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Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. This article focuses on the health worker survey. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion of staff favouring emigration, their high tolerance of informal user payments, as well as their limited exposure to rural areas during training. Based on our findings, we highlight measures which could improve rural recruitment and retention in Guinea and similar settings. These include offering upgrading and specialization in return for rural service; providing greater exposure to rural areas during training; increasing recruitment from rural areas; experimenting with fixed term contracts in rural areas; and improving working conditions in rural posts. The development of incentive packages should be accompanied by action to tackle wider issues, such as reforms to training and staff management., Competing Interests: This study was funded by a grant from the World Bank. The grant provided support in the form of salaries for the authors, including authors directly employed by the World Bank, and the larger study team, and also funded all field work related expenses. Aside from funding individuals involved in the study, the grant was also used to hire Oxford Policy Management, an international development consulting firm, to support overall study design, data collection and analysis. The specific roles of all authors are articulated in the ‘author contributions’ section Affiliation with the World Bank, Oxford Policy Management, or any other entity involved in the study, does not alter our adherence to PLOS ONE policies in sharing data and materials Please note that the findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or accep¬tance of such boundaries’.

Background: Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care., Purpose: We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce., Method: Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs., Findings: Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs., Discussion: We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery., Study Design: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression., Results: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days., Conclusions: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is a growing deficit of rural surgeons, and preparation to meet this need is inadequate. More research into stratifying factors that specifically influence choice in rural versus urban practice is needed., Methods: An institutional review board-approved survey related to factors influencing rural practice selection and increasing rural recruitment was distributed through the American College of Surgeons. The results were analyzed descriptively and thematically., Results: Of 416 respondents (74% male), 287 (69%) had previous rural experience. Of those, 71 (25%) did not choose rural practice; lack of professional or hospital support (30%) and lifestyle (26%) were the primary reasons. A broad scope of practice was most important among surgeons (52%), who chose rural practice without any previous rural experience. Over 60% of urban practitioners agreed that improved lifestyle and financial advantages would attract them to rural practice. The thematic analysis suggested institutional support, affiliation with academic institutions, and less focus on subspecialty fellowship could help increase the number of rural surgeons., Conclusions: Many factors influence surgeons' decisions on practice location. Providing appropriate hospital support in rural areas and promoting specific aspects of rural practice, including broad scope of practice to those in training could help grow interest in rural surgery. Strong collaboration with academic institutions for teaching, learning, and mentoring opportunities for rural surgeons could also lead to higher satisfaction, security, and potentially higher retention rate. These results provide a foundation to help focus specific efforts and resources in the recruitment and retention of rural surgeons., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Several definitive treatment options are available for prostate cancer, but geographic access to those options is not uniform. We created maps illustrating provider practice patterns relation to patients and assessed the influence of distance to treatment receipt., Methods and Materials: The patient cohort was created by searching the National Medicare Database for patients diagnosed and treated for prostate cancer from 2011 to 2014. The provider cohort was created by querying the American Medical Association Physician Masterfile to identify physicians who had treated patients with prostatectomy, intensity modulated radiation therapy (IMRT), brachytherapy, stereotactic body radiation therapy (SBRT), or proton therapy. Maps detailing the location of providers were created for each modality. Multivariate multinomial logistic regressions were used to assess the association between patient-provider distance and probability of treatment., Results: Cohorts consisted of 89,902 patients treated by 5518 physicians. Substantial numbers of providers practicing established modalities (IMRT, prostatectomy, and brachytherapy) were noted in major urban centers, whereas provider numbers were reduced in rural areas, most notably for brachytherapy. Ninety percent of prostate cancer patients lived within 35.1, 28.9, and 55.6 miles of a practitioner of prostatectomy, IMRT, and brachytherapy, respectively. Practitioners of emerging modalities (SBRT and proton therapy) were predominantly concentrated in urban locations, with 90% of patients living within 128 miles (SBRT) and 374.5 miles (proton). Greater distance was associated with decreased probability of treatment (IMRT -3.8% per 10 miles; prostatectomy -2.1%; brachytherapy -2%; proton therapy -1.6%; and SBRT -1.1%)., Conclusions: Geographic disparities were noted for analyzed treatment modalities, and these disparities influenced delivery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: In certain regions of the United States, there has been a dramatic proliferation of trauma centers. The goal of our study was to evaluate transport times during this period of trauma center proliferation., Methods: Aggregated data summarizing level I trauma center admissions in Arizona between 2009 and 2018 were provided to our institution by the Arizona Department of Health Services. We evaluated patient demographics, transport times, and injury severity for both rural and urban injuries., Results: Data included statistics summarizing 266,605 level I trauma admissions in the state of Arizona. The number of state-designated trauma centers during this time increased from 14 to 47, with level I centers increasing from 8 to 13. Slight decreases in mean Injury Severity Score (rural, 9.4 vs. 8.4; urban, 7.9 vs. 7.0) were observed over this period. Median transport time for cases transported from the injury scene directly to a level I center remained stable in urban areas at 0.9 hours in both 2009 and 2018. In rural areas, transport times for these cases were approximately double but also stable, with median times of 1.8 and 1.9 hours. Transport times for cases requiring interfacility transfer before admission at a level I center increased by 0.3 hours for urban injuries (5.3-5.6 hours) and 0.9 hours for rural injuries (5.6-6.5 hours)., Conclusion: Despite the threefold increase in the number of state-designated trauma centers, transport time has not decreased in urban or rural areas. This finding highlights the need for regulatory oversight regarding the number and geographic placement of state-designated trauma centers., Level of Evidence: Care management, level IV, Epidemiological, level III., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Physician shortages and maldistribution, particularly within family medicine, have led many medical schools worldwide to create regional medical campuses (RMCs) for clerkship training. However, Canadian medical schools have developed a number of RMCs in which all years of training (i.e., a combined model that includes both preclerkship and clinical training) are provided geographically separate from the main campus. This study addresses the question: Are combined model RMC graduates more likely to enter postgraduate training in family medicine and rural-focused programs relative to main campus graduates?, Method: The authors used a quasi-experimental research design and analyzed 2006-2016 data from the Canadian Resident Matching Service (CaRMS). Graduating students (N = 26,525) from 16 Canadian medical schools who applied for the CaRMS match in their year of medical school graduation were eligible for inclusion. The proportions of graduates who matched to postgraduate training in (1) family medicine and (2) rural-focused programs were compared for combined model RMCs and main campuses., Results: Of RMC graduates, 48.4% matched to family medicine (95% confidence interval [CI] = 46.1-50.7) compared with 37.1% of main campus graduates (95% CI = 36.5-37.7; P < .001). Of RMC graduates, 23.9% matched to rural-focused training programs (95% CI = 21.8-25.9) compared with 10.4% of main campus graduates (95% CI = 10.0-10.8; P < .001). Subanalyses ruled out a variety of potentially confounding variables., Conclusions: Combined model RMCs, in which all years of training take place away from the medical school's main campus, are associated with greater proportions of medical students entering family medicine postgraduate training and rural-focused training programs. These findings should encourage policymakers, health services agencies, and medical schools to continue seeking complements to academic medical center-based medical education., (Copyright © 2020 by the Association of American Medical Colleges.)

