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To (i) determine the proportion of deaths from CVD that could be avoided in both rural and metropolitan Australia if public health recommendations were met; (ii) assess the impact on the rural CVD mortality; and (iii) determine if policy priorities should be different by rurality for CVD prevention.
A macro-simulation modelling study of population data. Population, risk factor and CVD death data stratified by rurality were analysed using the Preventable Risk Integrated Model. The baseline scenario was the current risk factor levels (including physical activity, smoking, diet and alcohol). The counterfactual scenario was the population levels of these risk factors expected if public health recommendations were met.
Metropolitan and rural Australia.
Rural- and metropolitan-dwelling adults in Australia.
Both populations would experience similar relative declines in the proportion of deaths from CVD. A total of 14 892 deaths from CVD would be avoided annually; with similar declines in the proportions of deaths by rurality. Critically, the order of policy priorities for public health recommendation attainment would differ by rurality CVD prevention, with addressing fat intakes being a higher priority in rural areas.
Achieving public health recommendations in Australia would result in large declines in CVD mortality. Despite declines in overall CVD mortality under this scenario, an inequality in CVD burden would persist for rural populations. The order of risk factor priorities would differ by rurality.
Social exclusion amongst rural-dwelling older adults and the role of the diversity of people and places in mediating the construction of that exclusion has not been adequately investigated or conceptualised in the international literature. Consequently, how ageing in a rural community can function to disadvantage or protect older people remains poorly understood. With the aim of advancing conceptual understanding on rural old-age social exclusion, this article explores how exclusion is manifest in the lifecourse experiences of rural-dwelling older adults and the role of mediating factors in the construction of exclusion in different kinds of rural places. The analysis draws on ten rural case-study sites across Ireland and Northern Ireland, encompassing five kinds of rural communities: dispersed rural; remote rural; island rural; village rural; and near-urban rural. Data come from 106 interviews with older people ranging in age from 59 to 93 years. Rural old-age social exclusion is confirmed as a multi-dimensional construct, involving: social relations; service infrastructure; transport and mobility; safety, security and crime; and financial and material resources. This analysis demonstrates that social exclusion for rural-dwelling older people is multi-layered, and its prevalence and form is shaped by four mediating factors: individual capacities; lifecourse trajectories; place; and macro-economic forces. The findings are used to present a conceptual framework that emphasises the role of mediating forces on rural old-age social exclusion.
To examine the frequency of shopping at different food sources and the associations between shopping at different food sources and fruit and vegetable (FV) intake among upstate New York rural residents.
Cross-sectional study. Descriptive statistics and linear mixed models were used.
Eighty-two rural communities in upstate New York, USA.
Adults (n 465; 82·3 % female, mean age 51·5 years, mean BMI 31·7 kg/m2).
Within one’s community, the majority of participants reported often going to supermarkets (73·1 %). Many participants sometimes or occasionally shopped at superstores (48·0 %), convenience stores (57·9 %), small grocery stores or local markets (57·2 %), farmers’ markets or FV stores (66·6 %), dollar stores (51·5 %), pharmacies (46·0 %), or farm stands or community-supported agriculture (56·8 %). Most participants had never utilized food banks or food pantries (94·0 %), community gardens (92·7 %) or home food delivery (91·9 %). While frequent visits to farmers’ markets or farm stands were associated with higher fruit intake (P < 0·001), frequent visits to food co-ops or food hubs were associated with lower fruit intake (P = 0·004). Frequent visits to convenience stores (P = 0·002) and dollar stores (P = 0·004) were associated with lower vegetable intake. When FV intakes were combined, frequent visits to farmers’ markets or farm stands (P < 0·001) were associated with higher FV intake, and frequent visits to convenience stores (P = 0·005) were associated with lower FV intake.
Findings from the present study provide important insight for informing future food environment interventions related to helping rural residents consume adequate FV.
This study is aimed at developing a Rural Primary Health Care (PHC) Model for delivering comprehensive PHC for dementia in rural settings and addressing the gap in knowledge about disseminating and implementing evidence-based dementia care in a rural PHC context.
Limited access to specialists and services in rural areas leads to increased responsibility for dementia diagnosis and management in PHC, yet a gap exists in evidence-based best practices for rural dementia care.
