Documenting effective coordination of medical education programs in response to medical underservice.

The Federal government has in the past initiated a variety of programs in an effort to address the issue of medical underservice throughout the United States. The results of two such programs sponsored by the University of Colorado Health Sciences Center are examined. Their federal and state support have been decreased at a time when encouraging progress was being made in reducing rural Coloradoans' inaccessibility to medical care, although much of the state remains designated a primary care health manpower shortage area. This paper challenges the Federal Government's policy of temporarily "seed" funding programs whose interventions require several years to complete, under the assumption that state legislatures will eagerly pick up financial support for all that document continuing need and effectiveness. It also describes the difficulties this policy and prevailing state legislative attitude pose for program evaluators in performing their professional function.     

The Problems for Academic and Entrepreneurial Research in the Use of Health Services: the Case of Unstable Structural Relationships*

Multiple regression analysis was used to determine the longitudinal stability of the structural relationships between the predisposing, enabling, and illness-morbidity characteristics of the population-at-risk and measures of health services utilization. The structural coefficients estimated from the 1971, 1972, and 1973 Health Interview Surveys were examined using the Relative Instability Ratio (RIR) presented in this paper. The RIR values indicate that—except for age, family size, occupation, and family income—all the predisposing, enabling, and illness-morbidity characteristics produce unstable structural relationships. In addition, a negative monotonic relationship was found between the temporal ordering of the groups of characteristics and their ability to produce stable structural relationships. These results demonstrate the need for entrepreneurial health manpower projection techniques and abstract academic explanatory models of health services utilization to become dynamic, rather than remaining in their present static states.     

A survey of Colorado's migrant farmworkers: access to health care

This report utilizes data collected in a 1986 sample survey of 329 adult (18 to 50 years old) migrant farmworkers in Colorado to determine their health needs, health services utilization, and overall access to care. Health needs include selected indices of medical, dental, nutrition, and reproductive health. About 1/4 of the population had no usual source of health care. Upstream states such as Colorado are responsible as the primary providers of health services for those who either have no source of health care at their home base or experience a variety of barriers in their attempts to access services. Women are most likely to have had a medical visit over the past 12 months and are more likely to have experienced hospitalization. Unfortunately, although their contact with medical professionals is more frequent, the family planning needs of women are not being met. A large disparity exists between ideal family size and number of pregnancies and live births. The findings of this survey document the inferior health status of the migrant farmworker population in Colorado. Hunger, poverty, and environmental hazards increase the risk of illness, while at the same time, barriers to care often prevent migrants from accessing needed health services. Recommendations include 1) promoting and funding family planning and reproductive health services for migrant farmworker women and their partners, 2) incorporating trained family planning promoters in the migrant health delivery system, 3) maintaining successful models of restorative dental care for adults, 4) increasing access to services in nontraditional settings, 5) increasing use of ancillary personnel to provide services, especially dental services, 6) maintaining outreach programs in the available food programs, and 7) encouraging migrant health programs to provide leadership in the development of alternative food sources.     

Telemedicine,rural elderly,and policy issues

Historically, rural America has had a difficult time providing health care to its residents, particularly its frail elderly population. Rural health care is often faced with a shortage of health care specialists, facilities with inferior equipment, and insufficient resources compared to health care in more urban areas. It is anticipated that the use of telemedicine will help address many of the problems facing the delivery of health care services to rural elderly. This paper reviews some innovative projects delivering services to the elderly. Also, the paper discusses several issues that need to be addressed before telemedicine can reach its full potential in improving access to health care, including reimbursement policies, patient and provider liability and confidentiality, and the infrastructure supporting telemedicine. Although telecommunications has tremendous potential to address the care needs of frail isolated elderly, without comprehensive reimbursement policies, guidelines for ethical conduct of a teleconsultation, acceptable security measures of patient records, and adequate as well as compatible infrastructure, that potential cannot be completely realized.     

Health,personal mobility and the use of health services in rural Norfolk

Trends towards the centralisation of both primary care and hospital services are increasing the distances that rural residents must travel to receive health care. Contradicting the widely held image of the healthiness of rural people, data from social surveys in Norfolk show that some of the remoter rural areas have populations with a relatively high need for health care. Furthermore, the groups with most need for health care (the old, the disabled, the poor, etc.) are also those with low levels of personal mobility, for whom travelling long distances to centralised health services is particularly difficult. After adjustments have been made for variations in need, it is shown that people in the remoter areas receive much less health care than comparable people in more accessible areas. However, branch surgeries do seem to make the general practitioner service more accessible, particularly to less mobile rural residents.     