Objectives: Almost 15% of all US births occur in rural hospitals, yet rural hospitals are closing at an alarming rate because of shortages of delivering clinicians, nurses, and anesthesia support. We describe maternity staffing patterns in successful rural hospitals across North Carolina., Methods: All of the hospitals in the state with ≤200 beds and active maternity units were surveyed. Hospitals were categorized into three sizes: critical access hospitals (CAHs) had ≤25 acute staffed hospital beds, small rural hospitals had ≤100 beds without being defined as CAHs, and intermediate rural hospitals had 101 to 200 beds. Qualitative data were collected at a selection of study hospitals during site visits. Eighteen hospitals were surveyed. Site visits were completed at 8 of the surveyed hospitals., Results: Nurses in CAHs were more likely to float to other units when Labor and Delivery did not have patients and nursing management was more likely to assist on Labor and Delivery when patient census was high. Anesthesia staffing patterns varied but certified nurse anesthetists were highly used. CAHs were almost twice as likely to accept patients choosing a trial of labor after cesarean section (CS) than larger hospitals, but CS rates were similar across all hospital types. Hospitals with only obstetricians as delivering providers had the highest CS rate (32%). The types of hospitals with the lowest CS rates were the hospitals with only family physicians (24%) or high proportions of certified nurse midwives (22%)., Conclusions: Innovative staffing models, including family physicians, nurse midwives, and nurse anesthetists, are critical for the survival of rural hospitals that provide vital maternity services in underserved areas.

