19 in the North-Eastern region of India, this study was conducted to survey the felt needs of the medical professionals with regards to education on the evidence-based management of COVID-19. A total of 25 North-East leaders were recruited and a baseline survey was conducted through the digital medium. Out of 25 North-East leaders, 52% were undergoing training in evidence-based medicine in the capacity-building program for evidence-based child health. Participants (48%) strongly agreed and 40% agreed on the possibility of enhanced care by capacity building in the areas of COVID-19 management through discussing cases. Out of 25 North East leaders, 48% agreed to join both as a speaker as well as a participant. Various priority topics on COVID-19 management e.g. childhood, adult, ocular manifestation, ICU management, telemedicine, vaccines, lab protocols, psychological distress, and treatment strategy have emerged. We have presented the findings of the survey which will help guide the mentoring program focusing on evidence-based management of COVID-19 in remote areas through Tele-education.

Challenges facing the More Doctors program (Programa Mais Médicos) in vulnerable and peri-urban areas in Greater Brasilia, Brazil.

BACKGROUND: A shortage of physicians, especially in vulnerable and peri-urban areas, is a global phenomenon that has serious implications for health systems, demanding policies to assure the provision and retention of health workers. The aim of this study was to analyze the strategies employed by the More Doctors Program (Programa Mais Médicos) to provide primary care physicians in vulnerable and peri-urban parts of Greater Brasilia. METHODS: The study used a qualitative approach based on the precepts of social constructivism. Forty-nine semi-structured interviews were conducted: 24 with physicians employed as part of the More Doctors program, five with program medical supervisors, seven with secondary care physicians, twelve with primary care coordinators, and one federal administrator. The interviews occurred between March and September 2019. The transcripts of the interviews were submitted to thematic content analysis. RESULTS: The partnership between the Ministry of Health and local authorities was essential for the provision of doctors-especially foreign doctors, most from Cuba, to assist vulnerable population groups previously without access to the health system. There was a notable presence of doctors with experience working with socioeconomically disadvantaged populations, which was important for gaining a better understanding of the effects of the endemic urban violence in the region. The incentives and other institutional support, such as enhanced salaries, training, and housing, transportation, and food allowances, were factors that helped provide a satisfactory working environment. However, the poor state of the infrastructure at some of the primary care units and limitations of the health service as a whole were factors that hampered the provision of comprehensive care, constituting a cause of dissatisfaction. CONCLUSIONS: More Doctors introduced a range of novel strategies that helped ensure a supply of primary care doctors in vulnerable and peri-urban parts of Greater Brasilia. The inclusion of foreign doctors, most from Cuba, was crucial for the success of the health services provided for the local communities, who subsist in violent and socioeconomically deprived urban areas. However, it became clear that barriers from within the health service itself hampered the physicians' capacity to provide a satisfactory service. As such, what is needed for primary care to be effective is not just the recruitment, training, and deployment of doctors, but also investment in the organization of the whole health system.

Improving the Performance of Time-Relative GNSS Precise Positioning in Remote Areas.

Global navigation satellite systems (GNSS) can attain centimeter level positioning accuracy, which is conventionally provided by real-time precise point positioning (PPP) and real-time kinematic (RTK) techniques. Corrections from the data center or the reference stations are required in these techniques to reduce various GNSS errors. The time-relative positioning approach differs from the traditional PPP and RTK in the sense that it does not require external real-time corrections. It computes the differences in positions of a single receiver at different epochs using phase observations. As the code observations are not used in this approach, its performance is not affected by the noise and multipath of code observations. High reliability is another advantage of time-relative precise positioning because the ambiguity resolution is not needed in this approach. Since the data link is not required in the method, this approach has been widely used in remote areas where wireless data link is not available. The main limitation of time-relative positioning is that its accuracy degrades over time between epochs because of the temporal variation of various errors. The application of the approach is usually limited to be within a time interval of less than 20 min. The purpose of this study was to increase the time interval of time-relative positioning and to extend the use of this method to applications with a longer time requirement, especially in remote areas without wireless communication. In this paper, the main error sources of the time-relative method are first analyzed in detail, and then the approach to improve the accumulated time relative positioning method is proposed. The performance of the proposed method is assessed using both static and dynamic observations with a duration as long as several hours. The experiments presented in this paper show that, among the four scenarios tested (i.e., GPS, GPS/Galileo, GPS/Galileo/BeiDou, and GPS/Galileo/BeiDou/GLONASS), GPS/Galileo/BeiDou performed best and GPS/Galileo/BeiDou/GLONASS performed worst. The maximum positioning errors were mostly within 0.5 m in the horizontal direction, even after three hours with GPS/Galileo/BeiDou. It is expected that the method could be used for positioning and navigation for as long as several hours with decimeter level horizontal accuracy in remote areas without wireless communication.

