Retention of physicians and surgeons in rural areas—what works?

2020 ◽  
Author(s):  
Shireen Kumar ◽  
Bridget Clancy
Keyword(s):  
Rural Health ◽  
Low Income ◽  
Rural Areas ◽  
Financial Incentives ◽  
English Literature ◽  
Professional Support ◽  
Low Income Countries ◽  
Rural Environment ◽  
Retention Strategies ◽  
Rural Doctor

Abstract Background Causes for health inequity among rural populations globally are multifactorial, and include poorer access to healthcare professionals. This study summarizes the recent literature identifying factors that influence rural doctor retention and analyses strategies implemented to increase retention. Uniquely, this study addresses the importance of context in the planning, implementation and success of these strategies, drawing on literature from high-, middle- and low-income countries. Methods A systematic review of the English literature was conducted in two parts. The first identified factors contributing to rural doctor retention, yielding 28 studies (2015–2019). The second identified 19 studies up to 2019 that assessed the outcomes of implemented rural retention strategies. Results Universal retention factors for health professionals in a rural environment include rural background, positive rural exposure in training or in the early postgraduate years and personal and professional support. Financial incentives were less influential on retention, but results were inconsistent between studies and differed between high-, middle- and low-income nations. Successful strategies included student selection from rural backgrounds into medical school and undergraduate education programs and early postgraduate training in a rural environment. Bundled or multifaceted interventions may be more effective than single factor interventions. Conclusion Rural health workforce retention strategies need to be multifaceted and context specific, and cannot be effective without considering the practitioner’s social context and the influence of their family in their decision making. Adequate rural health facilities, living conditions, work-life balance and family, community and professional support systems will maximize the success of implemented strategies and ensure sustainability and continuity of healthcare workforce in rural environments.

scholarly journals A Garden-Based Intervention to Improve Dietary Diversity in Kenyan School Children: Results from a Natural Experiment

2020 ◽  
Vol 4 (Supplement_2) ◽  
pp. 810-810 ◽  
Author(s):  
Sara Benjamin-Neelon ◽  
Tiange Liu ◽  
Eve S Puffer ◽  
Liz Turner ◽  
Daniel Zaltz ◽  
...  
Keyword(s):  
Low Income ◽  
Rural Areas ◽  
Primary Schools ◽  
Dietary Diversity ◽  
Food Group ◽  
Low Income Countries ◽  
Severe Drought ◽  
School Gardens ◽  
Post Intervention

Abstract Objectives School gardens may improve child diet, but little is known about their effectiveness in rural areas in low-income countries. We evaluated the ability of school gardens to improve child diet in rural Kenya. We hypothesized that children in intervention schools would improve their dietary diversity and specifically their produce intake. Methods An non-government organization installed gardens in 2 primary schools. We selected 2 geographically proximal additional schools as comparisons. We conducted baseline assessments in 2013, prior to garden installation, and follow-up assessments a year later in 2014 in all 4 schools. We measured child dietary intake via a single 24-hour recall. We calculated dietary diversity using the women's dietary diversity score (WDDS) (continuous) and also examined each of the 10 food group components defined as adequate ≥15 g (binary). We conducted marginal linear or logistic regression models using a generalized estimating equation and included an exposure x time interaction to assess differences in outcomes between intervention and comparison schools from baseline to follow up. We controlled for child age, gender, and orphan status. Results We assessed 855 children (n = 438 intervention; n = 417 comparison) at baseline and 688 children (n = 383 intervention; n = 305 comparison) at follow up. Children in intervention schools were 51.8% male, compared to 56.5% in comparison schools. Mean (standard deviation) age was 11.6 (2.1) years in intervention and 11.8 (2.3) years in comparison schools. All children's WDDS worsened post-intervention. In adjusted difference in difference analyses, WDDS did not differ in intervention vs. comparison schools pre- to post-intervention (β 0.04, CI −0.19, 0.27). However, we observed less of a decrease in meeting adequate intake for pulses (OR 2.18, CI 1.18, 4.01) and other fruits (OR 1.55, CI 1.00, 2.40) in intervention versus comparison schools. Conversely, children in comparison schools had less of a decrease in meat, poultry, and fish compared to children in intervention schools (OR 0.67, CI 0.45, 0.99). Conclusions Children's WDDS worsened in all 4 schools, likely due to a severe drought that affected the region in 2014. We observed some differences in intervention vs. comparison children, but cannot attribute these improvements to school gardens. Funding Sources Duke Global Health Institute.