Background: The World Health Organization (WHO) launched a guideline in 2015 for managing Possible Serious Bacterial Infection (PSBI) when referral is not feasible in young infants aged 0-59 days. This guideline was implemented across 303 Basic Health Unit (BHU) Plus primary health care (PHC) facilities in peri-urban and rural settings of Sindh, Pakistan. We evaluated the implementation of PSBI guideline, and the quality of care provided to sick young infants at these facilities., Methods: Thirty (10%) out of 303 BHU Plus facilities were randomly selected for evaluation. A survey team visited each facility for one day, assessed the health system support, observed the management of sick young infants by health care providers (HCP), validated their management, interviewed HCPs and caretakers of sick infants. HCPs who were unable to see a young infant on the day of survey were evaluated using pre-prepared case scenarios., Results: Thirty (100%) BHU Plus facilities had oral amoxicillin, injectable gentamicin, thermometers, baby weighing scales and respiratory timers available; 29 (97%) had disposable syringes and needles; 28 (93%) had integrated management of childhood illness (IMCI)/PSBI chart booklets and job aids and 18 (60%) had a functional ambulance. Each facility had at least one HCP trained in PSBI, and 21 (70%) facilities had been visited by a supervisor in the preceding six months. Of 42 HCPs, 19 (45.3%) were trained within the preceding 12 months. During the survey, 26 sick young infants were identified in 18 facilities. HCPs asked about history of breastfeeding in 23 (89%) infants, history of vomiting in 17 (65%), and history of convulsions in 14 (54%); weighed 25 (97%) infants; measured respiratory rate in all (100%) and temperature in 24 (92%); assessed 20 (77%) for movement and 14 (54%) for chest indrawing. HCPs identified two infants with fast breathing pneumonia and managed them correctly per IMCI/PSBI protocol. HCPs identified six (23%) infants with clinical severe infection (CSI), two of them were referred to a higher-level facility, only one accepted the referral advice. Only one CSI patient was managed correctly per IMCI/PSBI protocol at the outpatient level. HCPs described the PSBI danger signs to eight (31%) caretakers. Caretakers of five infants with CSI and two with pneumonia were not counselled for PSBI danger signs. Five of the six CSI cases categorized by HCPs were validated as CSI on re-examination, whereas one had pneumonia. Similarly, one of the two pneumonia patients categorized by HCPs had CSI and one identified as local bacterial infection was classified as CSI upon re-examination., Conclusion: Health system support was adequate but clinical management and counselling by HCPs was sub-optimal particularly with CSI cases who are at higher risk of adverse outcomes. Scaling up PSBI management is potentially feasible in PHC facilities in Pakistan, provided that HCPs are trained well and mentored, receive refresher training to appropriately manage sick young infants, and have adequate supplies and counselling skills., Competing Interests: The study hired independent consultant ZQ for development of methods by Aga Khan University, Pakistan has no other commercial affiliation or role in the study. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: There is a great need for primary care across the country especially in rural and underserved areas. Nurse practitioners (NPs) are filling these access gaps by providing high-quality, cost-effective primary care. However, one rural midwestern state does not address NP workforce data separately from other types of nursing data. In addition, these data are not included in the state's overall primary care workforce. Therefore, the data cannot be compared to the state's needs or national workforce trends., Purpose: The purpose of this investigation was to describe North Dakota's (NDs) NP workforce and compare this with national data., Methods: A cross-sectional descriptive design was used to collect and analyze NP workforce data from several sources. State Board of Nursing licensure data were used for description of the NDs current NP workforce. Six other data sources or reports were used to complete the data picture. State information was then compared with national NP survey results., Results: Both ND and national data sources reported the largest percentage of NPs certified in either primary care or adult care and practice primary care at either an outpatient or inpatient setting. North Dakota has a higher percentage of NPs working in primary care as compared with the national numbers. However, inconsistent categories are used in ND's NP workforce data and national surveys making comparisons difficult., Implications for Practice: Accurate inclusion of NP workforce data in the overall health care workforce data will better guide state and national policy makers on necessary changes to decrease provider shortages and promote increased access to rural primary care services.

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas., Study Design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas., Data Sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature., Data Synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle-Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12-3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48-2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80-7.46; eight studies)., Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce., Protocol Registration: PROSPERO, CRD42017074943 (updated 1 February 2018)., (© 2020 AMPCo Pty Ltd.)

Purpose: There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders. Building the workforce for this population is a national priority. We investigated the feasibility of regular systematic case reviews through telepsychiatric consultation, within collaborative care for depression, as a continuous training and workforce development strategy in rural clinics., Methods: We developed and pilot-tested a qualitative interview guide based on a conceptual model of training and learning. We conducted individual semistructured interviews in 2018 with diverse clinical and nonclinical staff at 3 rural primary care sites in Washington state that used ongoing collaborative care and telepsychiatric consultation. Two qualitative researchers independently analyzed transcripts with iterative input from other research team members., Results: A total of 17 clinical, support, and administrative staff completed interviews. Participants' feedback supported the view that telepsychiatric case review-based consultation enhanced skills of diverse clinical team members over time, even those who had not directly participated in case reviews. All interviewees identified specific ways in which the consultations improved their capacity to identify and treat psychiatric disorders. Perceived benefits in implementation and sustainability included fidelity of the care process, team resilience despite member turnover, and enhanced capacity to use quality improvement methods., Conclusions: Weekly systematic case reviews using telepsychiatric consultation served both as a model for patient care and as a training and workforce development strategy in rural primary care sites delivering collaborative care. These are important benefits to consider in implementing the collaborative care model of behavioral health integration., (© 2020 Annals of Family Medicine, Inc.)

