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Introduction: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. Methods: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. Results: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. Conclusion: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs. [ABSTRACT FROM AUTHOR]

Social workers and other health care researchers have examined benefits and challenges of telehealth in rural communities before the COVID-19 pandemic. Yet, experience with virtual platforms and other technologies have rapidly evolved during the pandemic. The research team interviewed 14 health care providers and 17 patients after the onset of the pandemic in a predominantly rural state to examine perceptions of telehealth. MaxQDA analytic software was used to identify benefits and challenges in the use of telehealth. Findings identified commonly discussed benefits of telehealth including convenience for patients, increasing patient access to care, improved patient experience of care, and ability of telehealth to attract/retain patients. Challenges identified in this study included concerns about quality of care being compromised, patients' comfort and access to technology, policy challenges for providers, and the impersonal nature of telehealth visits. Persistent issues warrant research, education, and policy advocacy to improve access for rural populations. Social workers should play a key role in educating the emerging and existing workforce around barriers such as quality of care and patient comfort with technology, convening professionals and patients to establish sustained and effective reimbursement models, and advocating for structural access via enhanced broadband and other resource allocations. [ABSTRACT FROM AUTHOR]

Introduction: Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. Methods: Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. Results: The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. Conclusion: It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process. [ABSTRACT FROM AUTHOR]

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1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities. With an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio. Among the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference. The receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities. [ABSTRACT FROM AUTHOR]

Background: Adequate medication reconciliation is related to patients' safety. Rural populations are at increased risk of adverse drug events due to errors in medication reconciliation and often receiving medical care across multiple health care entities and across long distances with separate electronic medical records. Methods: This study examined the implementation of Medications at Transitions and Clinical Handoffs Toolkit (MATCH) in a rural primary care clinic and assessed the acceptability and feasibility of implementation. Intervention: MATCH was developed as a workflow process intervention to improve medication reconciliation. Results: Findings from MATCH implementation indicate that the process improved medication reconciliation workflow. A shared definition of current medications across providers and patients was essential. Conclusions: Empowering patients and caregivers with tools and language to work with providers, particularly nurses, to conduct medication reconciliation during primary care clinic visits is key to improving patient medication reconciliation in rural settings. [ABSTRACT FROM AUTHOR]

Objective: To assess the geographic dispersion of CT colonography (CTC) as well as differences in CTC utilization in rural versus urban areas in individuals with commercial insurance.Methods: Claims data from approximately 18.5 million commercially insured individuals across the United States were used to determine CTC utilization based on geographic area. Geographic areas were defined as metropolitan statistical areas (MSAs) and statewide non-MSAs. Utilization rates per 100,000 covered person-years were calculated for each geographic area for both screening and diagnostic CTC using 2017 data (the most recent full-year data available). Differences in CTC utilization between MSAs (urban) and non-MSAs (rural) were evaluated using weighted multivariate logistic regression.Results: CTC is widely dispersed across the United States with substantial geographic variability. Utilization of screening CTC was considerably lower among individuals residing in rural areas compared with those in urban areas (adjusted odds ratio = 0.353, P = .005). For individuals aged 50 to 64 years, screening CTC utilization was 2.38 per 100,000 in rural areas versus 6.67 per 100,000 in urban areas (P = .005). Utilization of diagnostic CTC was also lower in rural compared with urban areas, though this difference was not statistically significant (8.40 per 100,000 versus 13.11 per 100,000 respectively, P = .070).Conclusions: Although CTC is performed widely across the United States, utilization is generally low and varies substantially based on geographic region. CTC utilization is lower among individuals in rural compared with urban areas. [ABSTRACT FROM AUTHOR]