Elements of the Rural PHC Model for Dementia were based on seven principles of effective PHC for dementia identified from published research and organized into three domains: team-based care, decision support, and specialist-to-provider support. Since 2013 the researchers have collaborated with a rural PHC team in a community of 1000 people in the Canadian province of Saskatchewan to operationalize these elements in ways that were feasible in the local context. The five-step approach included: building relationships; conducting a problem analysis/needs assessment; identifying core and adaptable elements of a decision support tool embedded in the model and resolving applicability issues; implementing and adapting the intervention with local stakeholders; and sustaining the model while incrementally scaling up.
Developing and sustaining relationships at regional and PHC team levels was critical. A comprehensive needs assessment identified challenges related to all domains of the Rural PHC Model. An existing decision support tool for dementia diagnosis and management was adapted and embedded in the team’s electronic medical record. Strategies for operationalizing other model elements included integrating team-based care co-ordination into the decision support tool and family-centered case conferences. Research team specialists provided educational sessions on topics identified by the PHC team. This paper provides an example of a community-based process for adapting evidence-based practice principles to a real-world setting.
Increased mortality after spousal bereavement has been observed in many populations. Few studies have investigated the widowhood effect in a traditional culture where the economy is underdeveloped. The reasons for the widowhood effect and its gender dynamic are not well understood. In this study, we assessed whether the widowhood-associated excess mortality exists and differs by gender and living arrangement in rural China. We used a six-wave panel of data derived from rural people over 60 years old in the Chaohu region of China. Cox regression analyses suggest that there was a positive effect of spousal loss on mortality for older rural Chinese and this effect was gender different. Our findings also suggest that living with adult children after spousal loss played a protective role in reducing the risk of older men's death, though it tended to increase older men's mortality risk in general.
The current paper describes methods of evaluating dietary habits of Sri Lankan adolescents based on the Diet Quality Index–International (DQI-I), which has been used in multiple international studies to describe dietary variety, moderation, adequacy and balance. The paper describes the method for calculating DQI-I scores and examines associations between DQI-I scores and dietary intake, and between DQI-I scores and sociodemographic factors.
The study followed a three-stage cluster randomised sampling method. Dietary intake was collected using a validated FFQ. Estimated micronutrient intakes and number of servings consumed were described according to DQI-I quartiles. DQI-I scores were tabulated according to sociodemographic characteristics. Multilevel modelling was used to examine associations between sociodemographic characteristics and DQI-I scores.
Secondary schools in rural Sri Lanka.
Adolescents (n 1300) aged 12–18 years attending secondary school in rural Sri Lanka.
DQI-I scores increased with consumption of fat (% energy), cholesterol (mg/d), energy (kJ/d), protein (% energy), Na (mg), dietary fibre (g), Fe (mg) and Ca (mg), but decreased according to percentage of energy coming from carbohydrates. DQI-I scores were significantly lower among females and students with lower levels of maternal education.
Policies are needed to increase the availability and affordability of nutrient-rich foods such as fruits, vegetables and high-protein foods, particularly to students from lower socio-economic backgrounds. Significant differences in diet quality according to sex, socio-economic status and district suggest there is potential for targeted interventions that aim to increase access to affordable, nutrient-rich foods among these groups.
This descriptive paper aims to describe the design and implementation of a community engaged primary healthcare strategy in rural Australia, the Primary Healthcare Registered Nurse: Schools-Based strategy. This strategy seeks to address the health, education and social inequities confronting children and adolescents through community engaged service provision and nursing practice.
There have been increasing calls for primary healthcare approaches to address rural health inequities, including contextualised healthcare, enhanced healthcare access, community engagement in needs and solutions identification and local-level collaborations. However, rural healthcare can be poorly aligned to community contexts and needs and be firmly entrenched in health systems, marginalising community participation.
This strategy has been designed to enhance nursing service and practice responsiveness to the rural context, primary healthcare principles, and community experiences and expectations of healthcare. The strategy is underpinned by a cross-sector collaboration between a local health district, school education and a university department of rural health. A research framework is being developed to explore strategy impacts for service recipients, cross-sector systems, and the establishment and maintenance of a primary healthcare nursing workforce.
Although in the early stages of implementation, key learnings have been acquired and strategic, relationship, resource and workforce gains achieved.
The present research aimed to describe perceptions and behaviours around the consumption of water and sugar-sweetened beverages (SSB) by youths.