Introduction: The allied health workforce is one of the largest workforces in the health industry. It has a critical role in cost-effective, preventative health care, but it is poorly accessible in rural areas worldwide. This review aimed to inform policy and research priorities for increasing access to rural allied health services in Australia by describing the extent, range and nature of evidence about this workforce., Methods: A scoping review of published, peer-reviewed rural allied health literature from Australia, Canada, the USA, New Zealand and Japan was obtained from six databases (February 1999 - February 2019)., Results: Of 7305 no-duplicate articles, 120 published studies were included: 19 literature reviews, and 101 empirical studies from Australia (n=90), Canada (n=8), USA (n=2) and New Zealand (n=1). Main themes were workforce and scope (n=9), rural pathways (n=44), recruitment and retention (n=31), and models of service (n=36). Of the empirical studies, 83% per cent were cross-sectional; 64% involved surveys; only 7% were at a national scale. Rural providers were shown to have a breadth of practice, servicing large catchments with high patient loads, requiring rural-specific skills. Most rural practitioners had rural backgrounds, but rural youth faced barriers to accessing allied health courses. Rural training opportunities have increased in Australia but predominantly as short-term placements. Rural placements were associated with increased likelihood of rural work by graduates compared with discipline averages, and high quality placement experiences were linked with return. Recruitment and retention factors may vary by discipline, sector and life stage but important factors were satisfying jobs, workplace supervision, higher employment grade, sustainable workload, professional development and rural career options. Patient-centred planning and regional coordination of public and private providers with clear eligibility and referral to pathways facilitated patient care. Outreach and telehealth models may improve service distribution although require strong local coordination and training for distal staff., Conclusion: Evidence suggests that more accessible rural allied health services in Australia should address three key policy areas. First, improving rural jobs with access to senior workplace supervision and career options will help to improve networks of critical mass. Second, training skilled and qualified workers through more continuous, high quality rural pathways is needed to deliver a complementary workforce for the community. Third, distribution depends on networked service models at the regional level, with viable remuneration, outreach and telehealth for practice in smaller communities. More national-scale, longitudinal, outcomes-focused studies are needed using controlled designs.

Introduction: To address regional differences in the distribution of health workers between rural and urban areas, the Nepal government has adopted the policy of deploying fresh medical graduates to remote areas for 2 years under a compulsory bonding service program. However, the impact of such an approach of redistribution of human resources for health is not well understood, nor is the experience of the health workers who are deployed. This study aimed to understand the experience of the medical graduates who have served under the bonding service program and suggest ways to improve the program as well as to make health service provision easier through the young doctors., Methods: A semi-structured questionnaire-based survey was administered online to 69 young medical doctors who had worked under the bonding service program. The responses were analysed qualitatively and the findings were presented in separate pre-established domains., Results: Most young doctors felt they were not adequately prepared for the bonding service program. Adapting to the deployed place and to the local culture was a challenge to some young doctors, which hindered their potential to serve the local community. Most found the response from the rural communities to be positive even though they faced some challenges in the beginning. While the young doctors found serving the rural communities motivating, they felt that they were limited in their capacity to provide an optimal level of health service due to limitations of infrastructure and medical equipment. They also felt that the compulsory bonding program had stunted their growth potential as medical doctors without adequately compensating them for their time and service., Conclusion: Despite the program's noble intentions, the medical doctors who were involved with the bonding service program felt that the program had yet to address several basic needs of the doctors who were deployed for service provision. In order to motivate the doctors to work in rural areas in future after the compulsory binding has ended, the stakeholders need to address the existing gaps in policies and infrastructure.

Background and objectives: Having fair access to medical services may probably be a standard feature and indisputable right of all health policies. The health policy of Iran enunciates this right. Unfortunately, as may happen in many countries, the execution of this policy depends on different factors. Among these parameters, the suitable distribution of professionals, hospitals, and medical facilities should be quoted. On the other hand, in Iran, there are many other problems linked to accessing areas with natural hindrances. Materials and m ethods: A literature search was conducted in PubMed and CINAHL libraries, specifically studies from 2010 to 2019. A Boolean operated medical subject headings (MeSH) term was used for the search. Newcastle-Ottawa Scale (NOS) scoring was adopted to assess the quality of each study. Results: A total of 118 studies were displayed, and among them, 102 were excluded due to duplication and study relevance. Study selection was made based on content classified into two groups: (1) shortage and unsuitable distribution of specialist and subspecialist physicians in Iran and (2) studies that explained the status of degradation in different areas of Iran. Outcomes demonstrated that Iran is generally suffering a shortage and unsuitable distribution of specialists and subspecialists. This lack is particularly crucial in deprived and areas far away from the cities. Conclusions: The present study analyzed in detail research studies regarding policies and challenges that reflect on the provision of specialists and subspecialists in Iranian rural areas.