CONTEXT: Over the past 25 years, the attrition of small volume rural surgery programs across Western Canada has been significant and sustained. The 'Joint position paper on rural surgery and operative delivery' (JPP) offers a consensus policy framework for the sustainability of rural surgical programs by nesting them within larger regional programs. The many recommendations in the JPP coalesce around the recognition that surgical care should be provided as close to home as possible. To achieve this, surgical care should be delivered within rural and regional surgical programs integrated into well-functioning networks staffed by generalist specialist surgeons trained across surgical disciplines and family physicians with enhanced surgical skills (FPESS). ISSUES: There are important issues to be addressed in the creation of these networks, not the least of which is the sometimes challenging relationships between the stakeholders in these networks and skepticism about the training of FPESS and the safety and quality of low volume surgical programs. Relationships extend from the patient-provider nexus to include interprofessional relationships and those between the pentagram partners (patients/communities, care providers, administrators, researchers and policymakers). Equally important to resolve is the issue of the minimum threshold volume of local surgical activity required for a sustainable professional workforce in a small rural program. LESSONS LEARNED: A collaborative effort by key stakeholders in British Columbia has produced a program designed to overcome these challenges and build effective networks of rural surgical care, based on the synergistic interplay of five key pillars to support small surgical sites. These five pillars include clinical coaching, continuing quality improvement (CQI), remote presence technology to mitigate geographic challenges, sustainable local surgical capacity, and evaluation of dimensions of network function and clinical outcomes. This is the first time that the integration of these five pillars, each derived from best available evidence, have been positioned together as deliberate strategic policy to improve rural surgical care. [ABSTRACT FROM AUTHOR]

Introduction: For the past 50 years paramedic services and paramedic roles in high-income nations have evolved in response to changes in community needs and expectations. The aim of this article is to review paramedic models of service delivery, with an emphasis on models that have the potential to improve the health and wellbeing of frontier and remote populations. Methods: Paramedic models of relevance to rural and frontier settings were identified from searches of CINHAL and Medline, while key paramedic-specific journals were individualy searched in the event that they were not indexed. Search terms were ambulance, paramedic and EMS. These were then combined with model* and rural, remote and frontier. These findings were then synthesised. Results: During the 1950s and 1960s the volunteer transport model, based on the values of community informed self-determination, developed to meet local needs for transport to local hospitals and medical services. Somewhat later, the technological model, characterised by professionally staffed and managed paramedic systems providing prehospital using advanced technology and technically skilled staff, became the dominant model in metropolitan and regional settings. Paramedic practitioner models are now emerging that are part of integrated prehospital systems. These provide a range of services to prevent injury and illness, respond to emergencies and facilitate recovery, and contribute to efforts to produce a healthy community. Conclusions: Implementation of paramedic practitioner models in frontier and remote settings raises challenging policy and practice issues, including changes in scopes of practice, design of education programs, self-regulation of paramedics, and reimbursement. [ABSTRACT FROM AUTHOR]

The elderly who suffer from chronic conditions have an increasingly difficult time accessing health care in rural areas compared with their healthy counterparts who seek and utilize less specialty care. Parkinson disease affects approximately 0.3% to 5% of the elderly population. However, a large portion of that population has difficulty accessing health care. The purpose of this study was to obtain an understanding of the access to care issues for patients with Parkinson disease and review solutions to aid their provision of care. A review of the literature found several models of care available to improve access to care issues for patients with Parkinson disease. [ABSTRACT FROM AUTHOR]

In developing countries, population increase is not sufficiently matched by increase in available health care resources. Inspite of technology advances, proper medical facility and resources are still not available to a large percentage of population, especially those having low income and living in rural or remote areas. There is an urgent need for development of a low cost and highly reliable technology for monitoring healthcare for those living in such areas that provides rapid monitoring of basic vital health parameters for large numbers of people, and making this data readily available to doctor present anywhere in the world. A novel and an efficient biomedical device has been designed which can quickly monitor the vital signs of large number of people simultaneously and transmit that information wirelessly to the doctor or medical facility present anywhere in the world. The instrument is represented by a hub and spoke model with the spokes being the sensor nodes consisting of a microcontroller MSP430G2553 and a wireless transceiver nRF24L01 (IEEE 802.15.4). The hub consists of a Raspberry Pi 3 with the same transceiver. The data received at the hub can be transmitted to the doctor through the inbuilt IEEE 802.11 (Wi-Fi protocol) of Raspberry Pi 3. All that the instrument needs to work is a Wi-Fi or an Ethernet connection and all the sensor nodes can be powered from the coin cell batteries. [ABSTRACT FROM AUTHOR]