Evaluation of a Community-Run and General-Practitioner-Supervised Self-Care for Minor Illnesses (CGPSC) Program in a Remote Area in Taiwan.

Although Taiwanese citizens benefit from affordable health care, residents in remote areas extensively rely on unsafe self-care practices because of a lack of easy access to medical services. To improve self-care safety, ten easy-access self-care medical spots (ESCMSs) managed by trained residents were established in two remote villages. This study aimed to assess the impact of ESCMSs on self-care and access to medical services. For a total of six commonly experienced minor illnesses, the average number of illnesses for which residents were confident to perform self-care increased from 2.78 in the pretest to 3.58 in the post-test. ESCMSs were also the first choice when experiencing minor illnesses for 31.25% residents who did not visit a doctor. Residents' personal experience with ESCMSs correlated with their perception of ESCMSs' function. Compared with residents who had no personal experience of using ESCMSs, those who used the ESCMS service were less likely to store medications for minor illnesses at home (51.02% vs. 76.67%). Furthermore, those who attribute the reduced needs for professional help to ESCMSs had used medications for minor illnesses at ESCMSs. These results suggest that establishing ESCMSs is a viable alternative to increase the self-care capacity of residents in remote areas and increase the access to medical resources. Moreover, because residents are less likely to store medication and travel for professional help, ESCMSs could indirectly reduce the risks of self-medication and traffic accidents, respectively. However, caution should be exercised when generalizing these results to more populated areas that also lack medical resources.

How Geographical Isolation and Aging in Place Can Be Accommodated Through Connected Health Stakeholder Management: Qualitative Study With Focus Groups.

BACKGROUND: In remote areas, connected health (CH) is needed, but as local resources are often scarce and the purchasing power of residents is usually poor, it is a challenge to apply CH in these settings. In this study, CH is defended as a technological solution for reshaping the direction of health care to be more proactive, preventive, and precisely targeted-and thus, more effective. OBJECTIVE: The objective of this study was to explore the identity of CH stakeholders in remote areas of Taiwan and their interests and power in order to determine ideal strategies for applying CH. We aimed to explore the respective unknowns and discover insights for those facing similar issues. METHODS: Qualitative research was conducted to investigate and interpret the phenomena of the aging population in a remote setting. An exploratory approach was employed involving semistructured interviews with 22 participants from 8 remote allied case studies. The interviews explored perspectives on stakeholder arrangements, including the power and interests of stakeholders and the needs of all the parties in the ecosystem. RESULTS: Results were obtained from in-depth interviews and focus groups that included identifying the stakeholders of remote health and determining how they influence its practice, as well as how associated agreements bring competitive advantages. Stakeholders included people in government sectors, industrial players, academic researchers, end users, and their associates who described their perspectives on their power and interests in remote health service delivery. Specific facilitators of and barriers to effective delivery were identified. A number of themes, such as government interests and power of decision making, were corroborated across rural and remote services. These themes were broadly grouped into the disclosure of conflicts of interest, asymmetry in decision making, and data development for risk assessment. CONCLUSIONS: This study contributes to current knowledge by exploring the features of CH in remote areas and investigating its implementation from the perspectives of stakeholder management. It offers insights into managing remote health through a CH platform, which can be used for preliminary quantitative research. Consequently, these findings could help to more effectively facilitate diverse stakeholder engagement for health information sharing and social interaction.