The chance of conception during lactation

1977 ◽  
Vol 9 (S4) ◽  
pp. 41-54 ◽  
Author(s):  
Jeroen K. van Ginneken
Keyword(s):  
Menstrual Cycle ◽  
Milk Production ◽  
Breast Feeding ◽  
Low Income ◽  
Rural Areas ◽  
Spacing Effect ◽  
Birth Spacing ◽  
Low Income Countries ◽  
Newborn Child

Many mothers in low-income countries, particularly in rural areas, nurse their children for 1–2 years on the average. The main purpose of this practice is, of course, to provide the newborn child with the nutrition necessary for its survival. Prolonged breast-feeding, however, also has a birth-spacing effect and postpones the next pregnancy by inhibiting ovulation and by delaying resumption of the menstrual cycle. Suckling of the infant is important for this suppression of the menstrual cycle because it leads to the release of prolactin, which not only plays an important role in milk production but also inhibits the release of gonadotrophins which initiate resumption of the menstrual cycle. For further details about these endocrinological aspects of lactation see, for example, Rolland et al. (1975); Thomson, Hytten & Black (1975) and Buchanan (1975).

scholarly journals Geographical and socioeconomic inequalities in the utilization of maternal healthcare services in Nigeria: 2003–2017

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Chijioke Okoli ◽  
Mohammad Hajizadeh ◽  
Mohammad Mafizur Rahman ◽  
Rasheda Khanam
Keyword(s):  
Low Income ◽  
Rural Areas ◽  
Healthcare Services ◽  
Socioeconomic Inequalities ◽  
Low Income Countries ◽  
Theil Index ◽  
Maternal Healthcare ◽  
North East ◽  
Birth Attendance ◽  
Urban And Rural Areas

Abstract Background Maternal mortality has remained a challenge in many low-income countries, especially in Africa and in Nigeria in particular. This study examines the geographical and socioeconomic inequalities in maternal healthcare utilization in Nigeria over the period between 2003 and 2017. Methods The study used four rounds of Nigeria Demographic Health Surveys (DHS, 2003, 2008, 2013, and 2018) for women aged 15–49 years old. The rate ratios and differences (RR and RD) were used to measure differences between urban and rural areas in terms of the utilization of the three maternal healthcare services including antenatal care (ANC), facility-based delivery (FBD), and skilled-birth attendance (SBA). The Theil index (T), between-group variance (BGV) were used to measure relative and absolute inequalities in the utilization of maternal healthcare across the six geopolitical zones in Nigeria. The relative and absolute concentration index (RC and AC) were used to measure education-and wealth-related inequalities in the utilization of maternal healthcare services. Results The RD shows that the gap in the utilization of FBD between urban and rural areas significantly increased by 0.3% per year over the study period. The Theil index suggests a decline in relative inequalities in ANC and FBD across the six geopolitical zones by 7, and 1.8% per year, respectively. The BGV results do not suggest any changes in absolute inequalities in ANC, FBD, and SBA utilization across the geopolitical zones over time. The results of the RC and the AC suggest a persistently higher concentration of maternal healthcare use among well-educated and wealthier mothers in Nigeria over the study period. Conclusion We found that the utilization of maternal healthcare is lower among poorer and less-educated women, as well as those living in rural areas and North West and North East geopolitical zones. Thus, the focus should be on implementing strategies that increase the uptake of maternal healthcare services among these groups.

scholarly journals Prevalence and access to care for cardiovascular risk factors in older people in Sierra Leone: a cross-sectional survey

BMJ Open ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. e038520
Author(s):  
Maria Lisa Odland ◽  
Tahir Bockarie ◽  
Haja Wurie ◽  
Rashid Ansumana ◽  
Joseph Lamin ◽  
...  
Keyword(s):  
Risk Factors ◽  
Access To Care ◽  
Sierra Leone ◽  
Low Income ◽  
Rural Areas ◽  
Urban Areas ◽  
Disease Risk ◽  
Cardiovascular Disease Risk ◽  
Health System Strengthening ◽  
Low Income Countries

IntroductionPrevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions.MethodsThis study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested (‘screened’), knew of their condition (‘diagnosed’), were on treatment (‘treated’) or were controlled to target (‘controlled’). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded.ResultsOf 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost.ConclusionsIn Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.

scholarly journals Treatment Engagement of Psychotic Patients with a Mobile Mental Health Unit in Rural Areas in Greece: A Five-Year Study

2013 ◽  
Vol 2013 ◽  
pp. 1-6 ◽  
Author(s):  
Vaios Peritogiannis ◽  
Athina Tatsioni ◽  
Nefeli Menti ◽  
Aikaterini Grammeniati ◽  
Vassiliki Fotopoulou ◽  
...  
Keyword(s):  
Mental Health ◽  
Community Mental Health ◽  
Low Income ◽  
Rural Areas ◽  
Psychotic Disorders ◽  
Low Income Countries ◽  
Community Mental Health Service ◽  
Health Unit ◽  
Mobile Mental Health ◽  
Mental Health Unit

Objectives. Treatment of psychotic disorders is impended by high rates of disengagement from mental health services and poor adherence to antipsychotic medication. This study examined the engagement rates of psychotic patients with a community mental health service during a 5-year period.Methods. The Mobile Mental Health Unit of Ioannina and Thesprotia (MMHU I-T) delivers services in remote, rural, mountainous areas using the resources of the primary care system. Clinical and demographic information for patients with a diagnosis of schizophrenia and related psychoses was obtained from the medical records of our unit.Results. A total of 74 psychotic patients initially engaged in treatment with our unit. In half of cases treatment was home-based. With the exclusion of patients who died or discharged, engagement rates were 67.2%. Statistical analysis was performed for 64 patients, and no differences were found between engaged and disengaged patients regarding clinical and demographic parameters. All engaged patients regularly refilled their antipsychotic prescriptions.Conclusion. Engagement rates in our study were comparable to previous research, involving urban settings and shorter follow-up duration. Community mental health teams may ensure treatment continuation for psychotic patients in deprived, remote areas. This is important for low-income countries, affected by economic crisis, such as Greece.

scholarly journals Rural vs urban residence and experience of discrimination among people with severe mental illnesses in Ethiopia

2019 ◽  
Author(s):  
Sarah Forthal ◽  
Abebaw Fekadu ◽  
Girmay Medhin ◽  
Medhin Selamu ◽  
Graham Thornicroft ◽  
...  
Keyword(s):  
Mental Health ◽  
Mental Illness ◽  
Low Income ◽  
Rural Areas ◽  
Negative Binomial ◽  
Mental Illnesses ◽  
Urban Setting ◽  
Low Income Countries ◽  
Urban Settings ◽  
Adjusted Risk

Abstract Background Few studies have addressed mental illness-related discrimination in low-income countries, where the mental health treatment gap is highest. We aimed to evaluate the experience of discrimination among persons with severe mental illnesses (SMI) in Ethiopia, a low-income, rapidly urbanizing African country, and hypothesised that experienced discrimination would be higher among those living in a rural compared to an urban setting. Methods The study was a cross-sectional survey of a community-ascertained sample of people with SMI who underwent confirmatory diagnostic interview. Experienced discrimination was measured using the Discrimination and Stigma Scale (DISC-12). Zero-inflated negative binomial regression was used to estimate the effect of place of residence (rural vs. urban) on discrimination, adjusted for potential confounders. Results Of the 300 study participants, 63.3% had experienced discrimination in the previous year, most commonly being avoided or shunned because of mental illness (38.5%). Urban residents were significantly more likely to have experienced unfair treatment from friends (χ2(1)=4.80; p=0.028), the police (χ2(1) =11.97; p=0.001), in keeping a job (χ2(1)=5.43; p=0.020), and in safety (χ2(1)=5.00; p=0.025), and had a significantly higher DISC-12 score than those living in rural areas (adjusted risk ratio: 1.66; 95% CI: 1.18, 2.33). Conclusions Persons with SMI living in urban settings report more experience of discrimination than their rural counterparts, which may reflect a downside of wider social opportunities in urban settings. Initiatives to expand access to mental health care should consider how social exclusion can be overcome in different settings.