Background: Community service doctors (CSDs) are often expected to administer anaesthesia after minimal training and with very little support, especially in rural hospitals. This leads to unnecessary stress on these junior doctors and may lead to poor anaesthesia outcomes. Objectives: The aim of this study was to understand the experiences of CSDs administering anaesthesia. This feedback will be used to improve the current intern training programme for anaesthesia and to structure the rotation according to their needs. Methods: A questionnaire was sent to Pietermaritzburg (PMB) interns who completed their anaesthesia intern rotation between 2008 and 2010. Two data sets were collected: quantitative data (this will be reported on in another paper) and qualitative data. The qualitative data included five open-ended questions about the intern rotation in anaesthesia. Results: Between 2008 and 2010, 298 interns completed an anaesthetic rotation. The survey was sent to 259 doctors of whom 189 responded (73%). The first three questions were about the structure of the intern rotation in anaesthesia. The responses were analysed together. The following feedback was common: more autonomy, longer duration of the anaesthesia rotation and more practical exposure during the rotation. Questions 4 and 5 were about the impact of internship and community service on future career choice. Community service had a greater impact on career choice than internship. Conclusion: Intern training in anaesthesia is essential to create confident CSDs. Feedback from previous interns should be used to improve intern training programmes. [ABSTRACT FROM AUTHOR]

Zusammenfassung Mit dem 1978 proklamierten Ende der Großen Proletarischen Kulturrevolution wurden viele Dinge, die für diese turbulente politische Epoche der VR China standen, verändert, zurückgenommen, abgeschafft. Das prominenteste Opfer dieser Reform war das System der Volkskommune, die radikalste Form der Kollektivwirtschaft der jungen VR China, die allerdings schon zehn Jahre vor der Kulturrevolution eingeführt worden war. Auf dem medizinischen Gebiet stand für den Westen der Barfußarzt synonym für die Kulturrevolution. Der Artikel zeigt auf, dass die Barfußärzte in China ebenfalls eine längere Tradition hatten, und dass sie nicht der post-kulturrevolutionären Abrechnung zum Opfer fielen, sondern in ein moderneres System überführt wurden – das System der Dorfärzte. Der Artikel profitiert von der nun 35-jährigen persönlichen Bekanntschaft des Autors mit einem ehemaligen Barfuß- und jetzigen Dorfarzt in der Provinz Anhui. After termination of the Great Proletarian Cultural Revolution had been proclaimed in 1978, many a thing representative of this turbulent political era of the PR China was changed, reduced, or abolished. The system of the people’s commune, being the most radical version of collective economy in the young PR China, which had been introduced ten years prior to the Cultural Revolution, became the most outstanding victim of the reform. With respect to health care, the West considered barefoot doctors as a synonym of the Cultural Revolution. This paper will point to the longer established history of barefoot doctors, demonstrating that they did not suffer extinction in the course of post-revolutionary retribution. Instead, they were converted into a modern system – the village doctors’ system. The article benefits from the author’s 35-years acquaintance with a former barefoot doctor who nowadays serves as a village doctor in the province of Anhui. [ABSTRACT FROM AUTHOR]