A formative, qualitative study which conducted four focus groups. Transcripts were analysed and themes related to reasons youths drink SSB and water, and conversely do not drink SSB and water, were analysed to reveal thematic clusters around sensory factors, environment and policy, access, marketing and role model influences, and health risks.
A rural, tri-ethnic community in New Mexico, USA.
Middle- and high-school students, parents and teachers.
Although youths and adults were aware of the health risks of soda, they did not translate this information to other SSB, including sports drinks and sweetened tea. Moreover, their perceptions of risks of dyes outweighed their concern with sugar. Youths and adults were aware of water’s health benefits, but they focused on short-term benefits. Youths and adults perceived water as unappealing. Adults were also concerned with water safety and access.
This formative research has implications for decreasing SSB consumption and simultaneously increasing water intake among youths in rural communities. Addressing unique access and safety concerns related to water in rural communities, as well as increasing awareness of the risks of all types of SSB, can work together in a positive feedback loop to change perceptions and behaviours with long-term health consequences. Specific policy suggestions include strengthening school policies to restrict all types of SSB and water promotion efforts that address access, safety and health benefits.
The US Department of Agriculture’s Summer Food Service Program and Seamless Summer Option (summer nutrition programmes (SNP)) aim to relieve food insecurity for children and teens during summer months. More needs to be known about when and where SNP are available, and how availability varies by community characteristics, particularly in rural areas where food insecurity and reduced food access are more prevalent.
The present study examined the geographic availability of SNP and summer meal uptake rates in 2016, using state-wide administrative claims data.
Public schools and SNP in California, USA.
Schools (n 8842) and SNP (n 4685).
Urban counties were more likely than rural counties to have higher summer uptake rates, calculated as the percentage of summer meals served relative to eligible students utilizing school meal programmes during the academic school year, but uptake overall was low at 18·2 % of target populations. Geographic availability analyses showed that 63·9 % of public urban schools had an SNP available within 1·6 km (1 mile), but availability was significantly higher within the proximity of larger, higher-poverty high schools with diverse or majority non-White students, and those with higher school-year breakfast participation rates. Availability of an SNP within 16 km (10 miles) of rural schools averaged 68·1 % but was significantly higher around larger schools, higher-poverty schools and those with diverse or majority non-White students.
While many communities have SNP available, much more work is needed to increase the availability of these programmes to reduce summer food insecurity for children, particularly in rural communities.
Researchers and citizens alike question the long-term impacts of the shale oil boom on local communities. Studies have considered the boom’s effects on employment, income, mobility, and human capital acquisition. This research specifically builds on research considering shale effects on secondary schooling. Using county-level data from Texas, we investigate two questions: (1) Has the latest oil boom led to a reduction in local high school graduation? (2) Is this effect different for immigrants, a group potentially vulnerable to local wage effects? Findings indicate insignificant overall effects; however, local oil drilling increases immigrant high school dropout rates.
The intent of this study was to determine whether there are differences in disaster preparedness between urban and rural community hospitals across New York State.
Descriptive and analytical cross-sectional survey study of 207 community hospitals; thirty-five questions evaluated 6 disaster preparedness elements: disaster plan development, on-site surge capacity, available materials and resources, disaster education and training, disaster preparedness funding levels, and perception of disaster preparedness.
Completed surveys were received from 48 urban hospitals and 32 rural hospitals.There were differences in disaster preparedness between urban and rural hospitals with respect to disaster plan development, on-site surge capacity, available materials and resources, disaster education and training, and perception of disaster preparedness. No difference was identified between these hospitals with respect to disaster preparedness funding levels.
