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

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

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

General health in the elderly and younger adults of rural areas in Fars province, Iran

There are critical gaps in assessment and research on health among the elderly living in rural communities. The state of aging and health in rural areas provides a snapshot of our older adults's need to necessary public health measures .The aim of this study was to determine the self-rated general health of adults residing in rural areas and compare the general health of the elderly with younger adults. In this population based study using multistage random sampling, 2259 adults aged [>/= 15 years old] were selected from rural areas of Shiraz, southern Iran. The participants were divided into three age groups: young adults [15-39 years old n=1574], middle aged adults [40-59 years old, n=530], and the elderly [>/= 60 years of age, n=155]. Data were gathered using a translated version of the general health questionnaire [GHQ-28] and analyzed using Chi-square, one-way ANOVA, Kruskal-Wallis tests and ANCOVA analysis. SPSS software, version 16, was used for analysis. 34.8%, 31.6%, 52.3% and 7.7% of the elderly had a probable mental disorder in the somatization, anxiety, social dysfunction and depression categories, respectively. Moreover, 9.7, 7.1, 3.9 and 4.5% of the elderly had a severe mental disorder in the four mentioned subscales, respectively. Compared with younger adults, the elderly showed a significantly higher disorder in all subscales except for anxiety. Our findings showed that chronic disease had a great effect on general health. Screening programs and prevention of chronic disease by the newly established family physician in rural districts can improve the overall community health

Health care inequities in north India: Role of public sector in universalizing health care.

Background & objectives: Income inequality is associated with poor health. Inequities exist in service utilization and financing for health care. Health care costs push high number of households into poverty in India. We undertook this study to ascertain inequities in health status, service utilization and out-of-pocket (OOP) health expenditures in two States in north India namely, Haryana and Punjab, and Union Territory of Chandigarh. Methods: Data from National Sample Survey 60th Round on Morbidity and Health Care were analyzed by mean consumption expenditure quintiles. Indicators were devised to document inequities in the dimensions of horizontal and vertical inequity; and redistribution of public subsidy. Concentration index (CI), and equity ratio in conjunction with concentration curve were computed to measure inequity. Results: Reporting of morbidity and hospitalization rate had a pro-rich distribution in all three States indicating poor utilization of health services by low income households. Nearly 57 and 60 per cent households from poorest income quintile in Haryana and Punjab, respectively faced catastrophic OOP hospitalization expenditure at 10 per cent threshold. Lower prevalence of catastrophic expenditure was recorded in higher income groups. Public sector also incurred high costs for hospitalization in selected three States. Medicines constituted 19 to 47 per cent of hospitalization expenditure and 59 to 86 per cent OPD expenditure borne OOP by households in public sector. Public sector hospitalizations had a pro-poor distribution in Haryana, Punjab and Chandigarh. Interpretation & conclusions: Our analysis indicates that public sector health service utilization needs to be improved. OOP health care expenditures at public sector institutions should to be curtailed to improve utilization of poorer segments of population. Greater availability of medicines in public sector and regulation of their prices provide a unique opportunity to reduce public sector OOP expenditure.

Incentivos para atraer y retener personal de salud de zonas rurales del Perú: un estudio cualitativo / Incentives to attract and retain the health workforce in rural areas of Peru: a qualitative study

El objetivo fue identificar incentivos de atracción y retención en zonas rurales y distantes de Ayacucho, Perú. Fueron realizadas entrevistas en profundidad con 80 médicos, enfermeras, obstetras y técnicos (20 por grupo) de las zonas más pobres y con 11 funcionarios. No existen políticas sistemáticas de atracción y retención de personal de salud en Ayacucho. Los principales incentivos, en orden de importancia, fueron mejoras salariales, oportunidades de formación y capacitación, estabilidad laboral y nombramiento, mejoras en infraestructura y equipos, e incremento del personal. Se mencionaron también mejoras en la vivienda y alimentación, mayor cercanía con la familia y reconocimiento por el sistema de salud. Existen coincidencias y singularidades entre los distintos grupos sobre los incentivos clave para estimular el trabajo rural, que deben considerarse al diseñar políticas públicas. Las iniciativas del Estado deben comprender procesos rigurosos de monitoreo y evaluación, para asegurar que las mismas tengan el impacto deseado.

The study aimed to identify the main incentives for attracting and retaining health workers in rural and remote health facilities in Ayacucho, Peru. In-depth interviews were performed with 80 physicians, obstetricians, nurses, and nurse technicians in the poorest areas (20 per group), plus 11 health managers. Ayacucho lacks systematic policies for attracting and retaining human resources. The main incentives, in order of relevance, were higher wages, opportunities for further training, longer/permanent contracts, better infrastructure and medical equipment, and more staff. Interviewees also mentioned improved housing conditions and food, the opportunity to be closer to family, and recognition by the health system. Health workers and policymakers share perceptions on key incentives to encourage work in rural areas. However, there are also singularities to be considered when designing specific strategies. Public initiatives thus need to be monitored and evaluated closely in order to ensure the intended impact.