People living in rural and remote areas have poorer ocular health outcomes compared with those living in metropolitan areas. Reasons for this are multiple and complex but access to care is consistently reported as a defining factor. The geographic maldistribution of eye-care professionals is a major obstacle for regional, rural and remote Australians seeking care. Research from the medical profession suggests adopting the 'rural pipeline' concept to address the issue of maldistribution. This approach appears to have had some success in medicine, and involves recruiting students from a rural background, exposing students to rural practice through placements and offering graduates incentives and support to practice rurally. Lessons could be learnt from the medical field as there is a dearth of literature describing the utilisation of the rural pipeline in allied health. However, given the differences between professions it cannot be assumed factors and results will be the same. A greater understanding is required to determine whether optometry is a profession which may benefit from the rural pipeline concept., (© 2019 Optometry Australia.)

Background: Trauma is a major cause of death and disability in the United States, and significant disparities exist in access to care, especially in non-urban settings. From 2007 to 2017 New Mexico expanded its trauma system by focusing on building capacity at the hospital level., Methods: We conducted a geospatial analysis at the census block level of access to a trauma center in New Mexico within 1 h by ground or air transportation for the years 2007 and 2017. We then examined the characteristics of the population with access to care. A multiple logistic regression model assessed for remaining disparities in access to trauma centers in 2017., Results: The proportion of the population in New Mexico with access to a trauma center within 1 h increased from 73.8% in 2007 to 94.8% in 2017. The largest increases in access to trauma care within 1 h were found among American Indian/Alaska Native populations (AI/AN) (35.2%) and people living in suburban areas (62.9%). In 2017, the most rural communities (aOR 58.0), communities on an AI/AN reservation (aOR 25.6), communities with a high proportion of Hispanic/Latino persons (aOR 8.4), and a high proportion of elderly persons (aOR 3.2) were more likely to lack access to a trauma center within 1 h., Conclusion: The New Mexico trauma system expansion significantly increased access to trauma care within 1 h for most of New Mexico, but some notable disparities remain. Barriers persist for very rural parts of the state and for its sizable American Indian community., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?', Design: Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines., Setting: Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016., Main Outcome Measures: Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context., Results: Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'., Conclusions: Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Uganda has one of the highest age-standardized incidence rates of cervical cancer in the world. The proportion of Ugandan women screened for cervical cancer is low. To evaluate barriers and facilitators to accessing cervical cancer screening, we performed a systematic review of reported views of Ugandan women and healthcare workers. The aim of this review is to inform development of cervical cancer screening promotional and educational programs to increase screening uptake and improve timely diagnosis for women with symptoms of cervical cancer., Methods: Fourteen studies that included the views of 4386 women and 350 healthcare workers published between 2006 and 2019 were included. Data were abstracted by two reviewers and findings collated by study characteristics, study quality, and barriers and facilitators., Results: Nineteen barriers and twenty-one facilitators were identified. Study settings included all districts of Uganda, and the quality of included studies was variable. The most frequently reported barriers were embarrassment, fear of the screening procedure or outcome, residing in a remote or rural area, and limited resources / health infrastructure. The most frequent facilitator was having a recommendation to attend screening., Conclusion: Understanding the barriers and facilitators to cervical cancer screening encountered by Ugandan women can guide efforts to increase screening rates in this population. Additional studies with improved validity and reliability are needed to produce reliable data so that efforts to remove barriers and enhance facilitators are well informed.