scholarly journals Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan

2019 ◽  
Vol 52 (4) ◽  
pp. 491-503
Author(s):  
Zubia Mumtaz ◽  
Afshan Bhatti ◽  
Sarah Salway
Keyword(s):  
Health Care ◽  
Caesarean Section ◽  
Low Income ◽  
Financial Incentives ◽  
Low Income Countries ◽  
Structured Interviews ◽  
Missed Opportunities ◽  
Health Visitors ◽  
Community Midwives ◽  
Unnecessary Intervention

AbstractAccess to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan – Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient–provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

Epidemiology of Acute Kidney Injury

2017 ◽  
Author(s):  
Verônica Torres Costa e Silva ◽  
Renato Antunes Caires ◽  
Elerson Carlos Costalonga ◽  
Emmanuel A. Burdmann
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Low Income ◽  
Rural Areas ◽  
Hospital Admissions ◽  
De Novo ◽  
Residual Disease ◽  
Multiorgan Failure ◽  
Kidney Injury ◽  
Low Income Countries

The worldwide incidence of acute kidney injury (AKI) is increasing. Recent surveys demonstrated that AKI occurs in 21% of hospital admissions. In low-income countries, AKI has a bimodal presentation. In large urban centers, the pattern of AKI is very similar to that found in high and upper middle-income countries, with a predominance of hospital-acquired AKI, occurring mostly in older, critically ill, multiorgan failure patients with comorbidities. At the same time, in regional hospitals in small urban communities and rural areas, AKI is usually a community-acquired disease (related to diarrheal and infectious diseases, animal venom, and septic abortion). Although AKI mortality seems to be decreasing, it remains extremely high, varying from 23.9 to 60% in recent series. The most important risk factors for short-term mortality (in hospital or < 90 days) in AKI are the primary diagnosis (sepsis) and the severity of the acute illness, expressed by the presence of nonrenal organ dysfunction. New biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18 measurements, have been able to identify patients with AKI who are at risk for a less favorable prognosis, such as the likelihood of the need for renal replacement therapy, nonrecovery of kidney function, and higher mortality. Several studies have demonstrated an association between hospital-associated AKI and postdischarge mortality in a variety of contexts, and the most important risk factors for this late lethality are older age, preexisting comorbid disease (chronic kidney disease [CKD], cardiovascular disease, or malignancy), and incomplete organ recovery with ongoing residual disease. AKI is associated with de novo end-stage renal disease (ESRD) (CKD, progression of preexisting CKD) and the occurrence of ESRD in the long term. Herein, it is suggested that high-risk patients recovering from an AKI episode, such as those with baseline CKD, diabetes mellitus, or heart failure and those dialyzed for AKI, should likely be followed by a nephrologist. 

Tuberculosis treatment outcome in a rural area of Senegal: a decade of experience from 2010 to 2019 by StopTB Italia

2021 ◽  
Author(s):  
Niccolò Riccardi ◽  
Simone Villa ◽  
Andrea Giacomelli ◽  
Mama M Diaw ◽  
Mamoud Ndiaye ◽  
...  
Keyword(s):  
Rural Area ◽  
Low Income ◽  
Rural Areas ◽  
Social Protection ◽  
Treatment Success ◽  
Pulmonary Involvement ◽  
Low Income Countries ◽  
People Living With Hiv ◽  
Living With Hiv ◽  
The Impact

Background: Tuberculosis (TB) unevenly affects individuals across the globe, especially in rural areas of low-income countries. Aim of the study was to assess the impact of social protection to increase TB awareness on treatment outcomes among TB patients in a rural area of Senegal. Materials & methods: The study, conducted in Fimela district (Senegal) from 1 January 2010 to 31 December 2019 and the intervention started from 31 January 2013, includes activities to increase awareness, active case finding, active follow-up and social protection. Results: Overall, 435 subjects – mainly male and young – were included in the analysis. Among TB cases, 94% had pulmonary involvement, 87% had no previous TB history, and 6% resulted positive HIV. Improved outcome was observed once intervention began (from 71 to 91%, p < 0.001); whereas mortality decreased (from 15 to 5%; p < 0.001), especially for those HIV co-infected for whom TB mortality rate dropped from 70 to 29%. Conclusion: After beginning the cooperation program, TB treatment success increased as a result of the decline of mortality, especially in people living with HIV.

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