Purpose: Sometimes, patients in rural settings with aortic stenosis not severe enough to require valve replacement desire to undergo elective noncardiac procedures at their small local hospital. This has important implications for all stakeholders, including perianesthesia nurses. The purpose of this evidence-based article was to determine when it is appropriate for patients with aortic stenosis to undergo noncardiac surgery in this setting. Methods: A systematic search strategy was applied. Findings: The search revealed 12 evidence sources meeting the inclusion criteria: one clinical practice guideline, one cohort study, two nonrandomized control trials, four case-control studies, and four narrative reviews. Conclusions: The evidence suggests that patients with aortic stenosis undergoing moderate and higher risk noncardiac surgical procedures require expertise and resources often unavailable in small rural hospitals. These patients should be appropriately evaluated before the procedure. It may be appropriate for these patients to undergo low risk noncardiac surgery in small rural hospitals if stable, and there is a low likelihood of fluid shifts and unstable hemodynamics. [Copyright &y& Elsevier]

Abstract: Adolescent consumption of sugar-sweetened beverages (SSBs) has increased drastically with detrimental effects such as weight gain, weakened bones, dental caries, and associated higher levels of type II diabetes in this population. While in the clinical setting, rural family nurse practitioner (FNP) students, using Kellogg-funded Smart Phones, screened adolescents aged 13 to 17 years for SSB consumption in the previous 24 hours. Adolescents initially were provided with a pamphlet and related oral teaching concerning SSBs by the FNP students, as well as a water bottle to encourage healthy fluid intake. Screening SSB information was loaded onto Smart Phones, which resulted in immediate access by the primary investigator sometimes even hundreds of miles distant. After 30 days, FNP students completed follow-up phone interviews to reassess SSB consumption in the previous 24 hours. Results concerning decreased SSB consumption were statistically significant. Additionally, Smart Phones were instrumental in high-speed data transfer. Both advantages and disadvantages were encountered when using this evolving technology. [Copyright &y& Elsevier]

Knowledge is limited about quality of care (QOC) in rural hospitals, including the smallest hospitals, critical access hospitals. Staff nurses from 7 critical access hospitals identified items important for QOC across 4 levels of care: patients, microsystems, organizations, and environments. Several items were unique to critical access hospitals. Most QOC items were at the microsystem level, yet few of these items are routinely measured. These findings offer beginning evidence about how to advance QOC evaluations in rural hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Homeopathy has attracted considerable recent attention from the Australian conventional medical community. However, despite such increased attention there has been little exploration of the interface between homeopathy and Australian conventional medical practice. This article addresses this research gap by exploring homeopathic practice and referral by rural and regional Australian general practitioners (GPs). Materials and methods: A 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional New South Wales, Australia (response rate 40.7%). Results: Few GPs in this study utilised homeopathy in their personal practice, with only 0.5% of GPs prescribing homeopathy in the past 12 months, and 8.5% referring patients for homeopathic treatment at least a few times over the past 12 months. Nearly two-thirds of GPs (63.9%) reported that they would not refer for homeopathy under any circumstances. Being in a remote location, receiving patient requests for homeopathy, observing positive responses from homeopathy previously, using complementary and alternative medicine (CAM) practitioners as information sources, higher levels of knowledge of homeopathy, and being interested in increasing CAM knowledge were all independently predictive of increased referral to homeopathy amongst GPs in this study. GPs in this study were less likely to refer to homeopathy if they used peer-reviewed literature as the major source of their information on CAM. Conclusions: Homeopathy is not integrated significantly in rural general practice either via GP utilisation or referral. There is significant opposition to homeopathy referral amongst rural and regional GPs, though some level of interaction with homeopathic providers exists. [Copyright &y& Elsevier]