[Health working conditions and environment: conceptual model for remote and rural areas]. / Condiciones y medio ambiente de trabajo en salud: modelo conceptual para áreas remotas y rurales.

This report proposes a conceptual model on workplace environment and working conditions that integrates the available evidence to facilitate the design and evaluation of interventions aimed at improving the attraction, recruitment and retention of health personnel at the first level of care in rural and remote areas. Theoretical, empirical and testimonial evidence was consulted to support the model, and 15 frameworks disseminated in the last 20 years were synthesized. The article shows the diversity of perspectives and the complexity involved in establishing the dimensions to be considered in a proposal that is useful to apply to human resources for health policies.The proposed model includes four categories of components: factors of the external context, organizational factors, employment and work conditions, and individual factors. The boundaries between the components -as well as the weight and influence of each one- vary according to the interrelationship among them and the interaction with the environment, and thus its interpretation must be adapted to the context in which it is intended to be applied.Based on this conceptual model, the design and evaluation of interventions aimed at increasing the availability of health personnel -particularly at the primary care level in rural and remote areas of the Region of the Americas- should emerge from an interaction between health and employment policies, and the realities and expectations of workers and the communities.

[Factors and interventions that affect working conditions and environment to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas]. / Factores e intervenciones que inciden en las condiciones y medio ambiente de trabajo para incrementar la atracción, captación y retención de recursos humanos en salud en el primer nivel de atención de áreas rurales, remotas o desatendidas.

OBJECTIVE: To identify and systematize available empirical evidence on factors and interventions that affect working conditions and environment in order to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas. METHODS: Rapid review of reviews selected according to relevance, eligibility and inclusion criteria. The search was conducted on electronic and manual databases, including grey literature. AMSTAR I was used to assess the quality of systematic reviews and a thematic analysis for synthesis of the results. RESULTS: Sixteen reviews were included, one of which contained 14 reviews. Of the total, 20 reviews analyzed factors and 9 evaluated the effectiveness of interventions. The evidence on factors is abundant, but of limited quality. Individual, family and "previous exposure to a rural setting" factors were associated with higher recruitment; organizational and external context factors were important for human resource retention. Networking and professional support influenced recruitment and retention. Evidence on the effectiveness of interventions was limited, both in quantity and quality. The most frequently used intervention was incentives. CONCLUSIONS: Evidence on factors that are positively related to recruitment and retention of workers at the first level of care in rural, remote or underserved areas is sufficient and should be taken into account when designing interventions. Quality evidence on the effectiveness of interventions is scarce. More controlled studies with methodological rigor are needed, particularly in the Americas.

Solar-Supplied Satellite Internet Access Point for the Internet of Things in Remote Areas.

As satellite communications provide ubiquitous coverage, they play a key role in providing Internet connectivity in remote or marginalized areas, so as to enable the vision of a truly global connectivity of the Internet of Things (IoT). However, these areas often lack reliable electricity supply. Thus, this paper proposes a satellite internet access point powered by solar energy, so that a stable Internet connection can be provided. The access point provides Wi-Fi coverage so that sensors, IoT, and devices can connect to the access point using the Wi-Fi, a common wireless technology. Our design took some cost-saving measures to make it affordable and selected the components that require minimal maintenance operations. The satellite access point costs about USD $500, and can provide four days of Internet connectivity without solar energy.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23-94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies. METHODS: The Yapatjarrathati project (named by the local First Nations community and meaning 'to get well') is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process. DISCUSSION: Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

Analysis of a decade of skin cancer prevention using a mobile unit in Brazil.