The results of this study provide an assessment of the current state of disaster preparedness in urban and rural community hospitals in New York. Differences in preparedness between the two settings may reflect differing priorities with respect to perceived threats, as well as opportunities for improvement that may require additional advocacy and legislation. (Disaster Med Public Health Preparedness. 2019;13:424-428)
There is a need to improve geographical and financial access to healthy foods for limited resource populations in rural areas. Community Supported Agriculture (CSA) programs can improve access to healthy foods in rural and limited-resource populations. However, research is needed to discern the most appealing conditions for a CSA (e.g. price, frequency, food quantity) among rural, low-income customers. The goal of this study was to understand low-income consumers' preferences related to participation in a CSA program, considering price, frequency, food quantity and accessibility (e.g. distance) conditions. A modified exploratory choice experiment exercise was embedded within in-depth interviews to examine willingness to participate in CSA under a variety of conditions among 42 low-income adults with at least one child in the household in North Carolina, New York, Vermont and Washington. Willingness to participate in a CSA under each condition was summed and compared across conditions. Results were stratified by race, number of children and household members and McNemar's test and Student's t-test were used to examine differences in willingness between conditions. Salient quotes were extracted to support themes related to each condition. Our analysis suggests that the ideal CSA would be a full-sized share of eight to nine items of mixed variety, distributed every other week, priced at less than US$15, no more than 10 min further than the supermarket (SM) from their home and preferably less expensive but no more than 20% more expensive than SM prices. CSAs interested in reaching rural low-income populations may benefit from considering these consumer-level preferences.
Evaluate the clinical outcomes for patients with dementia, delirium, or at risk for delirium supported by the person-centered volunteer program in rural acute hospitals.
A non-randomized, controlled trial.
Older adults admitted to seven acute hospitals in rural Australia. Intervention (n = 270) patients were >65 years with a diagnosis of dementia or delirium or had risk factors for delirium and received volunteer services. Control (n = 188) patients were admitted to the same hospital 12 months prior to the volunteer program and would have met eligibility criteria for the volunteer program, had it existed.
Trained volunteers provided 1:1 person-centered care with a focus on nutrition and hydration support, hearing and visual aids, activities, and orientation.
Medical record audits provided data on volunteer visits, diagnoses, length of stay (LOS), behavioral incidents, readmission, specialling, mortality, admission to residential care, falls, pressure ulcers, and medication use.
Across all sites, there was a significant reduction in rates of 1:1 specialling and 28 day readmission for patients receiving the volunteer intervention. LOS was significantly shorter for the control group. There were no differences in other patient outcomes for the intervention and control groups.
The volunteer intervention is a safe, effective, and replicable way to support older acute patients with dementia, delirium, or risk factors for delirium in rural hospitals. Further papers will report on cost effectiveness, family carer, volunteer, and staff experiences of the program.
It remains unclear whether ST-elevation myocardial infarction (STEMI) patients transported by ambulance over long distances are at risk for clinical adverse events. We sought to determine the frequency of clinical adverse events in a rural population of STEMI patients and to evaluate the impact of transport time on the occurrence of these events in the presence of basic life support paramedics.
We performed a health records review of 880 consecutive STEMI patients transported to a percutaneous coronary intervention centre. Patients had continuous electrocardiogram and vital sign monitoring during transport. A classification of clinically important and minor adverse events was established based on a literature search and expert consensus. A multivariate ordinal logistic regression model was used to study the association between transport time (0-14, 15-29, ≥30 minutes) and the occurrence of overall clinical adverse events.
Clinically important and minor events were experienced by 18.5% and 12.2% of STEMI patients, respectively. The most frequent clinically important events observed were severe hypotension (6.1%) and ventricular tachycardia/ventricular fibrillation (5.1%). Transport time was not associated with a higher risk of experiencing clinical adverse events (p=0.19), but advanced age was associated with adverse events (p=0.03). No deaths were recorded during prehospital transport.
In our study of rural STEMI patients, clinical adverse events were common (30.7%). However, transport time was not associated with the occurrence of adverse clinical events in these patients.
Technologies and practices to remove carbon from the atmosphere (‘negative emissions technologies’) will be challenging to scale-up. Efforts to incentivize or govern their scale-up globally risk failing if they miss the social challenges. This paper analyzes prospective challenges for negative emissions through examining how decarbonization practices are evolving in one particular landscape: the Imperial Valley in southeast California, a desert landscape engineered for industrial agriculture. Based on semi-structured interviews and site visits, this paper examines how community actors have received, participated in, imagined or contested new energy technologies and climate practices, and draws out takeaways for negative emissions policy.
The aim of this study was to determine the feasibility and efficacy of a culturally tailored lifestyle intervention, ¡Vivir Mi Vida! (Live My Life!). This intervention was designed to improve the health and well-being of high risk late middle-aged Latino adults and to be implemented in a rural primary care system.
Rural-dwelling Latino adults experience higher rates of chronic disease compared with their urban counterparts, a disparity exacerbated by limited access to healthcare services. Very few lifestyle interventions exist that are both culturally sensitive and compatible for delivery within a non-metropolitan primary care context.