Operational issues and trends associated with the pilot introduction of zinc for childhood diarrhoea in Bougouni district, Mali.

Zinc for the treatment of childhood diarrhoea was introduced in a pilot area in southern Mali to prepare for a cluster-randomized effectiveness study and to inform policies on how to best introduce and promote zinc at the community level. Dispersible zinc tablets in 14-tablet blister packs were provided through community health centres and drug kits managed by community health workers (CHWs) in two health zones in Bougouni district, Mali. Village meetings and individual counselling provided by CHWs and head nurses at health centres were the principal channels of communication. A combination of methods were employed to (a) detect problems in communication about the benefits of zinc and its mode of administration; (b) identify and resolve obstacles to implementation of zinc through existing health services; and (c) describe household-level constraints to the adoption of appropriate home-management practices for diarrhoea, including administration of both zinc and oral rehydration solution (ORS). Population-based household surveys with caretakers of children sick in the previous two weeks were carried out before and four months after the introduction of zinc supplementation. Household follow-up visits with children receiving zinc from the health centres and CHWs were conducted on day 3 and 14 after treatment for a subsample of children. A qualitative process evaluation also was conducted to investigate operational issues. Preliminary evidence from this study suggests that the introduction of zinc does not reduce the use of ORS and may reduce inappropriate antibiotic use for childhood diarrhoea. Financial access to treatments, management of concurrent diarrhoea and fever, and high use of unauthorized drug vendors were identified as factors affecting the effectiveness of the intervention in this setting. The introduction of zinc, if not appropriately integrated with other disease-control strategies, has the potential to decrease the appropriate presumptive treatment of childhood malaria in children with diarrhoea and fever in malaria-endemic areas.

Community health nursing practices in contexts of poverty, uncertainty and unpredictability: a systematization of personal experiences

Several years of professional nursing practices, while living in the poorest neighbourhoods in the outlying areas of Brazil's Amazon region, have led the author to develop a better understanding of marginalized populations. Providing care to people with leprosy and sex workers in riverside communities has taken place in conditions of uncertainty, insecurity, unpredictability and institutional violence. The question raised is how we can develop community health nursing practices in this context. A systematization of personal experiences based on popular education is used and analyzed as a way of learning by obtaining scientific knowledge through critical analysis of field practices. Ties of solidarity and belonging developed in informal, mutual-help action groups are promising avenues for research and the development of knowledge in health promotion, prevention and community care and a necessary contribution to national public health programmers.

Muitos anos de prática profissional em enfermagem, vivendo nas vizinhanças mais pobres de áreas distantes da região Amazônica brasileira levaram a autora a desenvolver uma melhor compreensão das populações marginalizadas. O cuidado às pessoas com lepra e trabalhadores do sexo de comunidades ribeirinhas tem sido realizado em condições de incerteza, insegurança, imprevisibilidade e violência institucional. A questão levantada é como podemos desenvolver práticas de enfermagem na saúde da comunidade neste contexto. A sistematização de experiências pessoais baseadas na educação popular é usada e analisada como uma maneira de conhecer e obter conhecimento científico através da análise crítica das práticas da área. Laços de solidariedade e pertencimento desenvolvidos em ações de grupos informais de ajuda mútua são caminhos promissores para pesquisa e desenvolvimento do conhecimento em promoção a saúde, prevenção e cuidado à comunidade e uma contribuição necessária para os programas de saúde pública nacional.

Varios años de prácticas profesionales de enfermería, viviendo en los distritos más pobres de las áreas periféricas de la región amazónica de Brasil, llevaron o autor a desarrollar una mejor comprensión de poblaciones marginalizadas. La provisión de cuidados a personas con lepra y trabajadores del sexo en comunidades ribereñas ha sido llevado a cabo en condiciones de incertidumbre, inseguridad, imprevisibilidad y violencia institucional. Se pregunta como podemos desarrollar prácticas de enfermería en salud comunitaria en este contexto. Una sistematización de experiencias personales basada en educación popular es usada y analizada como un método de saber, obteniendo conocimiento científico mediante un análisis crítico de prácticas en el campo. Lazos de solidaridad y pertenencia desarrollados en grupos de acción informales, de ayuda mutua son caminos prometedores para la investigación y el desarrollo de conocimiento en la promoción de la salud, prevención y atención comunitaria y una contribución necesaria a programas nacionales de salud pública.

A survey of antimicrobial prescribing and dispensing practices in rural Bangladesh.