Background: Australians living in rural and remote areas have access to considerably fewer doctors compared with populations in major cities. Despite plentiful, descriptive data about what attracts and retains doctors to rural practice, more evidence is needed which informs actions to address these issues, particularly in remote areas. This study aimed to explore the factors influencing General Practitioners (GPs), primary care doctors, and those training to become GPs (registrars) to work and train in remote underserved towns to inform the building of primary care training capacity in areas needing more primary care services (and GP training opportunities) to support their population's health needs., Methods: A qualitative approach was adopted involving a series of 39 semi-structured interviews of a purposeful sample of 14 registrars, 12 supervisors, and 13 practice managers. Fifteen Australian Medical Graduates (AMG) and eleven International Medical Graduates (IMG), who did their basic medical training in another country, were among the interviewees. Data underwent thematic analysis., Results: Four main themes were identified including 1) supervised learning in underserved communities, 2) impact of working in small, remote contexts, 3) work-life balance, and 4) fostering sustainable remote practice. Overall, the findings suggested that remote GP training provides extensive and safe registrar learning opportunities and supervision is generally of high quality. Supervisors also expressed a desire for more upskilling and professional development to support their retention in the community as they reach mid-career. Registrars enjoyed the challenge of remote medical practice with opportunities to work at the top of their scope of practice with excellent clinical role models, and in a setting where they can make a difference. Remote underserved communities contribute to attracting and retaining their GP workforce by integrating registrars and supervisors into the local community and ensuring sustainable work-life practice models for their doctors., Conclusions: This study provides important new evidence to support development of high-quality GP training and supervision in remote contexts where there is a need for more GPs to provide primary care services for the population.

Introduction: Previous studies show that supply of behavioral health professionals in rural areas is inadequate to meet the need. Measuring shortage using licensure data on psychiatrists is a common approach. Although inexpensive, the licensure data have many limitations. An alternative is to implement an active surveillance system, which uses licensure data in addition to active data collection to obtain timely and detailed information., Methods: Nebraska Health Professions Tracking Service (HPTS) data were used to examine differences in workforce supply estimates between the passive (licensure data only) and active (HPTS data) surveillance systems. The impact of these differences on the designation of psychiatric professional shortage areas has been described. Information regarding the number of psychiatrists, advanced practice registered nurses and physician assistants specializing in psychiatry was not available from the licensure database, unlike HPTS., Results: Using licensure data versus HPTS data to estimate workforce, the counts of professionals actively practicing in psychiatry and behavioral health were overestimated by 24.1-57.1%. Ignoring work status, the workforce was overestimated by 10.0-17.4%. Providers spent 54-78% of time seeing patients. Based on primary practice location, 87% of counties did not have a psychiatrist and 9.6% were at or above the Health Professional Shortage Area designation ratio of psychiatrists to population., Conclusion: Enumeration methods such as ongoing surveillance, in addition to licensure data, curtails the issues and improves identification of shortage areas and future behavioral workforce related planning and implementation strategies.

Background: Ambulance services play a crucial role in providing pre-hospital emergency care. In order to ensure quick responses, the location of the bases, and the distribution of available ambulances among these bases, should be optimized. In mixed urban-rural areas, this optimization typically involves a trade-off between backup coverage in high-demand urban areas and single coverage in rural low-demand areas. The aim of this study was to find the optimal distribution of bases and ambulances in the Vestfold region of Norway in order to optimize ambulance coverage., Method: The optimal location of bases and distribution of ambulances was estimated using the Maximum Expected Covering Location Model. A wide range of parameter settings were fitted, with the number of ambulances ranging from 1 to 15, and an average ambulance utilization of 0, 15, 35 and 50%, corresponding to the empirical numbers for night, afternoon and day, respectively. We performed the analysis both conditioned on the current base structure, and in a fully greenfield scenario., Results: Four of the five current bases are located close to the mathematical optimum, with the exception of the northernmost base, in the rural part of the region. Moving this base, along with minor changes to the location of the four other bases, coverage can be increased from 93.46% to 97.51%. While the location of the bases is insensitive to the workload of the system, the distribution of the ambulances is not. The northernmost base should only be used if enough ambulances are available, and this required minimum number increases significantly with increasing system workload., Conclusion: As the load of the system increases, focus of the model shifts from providing single coverage in low-demand areas to backup coverage in high-demand areas. The classification rule for urban and rural areas significantly affects results and must be evaluated accordingly., Competing Interests: The authors have declared that no competing interests exist.

Mental illness is a leading cause of disability with many public health implications. Previous studies have demonstrated a national shortage of psychiatrists, particularly in rural areas. An analysis of how this workforce distribution relates to population demographics and public/behavioral health is lacking in the literature. This study encompassed a statewide assessment of the Indiana psychiatric workforce as it relates to population characteristics and public/behavioral health. This study's findings demonstrate a profoundly low psychiatry workforce in rural counties of Indiana. The low psychiatry workforce capacity in rural counties is so disparate that the demographic and public/behavioral health characteristics differ from the State averages in the same manner as counties without a psychiatrist at all. The psychiatric workforce distribution did not differ significantly on the basis of poverty prevalence. The potential utility of indicators of population health was also evaluated and revealed that social factors such as poverty and Medicaid prevalence may be superior to more traditional measures.