Introduction: The purpose of this mixed methods study was to examine the health issues and health management strategies utilized by rural low-income women and their families to inform the design, implementation, and evaluation of health reform in rural areas of the USA. Methods: Quantitative data was analyzed from 271 rural, low-income women and their families and qualitative data from a subsample of 44. Specifically explored were the: (1) types and perceived severity of health conditions rural, low-income individuals report; (2) perceived value and utilization of a usual source of care; and (3) strategies these individuals employ to manage their health. Results: Rural American families manage multiple healthcare needs with limited resources; 42.1% reported 1-4 chronic conditions in the family, 31.4% reported 5-8 conditions, and 17.7% reported 9 or more conditions. The majority of participants (79.0%) reported having a doctor or other healthcare professional that they usually see; 61.3% reported their partners had a usual provider, and 91.7% reported their children had a usual provider. Analysis of the qualitative data revealed two main themes regarding management of health conditions: (1) lack of engagement in managing overall health; and (2) ineffective utilization of health care. Conclusions: Rural low-income individuals in the US may benefit from new policies that promote patient-centered, personalized care. However, any policy change must be carefully designed to consider the ways in which rural American families manage their health in order to improve individual health status and reduce rural health disparities. [ABSTRACT FROM AUTHOR]

Due to the increasing likelihood of a pandemic it has become crucial that healthcare centers be adequately prepared for the unique challenges a pandemic will present. Rural hospitals face additional challenges due to their remote nature and a lack of shared resources. Effective pandemic preparedness education is critical to ensure the fullest use of available resources including staff, equipment, medicine, facilities, and other supplies. This study investigated the extent to which hospital pandemic preparedness coordinators perceive there is adequate communication between themselves and the North Dakota State Health Department (NDSHD) and the North Dakota Healthcare Association (NDHA). The results of the study suggest these coordinators and their facilities may not be adequately prepared for the next pandemic. [ABSTRACT FROM AUTHOR]

The experience of 10 foster families living in rural communities in the Northeastern United States was explored through phenomenological inquiry. Through an unstructured interview approach, parents were asked to describe what it was like to parent foster children with specialized health care needs. Recorded interviews were transcribed verbatim and analyzed using van Manen''s method. Data analysis revealed that parents fostering children in rural communities have concerns related to accessing medical care and decision making. They expressed feelings of being overwhelmed and unprepared, isolated, and stigmatized. [Copyright &y& Elsevier]

Context: In post-war Japan, a number of factors lead to a general shortage of physicians by the 1950s, which became acute in rural areas and has continued until recent times. Issue: Teamwork among national, prefectural, municipal governments and public medical schools has addressed this shortage of physicians. The national government doubled the number of medical schools in the 1960s and 1970s; each of the country's 47 prefectures, whether rural or not, has at least one medical school. In rural areas where private hospitals are not profitable, municipal governments have funded public hospitals and physician recruitment from their own budgets. A cooperative project among Japan's 47 prefectural governments and the national government established Jichi Medical University (JMU), which conducts a bound medical education program followed by obligatory rural service. As a result, the number of 'non-physician communities' (muichiku) nationwide has decreased by 73%; however, the gap between physician concentrations in urban and rural areas has not changed. Therefore, the government has recently implemented a JMU-like contractual program as a form of 'rural quota' at other medical schools in all 47 prefectures. If all the replicated programs work as successfully as JMU, the impact on the geographic distribution of physicians will be substantial. Lessons learned: The Japanese public-sector-led rural physician securing system could also be effective in countries where rural healthcare provision is the responsibility of the public sector and close cooperation among levels of government is possible. [ABSTRACT FROM AUTHOR]

Introduction: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. Methods: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. Results: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported improved communication between themselves and their primary healthcare provider. Conclusion: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes is a devastating and growing problem in the USA and throughout the world. Parts of Appalachia, especially the most rural and economically 'distressed' areas of the region, have disproportionately high levels of diabetes incidence and have had long-standing problems in healthcare access. Purpose: Little is known about the status of public health infrastructures and expertise available to address the diabetes epidemic, whether in Appalachia or elsewhere. This research examines the availability of professional diabetes care in Appalachia, including the economically distressed areas of the region. Methods: A 2006 cross-sectional survey of healthcare providers in the Appalachian Region identified diabetes service needs and availability in Appalachian healthcare facilities. Survey data and socioeconomic data were combined as a means to assess intraregional variation in service availability. Results: Participants perceived that diabetes prevalence was growing in Appalachia and that they were seeing increasing numbers of persons with diabetes. Healthcare facilities in the region rarely employed specialized health professional providers and the expertise concerning diabetes in some clinicians may be limited. Conclusions: The current and growing diabetes problem in Appalachia underscores the need for appropriate diabetes services and health professionals acquainted with current standards in diabetes care. Such problems in Appalachia have long been identified and linked with insufficient healthcare resources. The identification of ways to assure that local clinicians have current knowledge of diabetes standards of care is warranted. [ABSTRACT FROM AUTHOR]