“We don't want to talk about that”: Overcoming barriers to rural aging research and interventions on sensitive topics

Geographical, economic, social and cultural barriers to accessing services in rural areas are widely reported. Less widely discussed are dilemmas posed by individual and community reluctance to address sensitive health issues. This article, focusing on the highly sensitive area of mental health, and employing a participatory action approach, describes the natural history of a project, the Mental Health and Aging Initiative (MHAI) to enhance awareness of mental health issues in rural Kentucky-Appalachian communities and overcome the reluctance of individuals in these communities to seek assistance. Funded by the United States Department of Agriculture (USDA), MHAI involved an educational intervention to improve knowledge about mental health and aging in rural Appalachian counties. The need to overcome significant community reluctance to engage in discussion of mental health resulted in significant modification of the protocol. The intervention was grounded in recognition of four key aspects of the local situation: (1) the need to understand the sensitivity of mental health as an element of rural culture; (2) the critical role of local community leaders as points of entry, acceptance, and action; (3) the need to overcome social stigma and reframe the topic of mental health in a more positive light; and (4) the need for methodological innovation in developing an empowering educational action plan oriented toward community-wide long-term impact. The intervention model that emerged from these considerations was based on engaging community leaders, providing educational and technical resources, and nurturing the acceptance by individual rural residents of responsibility for monitoring community mental health. This motif became a central theme in a strategy designed to facilitate culture change and acceptance of mental health as a community concern. It involved active engagement of community representatives in defining and implementing an intervention consistent with participatory action research as a means of empowering rural residents in monitoring and addressing sensitive health care issues. Given that many issues in rural health are difficult to address because of such sensitivity, the approach described is considered to have application in other contexts.     

农村宅基地流转的风险防范

我国农村宅基地使用权制度产生于计划经济和城乡二元结构背景下,随着社会主义市场经济体制的进一步完善以及全国城市化、工业化的深入发展,这一制度已与城乡一体化、资源集约利用之间产生较大矛盾。进行农村宅基地流转,有利于农村土地集约节约利用;有利于增加农民财产性收入;有利于推进新型城镇化和加快城市化进程;有利于推动农业现代化建设和解决“三农”问题。当前推进农村宅基地流转的关键在于减少农村宅基地数量、盘活土地资源存量、提高土地资源利用效率;在此基础上,兼顾增加农民收入。     

Community Based Rural Health Care in India

SUMMARY

India is a large country, geographically as well as popula-tionwise. The majority of its population lives in rural areas, i.e., villages. Again, most of the villages are in remote areas. The State has been making sincere efforts to make the basic social services accessible to all in the rural area. Health being one of the vital services, it has been a challenging task before the State to extend it to the remote rural areas, many of which are not yet connected by motorable roads. As a result of various experiments carried out over the last five decades, the State has developed a fairly well-designed primary health care service, and it is in operation in rural areas. However, there appears to be a striking gap between the delivery of health services in rural areas and utilization of the services by the people. Attempts have been made in this article to apprise the readers of the health service system in India, and it discusses the issue of health service delivery at the village level. The discussion is based on a small study carried out in a rural area in the State of West Bengal (India) where students of social work of the University to which the author belongs are placed for field work. Following the inputs received through supervision of the students' work, the study was initiated and conducted.

This article based on the study seeks to focus on peoples' perception of the health services as provided by the State in rural areas, which in turn gets reflected in the extent to which they utilize the services. Social workers being an integral part of the health set up, their role bears special significance. Discussion, therefore, centres on scope for social work intervention at the community level as well as in institutional level of the health service delivery system to make the services meaningful and effective in rural areas. In fact, it has to take the leadership role in reforming the service delivery system when required.     

Demographic and socioeconomic determinants of female rural to urban migration in Sub-Saharan Africa