INTRODUCTION: For the past 10 years, skin cancer has been the most frequent malignant neoplasm in Brazil and worldwide. Each year, there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon. There were an estimated 188 000 new cases of skin cancer in Brazil in 2016. The prevention department of Barretos Cancer Hospital (BCH) runs some prevention programs for cancer such as breast, prostate, cervical, oral, colon and skin cancers. The skin cancer prevention program comprises educational activities and medical assistance conducted at the hospital and at a mobile unit (MU). The objective of this study is to evaluate the use of the MU as part of a skin cancer prevention program, 10 years after the implementation of this prevention program, using an MU in remote areas of Brazil. METHODS: The database of the BCH was used. These data refer to data collected by the BCH Prevention MU. A total of 45 872 patients with suspected skin cancer were evaluated at the MU from 2004 to 2013. Of these, 8954 surgical procedures (excisions and/or biopsy) were performed. RESULTS: This study demonstrated a significant number of skin cancer cases diagnosed and treated by the MU. CONCLUSIONS: This study showed that the MU positively contributes to the early diagnosis and treatment of skin cancer among populations residing in remote areas of Brazil.

"If I had known, I would have applied": poor communication, job dissatisfaction, and attrition of rural health workers in Sierra Leone.

BACKGROUND: Sierra Leone's health outcomes rank among the worst in the world. A major challenge is the shortage of primary healthcare workers (HCWs) in rural areas due to especially high rates of attrition. This study was undertaken to determine the drivers of job dissatisfaction and poor retention among Sierra Leone's rural HCWs. METHODS: Interviews were conducted with 58 rural and 32 urban primary HCWs in Sierra Leone's public health sector, complemented by key informant discussions and review of national policy documents. HCW interviews included (1) semi-structured discussion, (2) questionnaire, (3) card sort about HCW priorities, and (4) free-listing of most pressing challenges and needs. Sampling for HCW interviews was stratified purposive, emphasizing rural HCWs. RESULTS: Among 90 HCWs interviewed, 67% were dissatisfied with their jobs (71% rural vs 52% urban) and 61% intended to leave their post (75% rural vs 38% urban). While working and living conditions and remuneration were significant factors, a major reason for rural HCW disenchantment was their inability to access worker rights, benefits, and advancement opportunities. This was caused by HCWs' lack of knowledge about human resource (HR) policies and procedures, as well as ambiguity in many policies and inequitable implementation. HCWs reported feeling neglected and marginalized and perceived a lack of transparency. These issues can be attributed to the absence of systems for regular two-way communication between the Ministry of Health and HCWs; lack of official national documents with up-to-date, clear HR policies and procedures for HCWs; pay statements that do not provide a breakdown of financial allowances and withholdings; and lack of HCW induction. CONCLUSIONS: HCWs in Sierra Leone lacked accurate information about entitlements, policies, and procedures, and this was a driver of rural HCW job dissatisfaction and attrition. System-oriented, low-cost initiatives can address these underlying structural causes in Sierra Leone. These issues likely apply to other countries facing HCW retention challenges and should be considered in development of global HCW retention strategies.

Development of health-related quality of life and symptoms in patients with advanced cancer in Greenland.

A prospective national cohort study assessed the development of health-related quality of life (HRQoL) and symptoms in adult patients undergoing treatment and care for advanced cancer in Greenland. HRQol was examined by EORTC QLQ-C30 version 3.0 questionnaire monthly for 4 months. Changes over time and between-group comparisons were examined. Of 58 patients included in the study, 47% completed the questionnaire four times. Functioning was generally high, and improved social functioning was observed after 1 and 2 months. The highest symptom score was for fatigue followed by pain and nausea/vomiting. A high score for financial problems remained unchanged during the entire period. Patients with higher income had reduced pain intensity (p = .03) and diarrhoea (p = .05) than patients with income below the poverty line. After 1 month, reduction in pain intensity was observed for Nuuk citizens compared with non-Nuuk citizens (p = .05). After 2 months, non-Nuuk citizens reported improved social functioning compared with Nuuk citizens (p = .05). After 3 months, Global Health in Nuuk citizens was improved compared with non-Nuuk citizens (p = .05). An important clinical finding was that patients' needs for support are related to social status, and geographical factors should be taken into account when planning palliative care.