This study was undertaken to determine the patterns of antimicrobial prescription by 64 Rural Medical Practitioners (RMPs) from Bangladesh. The antimicrobial dispensing procedures followed by the local retail drug sellers along with the purchasing capacities of the patients was also assessed. All antimicrobial agents were prescribed mainly on the patient's complaints, and all available antibiotics were prescribed in inappropriate doses and duration. In most cases, the RMPs initiated treatment with a parenteral form of antibiotic, and a different oral antibiotic usually followed. Parenteral streptomycin was used most frequently in short inadequate courses. Almost half of the antibiotics were sold without any prescriptions, and even ordinary people without any knowledge of medicine asked the drug seller for specific antibiotics. This unregulated prescribing and dispensing practice has the potential risk for the development and spread of antimicrobial resistance on a global scale.

HIV-related knowledge, attitudes and risk perception amongst nurses, doctors and other healthcare workers in rural India.

BACKGROUND AND OBJECTIVE: People with HIV in India frequently encounter discrimination while seeking and receiving healthcare services. The knowledge and attitudes of healthcare workers (HCWs) influences the willingness and ability of people with HIV to access care, and the quality of the care they receive. Previous studies of HIV-related knowledge and attitudes amongst Indian HCWs have been conducted primarily in large urban hospitals. The objective of this study was to asses HIV-related knowledge, attitudes and risk perception among a group of rural north Indian HCWs, and to identify predictors of willingness to provide care for patients with HIV infection. METHODS: A cross-sectional survey of 266 HCWs (78% female) from seven rural north Indian health settings was undertaken in late 2002. A self-administered written questionnaire was made available in English and Hindi, and the response rate was 87 per cent. Information was gathered regarding demographic details (age, sex, duration of employment, job category); HIV-related knowledge and attitudes; risk perception; and previous experience caring for HIV-positive patients. Logistic regression modelling was undertaken to identify factors associated with willingness to care for patients with HIV. RESULTS: The HCWs in this study generally had a positive attitude to caring for people with HIV. However, this was tempered by substantial concerns about providing care, and the risk of occupational infection with HIV was perceived by most HCWs to be high. After controlling for confounding, HCWs willingness to provide care for patients with HIV was strongly associated with having previously cared for patients with HIV (P = 0.001). Knowledge of HIV transmission and perception of risk were not associated with willingness to provide care. INTERPRETATION AND CONCLUSION: The findings of this study showed a general willingness of HCWs to provide care for patients with HIV, tempered by concerns regarding provision of such care. Strategies to address HCWs concerns are likely to ameliorate the discrimination experienced by people with HIV when accessing healthcare services. These include the development of programmes to promote occupational safety of HCWs and involving people with HIV in awareness training of HCWs.

Answering the rehabilitation needs of leprosy-affected persons in integrated setting through primary health care services and community-based rehabilitation.

This article aims to discuss the strategies for answering the rehabilitation needs of persons with leprosy-related disabilities in integrated settings through primary health care (PHC) services and community-based rehabilitation (CBR). While the provision of rehabilitation services through the PHC system remains problematic in most developing countries, the article concludes that CBR programmes have the potential for rehabilitation of leprosy-affected persons in integrated settings. However, the limited coverage of CBR programmes may pose an obstacle to such an approach. The author suggests the use of existing specific rehabilitation infrastructures meant only for leprosy-affected persons for initiating, sustaining and extending the CBR coverage to the surrounding communities. At the same time, the author asks for support and strengthening of organizations of leprosy-affected persons, promoting their active involvement in all rehabilitation processes.

Rate of caesarean section as a process indicator of safe-motherhood programmes: the case of Kenya.

The study assessed the value of currently-available data on the rates of caesarean section as an indicator of safe-motherhood programmes. Data, collected through the routine health information system of the Ministry of Health, Kenya, were used for analyzing the available process indicators. The methodology of this study illustrates both usefulness and limitations of readily-available healthcare information. The rate of hospital-based caesarean section was 6.3% of all births (range 0.3-37%), whereas the rate of population-based caesarean section was 0.95% (range 0.1%-4%). The rate of population-based caesarean section indicates a significant unmet need for obstetric care in the rural areas and may be a useful tool for monitoring progress on safe-motherhood initiatives in poor settings. Rates of population-based caesarean section are low in Kenya, especially in the rural areas. The rate of caesarean section may be a valuable process indicator for identifying the gaps in obstetric care and may be used for advocating improvements for healthcare to the relevant authorities.

Programas prioritarios de recursos humanos en salud a evaluar. Perú / Priority programs of Human Resources in Health to be evaluated. Peru

Se describen a profundidad los programas de prioritarios de Recursos Humanos en Salud a evaluar en el Perú: Servicio Rural Urbano Marginal en Salud-SERUMS, Sistema Nacional de Residentado Médico-SINAREME, Programa de Especialización en Atención Primaria con énfasis en Salud Familiar y Comunitaria-PROFAM.