Participants were 37 Latino, Spanish-speaking adults aged 50–64-years-old, recruited from a rural health clinic in the Antelope Valley of California. ¡Vivir Mi Vida! was delivered by a community health worker-occupational therapy team over a 16-week period. Subjective health, lifestyle factors, and cardiometabolic measures were collected pre- and post-intervention. Follow-up interviews and focus groups were held to collect information related to the subjective experiences of key stakeholders and participants.
Participants demonstrated improvements in systolic blood pressure, sodium and saturated fat intake, and numerous patient-centered outcomes ranging from increased well-being to reduced stress. Although participants were extremely satisfied with the program, stakeholders identified a number of implementation challenges. The findings suggest that a tailored lifestyle intervention led by community health workers and occupational therapists is feasible to implement in a primary care setting and can improve health outcomes in rural-dwelling, late middle-aged Latinos.
Introduction: In many rural and remote communities in BC, family physicians who are providing excellent primary and emergency care would like to access useful, timely, and collegial support to ensure the highest quality of health services for their patients. We undertook a real-time virtual support project in Robson Valley, located in northern BC, to evaluate the use of digital technologies such as videoconferencing for on demand consultation between family physicians at rural sites and emergency physicians at a regional site. Telehealth consults also occurred between rural sites with nurses at community emergency rooms consulting with local on-call physicians. Our aim was to use telehealth to facilitate timely access to high quality, comprehensive, coordinated team-based care. An evaluation framework, based on the Triple Aim sought to: 1) Identify telehealth use cases and assess impact on patient outcomes, patient and health professional experience, and cost of health care delivery; and 2) Assess the role of relationships among care team members in progressing from uptake to normalization of telehealth into routine usage. Methods: Using a participatory approach, all members of the pilot project were involved in shaping the pilot including the co-development of the evaluation itself. Evaluation was used iteratively throughout implementation for ongoing quality improvement via regular team meetings, sharing and reflecting on findings, and adjusting processes as required. Mixed methods were used including: interviews with family physicians, nurses, and patients at rural sites, and emergency physicians at regional site; review of records such as technology use statistics; and stakeholder focus groups. Results: From November 2016 to July 2017, 26 cases of telehealth use were captured and evaluated. Findings indicate that telehealth has positively impacted care team, patients, and health system. Benefits for care team at the rural sites included confidence in diagnoses through timely access to advice and support, while emergency physicians at the regional site gained deeper understanding of the practice settings of rural colleagues. Nevertheless, telehealth has complicated the emergency department work flow and increased physician workload. Findings demonstrated efficiencies for the health system, including reducing the need for patient transfer. Patients expressed confidence in the physicians and telehealth system; by receiving care closer to home, they experienced personal cost savings. Implementation saw a move away from scheduled telehealth visits to real use of technology for timely access. Conclusion: Evidence of the benefits of telehealth in emergency settings is needed to support stakeholder engagement to address issues of workflow and capacity. This pilot has early indications of significant local impact and will inform the expansion of emergency telehealth in all emergency settings in BC.
This analysis examines how the narrative self of a person with dementia is maintained by family members in a small rural Nova Scotian community. In the literature, the expectation is often that rurality is a condition of isolation, distance from family and limited health resources. However, drawing on three years of ethnographic and interviewing research with a large extended family whose patriarch, Alexander, is a person with dementia, we demonstrate how a community's rurality influences interpretations of dementia. In Alexander's rurality, of particular import are local definitions of belonging, which privilege intimate knowledge of local history, working as a farmer to shape the land, and being of Scottish descent and male. As family members find Alexander's belonging to come into question in their community, we show them to employ narratives in which he is valorised for continuing to uphold local values – of ‘usefulness’ and of ‘being the land’. We show how the family members must also revisit and revise these narratives when Alexander's belonging is further called into question outside the family setting and, specifically, at the local farmer's market, where Alexander is often no longer greeted by other marketgoers. The men and women of the family arrive at different interpretations of this development, with the women considering marketgoers to demean and dehumanise Alexander, while the men feel that the marketgoers are avoiding interactions that would embarrass him. Such disagreements reveal the ongoing emotional labour of creating narratives that lack closure, certainty and consensus, as well as ways in which gender and rurality operate intersectionally in the process of meaning-making.