Introduction: The growing proportions of older people in rural areas have implications for the provision of health and social care services. Older people are more likely to have complex health needs compared with other age groups, requiring a full range of primary, community and acute hospital services. The provision of services to older people in rural areas is challenged by diseconomies of scale, travel costs and difficulties in attracting staff. Policy-makers are requested to include the 'voice' of older people to help provide services that match needs and context. In spite of this, what older people want from health and social care services is a neglected area of investigation. The reported study was conducted in 2005/2006 as part of a European Union Northern Periphery Programme (EU NPP) project called Our Life as Elderly. Its aims were to explore the views of those aged 55 years and over and living in remote communities about current and future health and social care service provision for older people. Evidence was to be collected that could inform policy-makers about changing or improving service delivery. This article summarises emergent themes and considers their implications. Methods: The study selected two small remote mainland Scottish Highland communities for in-depth case study. Semi-structured interviews (n = 23), 10 'informal conversations' and 4 focus groups were held with community members aged 55 years and over, in order to provide different types of qualitative data and 'layers' of data to allow reflection. Data analysis was assisted by computerised data management software and performed using the 'framework analysis' approach. Results: Participants did not consider themselves 'old' and expressed the need for independence in older age to be supported by services. Several aspects of services that were undergoing change or restructuring were identified, including arrangements for home care services, meals provision and technological support. Participants valued elements of the traditional model of care they had been receiving: these were local, personal emphasis and continuity. They were suspicious of new arrangements perceived to emphasise technical efficiency. Health and care services were described as inter-linked with other aspects of rural living, including transport and housing (which might have to be relinquished to pay for care). Proximity to family was desired for social and domestic support only; health and related support should be from generic service providers. Community members were involved in reciprocal help-giving of many types. Conclusion: The findings compare with results of other studies of older rural people internationally, and generic 'principles' of service derived could guide restructuring. There may be systemic challenges to empowering older people's 'voice' in designing sustainable rural services that stem from society's views of older people, attitudes of communities to collective roles and responsibilities, and the fragmented ways that services are sometimes provided. [ABSTRACT FROM AUTHOR]

Abstract: Genomics or the interaction of one''s genes and the environment is changing our concept of health and disease, available therapies, use of genetic testing, and related societal ramifications. As genomics integrates into all aspects of health care, the demand will increase for meaningful interpretation and application of the new genetic information. To meet this demand, new service delivery models must be considered. Nurse practitioners and genetic counselors are midlevel providers that can, together, provide clinical evaluation, case management, follow-up, and the genetic counseling aspects of a comprehensive medical genetics consultation. Midlevel providers working with a medical geneticist can expand access to this level of expertise, thereby reaching more patients and consumers. This nurse practitioner–genetic counselor practice model is described in the context of a rural setting. [Copyright &y& Elsevier]