Physicians' perceptions on the impact of telemedicine on recruitment and retention in underserved areas: a descriptive study in Senegal.

BACKGROUND: Similar to many places, physicians in Senegal are unevenly distributed. Telemedicine is considered a potential solution to this problem. This study investigated the perceptions of Senegal's physicians of the impact of telemedicine on their recruitment to and retention in underserved areas. METHODS: We conducted individual interviews with a random sample of 60 physicians in Senegal, including 30 physicians working in public hospitals and 30 physicians working in district health centres between January and June 2014, as part of a mixed methods study. Data were collected using a semi-structured interview guide comprising both open- and close-ended questions. Interviews were recorded, transcribed and coded thematically using NVivo 10 software using a priori and emergent codes. Participants' characteristics were analyzed descriptively using SPSS 23. RESULTS: The impact of telemedicine on physicians' recruitment and retention in underserved areas was perceived with some variability. Among the physicians who were interviewed, most (36) thought that telemedicine could have a positive impact on their recruitment and retention but many (24) believed the opposite. The advantages noted by the first included telemedicine's ability to break their professional isolation and reduce the stress related to this, facilitate their distance learning and improve their working conditions. They did acknowledge that it is not sufficient in itself, an opinion also shared by physicians who did not believe that telemedicine could affect their recruitment and retention. Both identified contextual, economic, educational, family, individual, organizational and professional factors as influential. CONCLUSION: Based on these opinions of physicians, telemedicine promotion is one intervention that, alongside others, could be promoted to assist in addressing the multiple factors that influence physicians' recruitment and retention in underserved areas.

The relationship of primary care providers to dental practitioners in rural and remote Australia.

BACKGROUND: Rural residents have poorer oral health and more limited access to dental services than their city counterparts. In rural communities, health care professionals often work in an extended capacity due to the needs of the community and health workforce shortages in these areas. Improved links and greater collaboration between resident rural primary care and dental practitioners could help improve oral health service provision such that interventions are both timely, effective and lead to appropriate follow-up and referral. This study examined the impact oral health problems had on primary health care providers; how primary care networks could be more effectively utilised to improve the provision of oral health services to rural communities; and identified strategies that could be implemented to improve oral health. METHODS: Case studies of 14 rural communities across three Australian states. Between 2013 and 2016, 105 primary and 12 dental care providers were recruited and interviewed. Qualitative data were analysed in Nvivo 10 using thematic analysis. Quantitative data were subject to descriptive analysis using SPSSv20. RESULTS: Rural residents presented to primary care providers with a range of oral health problems from "everyday" to "10 per month". Management by primary care providers commonly included short-term pain relief, antibiotics, and advice that the patient see a dentist. The communication between non-dental primary care providers and visiting or regional dental practitioners was limited. Participants described a range of strategies that could contribute to better oral health and oral health oral services in their communities. CONCLUSIONS: Rural oral health could be improved by building oral health capacity of non-dental care providers; investing in oral health promotion and prevention activities; introducing more flexible service delivery practices to meet the dental needs of both public and private patients; and establishing more effective communication and referral pathways between rural primary and visiting/regional dental care providers.

Concentrations of polycyclic aromatic hydrocarbons: Their potential health risks and sources at three non-urban sites in Japan.