Data from the 1986-90 Demographic and Health Surveys of Burundi, Ghana, Kenya, Mali, Nigeria, Senegal, Togo, and Uganda were used to examine the impact of fertility, child mortality, and socioeconomic and demographic factors on female rural-urban migration of six months or more duration. Several principles appear to direct the migration of high fertility women. High parity women are free from the male demands for more children. Rural areas lack basic amenities such as schools, health services, and modern housing. Additional children may strain family resources and require additional income from other sources. Husband and kin may have already moved. All data are nationally representative, with the exception of Uganda with an 80% sample. Women living in rural areas two years prior to the survey were included in the sample. Fertility and mortality data pertain to children aged under five years in the period two to seven years before the survey year. Multinomial logit analysis was based on an analytical model developed by Goldstein and Goldstein. High fertility was found to deter female migration to either urban or rural areas. Women, who had one surviving child aged under five years, were significantly less likely to move to urban areas only in Nigeria and Senegal and to other villages in Burundi compared to women without a recent birth. Women with two or more surviving children were significantly less likely (by 43-75%) to move to urban areas in five out of seven countries. Moves to rural areas were less likely by 36-61% in six out of eight countries. The evidence does not suggest that the reason for moves is to advance the children's material or physical well-being. The number of births, particularly in Kenya where fertility is very high in rural areas, acts as a deterrent to migration. Child mortality only constrains moves to urban areas. Unmarried women, single women, better educated women, and adults in their 20s are more likely to move to urban areas.     

Health status,health problems and practices among refugees from the Middle East,Eastern Europe and Southeast Asia

Recent refugees from Poland, Romania, Iraq, and Vietnam were extensively interviewed to assess their health, health care utilization, and health services use barriers. 277 recent arrivals from these countries and 63 previously arrived Laotians comprised the 1983-1985 sample from the Detroit metropolitan area. Results from a 195-item bilingual questionnaire indicated good overall health and little evidence of serious physical health symptoms. Dental health was the area of greatest reported need. Prenatal care and mental health services were additional areas of need noted by researchers. Barriers to health service utilization were primarily language related. There were major differences in both health problems and health service utilization among the 4 groups surveyed.     

CHILD CARE USE BY LOW‐INCOME FAMILIES IN RURAL AREAS

Using data from interviews with 323 low‐income women living in rural counties in 11 states, child care arrangements for 672 children under 13 are described in relation to women's employment status, partner availability, and child age. As found in previous studies of rural areas, informal care is frequently used, regardless of full‐ or part‐time work or partner availability. Single mothers rely more on regulated care arrangements than mothers with partners and are more likely to pay for informal care than other mothers. Work in part‐time and service jobs suggests the need for flexible arrangements. Public data on child care availability and access in rural areas, the cost of care, and state subsidy programs suggest reasons for rural women's child care decisions. Policy implications of the study findings are shared.     

An analysis of the basic population structure of Shanghai Municipality

This paper analyzes the changes in Shanghai's population structure over the last 30 years in the 4 aspects of age structure, sex composition, urban and rural composition, and labor and employment structure. In 1953 those of the 0 to 6 age group accounted for 21.2% of the total population; in 1957 the group represented a proportion of 24.6%. Since the 1960s, especially after the 1970s, the family planning program gradually took effect, and the birthrate of the entire municipality fell drastically. The number of school-age children in 1979 was 1 1/2 times more than the same age group in 1953; there should be no worry that population control may result in a shortage of manpower to meet the needs of the work force and the armed forces either toward the end of this century or at the beginning of the next. The economy in China is underdeveloped, production and technology remain at a low level, average wages for employees are low, and for a long time the low living standard of the people has shown little sign of improvement. The problem is mainly manifest in the following areas: 1) distribution of the work force in heavy and light industries is not sufficiently rational, 2) the distribution of the work force between captial construction and transport and communications on the 1 hand and the national economy on the other is out of proportion, 3) the distribution of the work force between commerce, service trades, and public utilities on the 1 hand and the national economy on the other is disproportionated, and 4) the distribution of the work force between undertakings of culture, education, scientific research, health, and medical care on the 1 hand and economic construction on the other is improper. How to control population growth and adjust parts of the population structure to suit the national economic development poses a problem that calls for further in-depth study and analysis to resolve it step by step.     

Access to health care in urban areas of developing societies

Emphasis on rural health problems has led to a relative neglect of urban health issues in developing societies. Yet the fact that a large proportion of the limited financial and human resources is allocated to urban health care makes it imperative for researchers and health planners to evaluate the effectiveness of the urban health care system. This paper examines data on health care utilization from a sample survey of 1500 households conducted in three areas of Accra, Ghana in 1982. The factors that influence the use of three types of health care services (clinics, drug vendors, and traditional healers) are examined. Suggestions are made for increasing the effectiveness of the health care system in Accra, with the aim of making medical care more accessible to all families.     