Background: Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators., Material and Methods: Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care., Results: One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%)., Conclusions: This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India., Competing Interests: The authors have no competing interests to declare., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Introduction: Several supply chain components are important to sustain point-of-care (POC) testing services in rural settings. To evaluate the availability of POC diagnostic tests in rural Ghana's primary healthcare (PHC) clinics, we conducted an audit of the supply chain management for POC diagnostic services in rural Upper East Region's (UER) PHC clinics, Ghana to determine the reasons/causes of POC tests deficiencies., Material and Methods: We conducted a review of accessible POC diagnostics in 100 PHC clinics in UER, Ghana from February to March 2018. We used a monitoring audit tool adopted from the World Health Organization and Management Science for Health guidelines for supply chain management of diagnostics for compliance. We determined a clinic's compliance with the stipulated guidelines, and a composite compliant score was defined as a percentage rating of 90 to 100%. We used univariate logistic regression analysis in Stata 14 to determine the level of association between supply chain management and the audit variables., Results: Overall, the composite compliant score of supply chain management for existing POC tests was at 81% (95%CI: 79%-82%). The mean compliance with distribution guidelines was at 93.8% (95%CI: 91.9%-95.6%) the highest score, whilst inventory management scored the lowest, at 53.5% (95%CI: 49.5%-57.5%) compliance. Of the 13 districts in the region, the results showed complete stock-out of blood glucose test in all selected PHC clinics in seven (53.8%) districts, haemoglobin and hepatitis B virus test in three (23.1%), and urine protein test in two (15.4%) districts. Based on our univariate logistics regression models, stock-out of tests at the Regional Medical and District Health Directorates stores in the region, high clinic attendance, lack of documentation of expiry date/expired tests, poor documentation of inventory level, poor monitoring of monthly consumption level, and failure to document unexplained losses of the various POC tests were significant predictors of complete test stock-out in most of the clinics in the Upper East Region., Discussion: There is poor supply chain management of POC diagnostic tests in UER's PHC clinics. Improvement in inventory management and human resource capacity for POC testing is critical to ensure accessibility and sustainability of POC diagnostic services in resource-limited settings PHC clinics., Competing Interests: The authors have declared that no competing interests exist.

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.

Background: Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers' views on privacy and satisfaction with quality of care were also assessed., Methods: The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes., Results: The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women's satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges., Conclusion: Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage.

Texas Tech&#39;s rural residency program is one of several across the United States that encourage physician training in rural areas to bring more physicians to small towns.

Despite poverty reduction and increased promotion of improved nutrition practices in the community, undernutrition in Ethiopia remains a concern. The present study aimed to explore the demand and supply side barriers that limit the uptake of nutrition services among pregnant women from the rural communities of the Tigray Region, Northern Ethiopia. A community-based qualitative study was conducted in December through January 2017. A total of 90 key informant in-depth interviews and 14 focus group discussions were undertaken. Study participants were purposively selected for specific characteristics, along with health professionals deployed at various levels of the health system, including health posts, health centers, woreda health offices, and the regional health bureau. Study participants were asked to identify the barriers and implementation challenges that limit access to nutrition services for pregnant women. Participants' responses were transcribed verbatim, without editing the grammar, to avoid losing meaning. The data were imported to ATLAS.ti 7 (qualitative data analysis software) for coding and analyzed using a thematic content analysis approach. The study findings indicated that the dietary quality of pregnant women in the study area remains poor and in some cases, poorer quality than pre-pregnancy. Across study sites, heavy workloads, food taboos and avoidances, low husband support, lack of economic resources, lack of awareness, low educational level of women, poor dietary habits, increased expenditure for cultural and religious festivities, "dependency syndrome", low physical access to health facilities, poorly equipped health facilities, focus on child health and nutrition, poor coordination among nutrition specific and sensitive sectors, and limited sources of nutrition information were identified as the demand and supply side barriers limiting the uptake of nutrition services during pregnancy. In conclusion, the community would benefit from improved social behavior change communication on nutrition during pregnancy and multi-sectoral coordination among nutrition-specific and nutrition-sensitive sectors., Competing Interests: The authors declare that they have no competing interests.

Background: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients., Methods: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015)., Results: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After., Conclusions: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome., Level of Evidence: Epidemiological, level III.

Objective: To propose a framework for examining both the spatial equity and sustainability of GP services., Design: A conceptual discussion based on a systematic literature review of spatial equity definitions and methods., Setting: Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintain equitable services into the future. The GP services are a key component of primary health care, which often aims to promote health equity. Despite the importance of spatially equitable and sustainable GP services, a framework for analysis has not yet been established., Main Outcome Measure: Examples of how the proposed framework could be implemented are provided from the New Zealand health care context., Result: The framework entails three steps: (i) defining spatial equity and sustainability; (ii) estimating current and future distributions of health services and needs; and (iii) quantifying spatial equity and sustainability. In step (i), a needs-based distribution is the most common definition of spatial equity, while sustainability is the ability to provide ongoing equitable access. Step (ii) depends on current and future estimates of access and need within a well-defined geographical area. In step (iii), spatial equity and sustainability should be quantified through measures, such as the Gini coefficient. Current and future levels of spatial equity should then be compared to assess the sustainability of equitable GP services., Conclusion: This article outlines a novel conceptual framework for examining the spatial equitability and sustainability of GP services., (© 2018 National Rural Health Alliance Ltd.)