Purpose: To investigate the perceived health care needs, foregone care, barriers to care, and associated risk factors in a non-urban population of adolescents.Methods: Tenth-grade students attending school and 15–17-year-old youth not attending school in a Midwestern county were surveyed or interviewed. Eighty-six percent provided usable data (n = 1948, 134 of whom were not in school). Nine focus groups (71 participants; 28 were not in school) were conducted in follow-up. Quantitative analysis included descriptive statistics, factor analysis, and logistic regression. Qualitative analysis of taped focus groups identified themes and interpreted findings.Results: Although 91% had seen a physician in the past 2 years, 44% reported foregoing needed care in the last year. Barriers for specific health needs were: cost of care and lack of insurance coverage for injuries and illnesses; lack of knowledge, distrust, and stigma for depression; embarrassment and transportation for birth control and sexually transmitted infections (STIs); and not knowing where or how to access care for drug and alcohol use. Youth most likely to have foregone care included those involved with dangerous activities under peer pressure (1.8, CI: 1.44–2.13), sexual intercourse (1.4, CI: 1.25–1.67), marijuana use (1.4, CI: 1.17–1.67), anticipating parenthood before age 20 years (1.2, CI: 1.04–1.33), male gender (2.5, CI: 1.89–2.86) and perceiving good health (1.7, CI: 1.45–1.85).Conclusions: Nearly half of this non-urban population (both in and out of school) reported foregoing needed care in the last year. The barriers to care include lack of information, lack of access, poor insurance coverage, parenting issues, and concern about confidentiality. [Copyright &y& Elsevier]

Drawing on chaos and complexity theories, we apply the concept of "strategy as simple rules" to analyze the success of one rural health clinic. We document how such rules may emerge as success is viewed retrospectively. We describe four simple rules that emerged in this setting and explicate how our case analysis may assist other rural providers. [ABSTRACT FROM AUTHOR]

Background: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients.Objective: The aim was to test the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas.Methods: In a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial, physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n=111) or to usual care (n=139). The remote collaborative care program used Web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the Web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment.Results: Six-month follow-up assessments were completed by 84.4% (221/250) of patients. The remote collaborative care program achieved higher user satisfaction (odds ratio [OR] 1.94, 95% CI 1.25-3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02-3.19) at 6 months compared to usual care. There were no statically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of remote collaborative care program were observed at 3 months for mental health-related quality of life (beta 3.11, 95% CI 0.19-6.02).Conclusions: Higher rates of treatment adherence in the remote collaborative care program suggest that technology-assisted interventions may help rural primary care teams in the management of depressive patients. Future cost-effectiveness studies are needed.Trial Registration: Clinicaltrials.gov NCT02200367; https://clinicaltrials.gov/ct2/show/NCT02200367 (Archived by WebCite at http://www.webcitation.org/6xtZ7OijZ). [ABSTRACT FROM AUTHOR]

Background: Kidney disease is a significant burden on health systems globally, with the rising prevalence of end stage kidney disease in Australia mirrored in many other countries. Approximately 25% of the Australian population lives in regional and rural areas and accessing complex tertiary services is challenging. Objective: We aim to compare the burden and outcomes of chronic kidney disease and end stage kidney disease in rural and urban regions of New South Wales (Australia's most populous state) using linked health data. Methods: This is a retrospective cohort study and we have defined two cohorts: one with end stage kidney disease and one with chronic kidney disease. The end stage kidney disease cohort was defined using the Australia and New Zealand Dialysis and Transplant Registry, identifying all patients living in NSW receiving renal replacement therapy at any time between 01/07/2000 and 31/07/2010. The chronic kidney disease cohort used the NSW Admitted Patient Data Collection (APDC) to identify patients with a diagnostic code relating to chronic renal failure during any admission between 01/07/2000 and 31/07/2010. Both cohorts were linked to the NSW APDC, the Registry of Births, Deaths and Marriages, and the Central Cancer Registry allowing derivation of outcomes by categories of geographical remoteness. Results: To date, we have identified 10,505 patients with 2,384,218 records in the end stage kidney disease cohort and 159,033 patients with 1,599,770 records in the chronic kidney disease cohort. Conclusions: This study will define the geographical distribution of end stage and chronic kidney disease and compare the health service utilization between rural and urban renal populations. [ABSTRACT FROM AUTHOR]