This investigation was undertaken to monitor particulate polycyclic aromatic hydrocarbons (PAHs) concentrations in order to determine their emission sources and potential human health risks in remote and rural areas of Japan. Seventeen PAHs in aerosol samples collected in remote (Kamihaya), coastal (Hiki) and inland (Higashi-Hiroshima) areas of Japan during 2013-2014 were analyzed using gas chromatography/mass spectrometry. Total PAH (Σ17PAH) concentrations in aerosol samples were in the range of 0.08-6.51 ng m(-3), 0.09-4.74 ng m(-3), and 0.21-6.53 ng m(-3) at Kamihaya, Hiki, and Higashi-Hiroshima sites, with mean concentrations of 1.63, 1.18, and 2.43 ng m(-3), respectively. Significant seasonal variation in concentrations occurred at Hiki and Higashi-Hiroshima, while no significant variation occurred at Kamihaya. Ambient air temperature greatly affected PAH concentrations in Higashi-Hiroshima, but had only moderate effects in Kamihaya and Hiki. Wind direction also influenced the concentrations of PAHs. Vehicle exhaust, industrial emissions, biomass combustion, and domestic heating and cooking were identified as the main PAH emission sources using principal component analysis. Backward trajectory calculations showed that domestically generated PAHs were significant in Kamihaya and Hiki, while in Higashi-Hiroshima concentrations were mainly influenced by long-range transport. The incremental lifetime lung cancer risk had values of 3.38 × 10(-5) and 1.84 × 10(-5) at Higashi-Hiroshima and Hiki, which are greater than the US EPA acceptable level (10(-6)). Typically, 5-6-ring PAHs contributed 95% to this overall health risk, of which benzo(a)pyrene was the largest contributor, followed by dibenz(a,h)anthracene at both residential sites. Clearly, stricter guidelines for PAHs need to be implemented at these sites to protect the population.

Enhanced electrical responsiveness in the cerebral cortex with oral melatonin administration after a small hemorrhage near the internal capsule in rats.

Intracerebral hemorrhage (ICH) can cause direct brain injury at the insult site and indirect damage in remote brain areas. Although a protective effect of melatonin (ML) has been reported for ICH, its detailed mechanisms and effects on remote brain injury remain unclear. To clarify the mechanism of indirect neuroprotection after ICH, we first investigated whether ML improved motor function after ICH and then examined the underlying mechanisms. The ICH model rat was made by collagenase injection into the left globus pallidus, adjacent to the internal capsule. ML oral administration (15 mg/kg) for 7 days after ICH resulted in significant recovery of motor function. Retrograde labeling of the corticospinal tract by Fluoro-Gold revealed a significant increase in numbers of positive neurons in the cerebral cortex. Immunohistological analysis showed that ML treatment induced no difference in OX41-positive activated microglia/macrophage at day 1 (D1) but a significant reduction in 8-hydroxydeoxyguanosin-positive cells at D7. Neutral red assay revealed that ML significantly prevented H2 O2 -induced cell death in cultured oligodendrocytes and astrocytes but not in neurons. Electrophysiological response in the cerebral cortex area where the number of Fluoro-Gold-positive cells was increased was significantly improved in ML-treated rats. These data suggest that ML improves motor abilities after ICH by protecting oligodendrocytes and astrocytes in the vicinity of the lesion in the corticospinal tract from oxidative stress and causes enhanced electrical responsiveness in the cerebral cortex remote to the ICH pathology.

The experiences of rural and remote families involved in an inter-hospital transfer to a tertiary ICU: a hermeneutic study.

BACKGROUND: Inter-hospital transfers are necessary for critically ill patients to improve their chance of survival. Rural and remote families experience significant disruption to family life when critically ill patients are required to undergo a transfer to a tertiary hospital. What is not known is how ICU staff can assist these families who are involved in an inter-hospital transfer to a tertiary ICU. PURPOSE: To gain an understanding of rural and remote critical care families' experiences during an inter-hospital transfer to a tertiary ICU. METHOD: A hermeneutic phenomenological approach was adopted informed by the philosophical world views of Heidegger and Gadamer. Data collection occurred by in-depth conversational interviews from a purposeful sample of seven family members. Interview transcripts, field notes and diary entries formed the text which underwent hermeneutic analysis. FINDINGS: Being confused, being engaged, being vulnerable and being resilient emerged as significant aspects of the rural and remote family members' experience during a transfer event. CONCLUSION: A better understanding of the experiences of rural and remote families during an inter-hospital transfer journey can inform the practice of ICU nurses. This study highlights the specific experiences of rural and remote families during an inter-hospital transfer journey to a tertiary ICU. It also informs nurses of the meaningful ways in which they can support these families with the uncertainty and chaos experienced as part of this journey.