Background: Mongolia is a country characterized by its vast distances and extreme climate. An underdeveloped medical transport infrastructure makes patient transfer from outlying regions dangerous. Providing pediatric surgical care locally is crucial to improve the lives of children in the countryside. This is the first structured assessment of nationwide pediatric surgical capacity., Methods: Operation rates were calculated using data from the Mongolian Center for Health Development and population data from the Mongolian Statistical Information Service. The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey tool was used to collect data at all survey sites. Descriptive data analyses were completed using Excel. Studies of association were completed using Stata. All reported percentages are of the hospitals outside of the capital (n = 21)., Results: All provincial hospitals have general surgeons; seven (33.3%) of them have pediatric surgeon(s). One facility has no anesthesiologist. All facilities perform basic procedures and provide anesthesia. Four (19%) can treat common congenital anomalies. All facilities have basic operating room equipment. Nine hospitals do not have pulse oximetry available. Twelve hospitals do not have pediatric surgical instruments always available. Pediatric supplies are lacking., Conclusions: Provincial hospitals in Mongolia can perform basic procedures. However, essential pediatric supplies are lacking. Consequently, certain life-saving procedures are not available to children outside of the capital. Only a few improvements would be amendable to low-cost process improvement adjustment, and the majority of needs require resource additions. Procedure, equipment, and supply availability should be further explored to develop a comprehensive nationwide pediatric surgical program.

Introduction: Many countries face the need to address medical resource shortages following various disasters. The dzud is a winter disaster that occurs in Mongolia following drought in dryland areas, and it leads to high livestock mortality. Affected provinces suffer increased mortality rates for children aged under 5 years. Using various factors, including medical resources, the present study aimed to evaluate the health risks for children during the dzud., Methods: Data from all of Mongolia's 21 provinces and the capital of Ulaanbaatar were analyzed. The change in child mortality (CCM) was defined as the difference in the under-five mortality rate from 2009 to 2010. To determine the correlations, the CCM was compared with the urbanization rate (proportion of urban population), number of physicians and nurses (per 1000 residents), average temperature, total precipitation (October 2009 to February 2010), and declining rate in livestock numbers for 2009-10 (percentage livestock loss) in each province., Results: The correlation coefficients between the CCM and each factor were as follows: number of physicians (r=&minus;0.506, p=0.016), urbanization rate (r=&minus;0.467, p=0.029), and percentage livestock loss (r=0.469, p=0.028). In the multiple regression analysis, the number of physicians was significantly negatively related to the CCM (standardizing coefficient &minus;0.492, p=0.020)., Conclusion: These results suggest that increased medical resources and infrastructure development have positive effects on child health - even in the setting where the dzud causes considerable damage to livestock.

A strong health workforce is widely recognized as a prerequisite for health care and a crucial determinant of health system performance. The number of health professionals in China increased following the 2009 health system reform, which, in part, aimed to address the shortage and unequal distribution of health professionals. We examined whether the distribution of health professionals was more equitable following the reform and whether the reform had targeted impacts in terms of the quantity of health professionals. We interacted economic (poor and non-poor counties) and geographic (eastern, central and western regions) dimensions to more precisely target vulnerable areas, focussing on the quantity and distribution of health professionals in rural China. We used a county-level longitudinal dataset from the National Health and Family Planning Commission consisting of 1978 counties in all 31 provinces in rural China, with measurements taken every other year from 2008 to 2014. The distribution of health professionals was summarized using descriptive and interaction analyses. We found a constant improvement in the number of health professionals per 1000 population co-existing with a worsening of the distribution across rural China following the health system reform. Most of the non-poor counties improved faster compared with poor counties across all geographic regions, especially in the western and eastern regions. The growth of the number of health professionals per 1000 population was greatest and fastest in western-non-poor counties and least and slowest in eastern-poor counties. As an example of the 'Central Region Downfall' phenomenon, the central counties (both poor and non-poor) performed poorly in terms of the quantity and distribution of health professionals. Based on an analysis of multiple dimensions, targeted and differential measures should be taken to reduce inequalities, and the central region should not be ignored in efforts to improve the distribution of health professionals in rural China.