Voluntary action in rural areas: the case of neighbourhood watch

This paper presents the results of an empirical investigation into active Neighbourhood Watch (NW) Schemes in Hereford and Worcester: an area which has experienced a rise in both crime rate and the number of active NW Schemes in the last ten years. The example of NW is used to examine the effectiveness of voluntary action to tackle social problems in rural areas and to consider the changing nature of social relations found there. More specifically, the study of these schemes allows an assessment to be made of the impact and nature of crime in rural areas and measures the effectiveness of NW in countering it. The paper reveals that NW does have an important role to play in reducing fear of crime and improving police relations. It confirms that NW operates with considerable social bias which is a recognised problem associated with voluntary action. The final discussion highlights the need for more systematic studies of the problem of rural crime.     

Should we provide oral health training for staff caring for people with intellectual disabilities in community based residential care? A cost-effectiveness analysis

Oral health training is often introduced into community-based residential settings to improve the oral health of people with intellectual disabilities (ID). There is a lack of appropriate evaluation of such programs, leading to difficulty in deciding how best to allocate scarce resources to achieve maximum effect. This article reports an economic analysis of one such oral health program, undertaken as part of a cluster randomized controlled trial. Firstly, we report a cost-effectiveness analysis of training care-staff compared to no training, using incremental cost-effectiveness ratios (ICERs). Effectiveness was measured as change in knowledge, reported behaviors, attitude and self-efficacy, using validated scales (K&BAS). Secondly, we costed training as it was scaled up to include all staff within the service provider in question. Data were collected in Dublin, Ireland in 2009. It cost between €7000 and €10,000 more to achieve modest improvement in K&BAS scores among a subsample of 162 care-staff, in comparison to doing nothing. Considering scaled up first round training, it cost between €58,000 and €64,000 to train the whole population of staff, from a combined dental and disability service perspective. Less than €15,000–€20,000 of this was additional to the cost of doing nothing (incremental cost). From a dental perspective, a further, second training cycle including all staff would cost between €561 and €3484 (capital costs) and €5815 (operating costs) on a two yearly basis. This study indicates that the program was a cost-effective means of improving self-reported measures and possibly oral health, relative to doing nothing. This was mainly due to low cost, rather than the large effect. In this instance, the use of cost effectiveness analysis has produced evidence, which may be more useful to decision makers than that arising from traditional methods of evaluation. There is a need for CEAs of effective interventions to allow comparison between programs. Suggestions to reduce cost are presented.     

Migration,urbanization, and fertility in the Philippines

3 groups of women are compared in this study of the effect of migration on fertility in a less developed country: 1) rural sedentary; 2) rural to rural migrants; and 3) rural to urban migrants. The data are from a 1970 household interview study conducted by the Institute of Behavioral Science, University of Colorado in Magsayay and Matanao, Davao Province, Mindanao, the Philippines. Social, economic, and mortality data were gathered from the household head and/or spouse for each household member and each child living elsewhere. Reproductive histories were obtained only from women for all women 15 years of age and older living in the 2 rural communities and living elsewhere. Age specific fertility rates and child woman ratios showed a declining gradient of fertility with social distance from the rural home communities. Age at marriage and education were positively associated with distance from the home communities and negatively associated with fertility. The data provide support for the hypothesis that recent migration is innovative, engaged in by more modernized persons who are motivated by aspiration to new goals, thus migration has a negative effect on fertility. Urbanization had its major impact after peak fertility years, 20-29, influencing urban migrants to bring their fertility under voluntary control. No such curtailment appeared in the late reproductive behavior of rural sedentary or migrant women. Urbanization seems to have a negative effect on fertility independent of migration. Young migrant women, in their teens, particularly those migrating to urban areas, did not fit the social mobility model; they tended to complete fewer years of school and married at an earlier age. These young urban migrants also had higher fertility than both rural sedentary and rural migrant females while in their teen years.     

'Reconnecting' the Unemployed

This paper discusses the potential uses of the Internet and other forms of information and communication technology (ICT) as a tool for delivering information services for unemployed people, comparing the experiences and attitudes of jobseekers in peri-urban and remote rural labour markets. The analysis is based upon research carried out in two areas: the first combining a remote rural town with a much larger, more sparsely populated, rural 'travel-to-work area'; the second, a centrally located peri-urban labour market. Survey research undertaken in the study areas gathered responses from 490 unemployed jobseekers. Emerging issues were then followed up during twelve focus groups. The study found that the use of ICT for job seeking remained a marginal activity for most unemployed people, but was much more important in remote rural communities. In these areas, jobseekers were more likely to use the Internet as a search tool and were particularly dependent on telephone helplines provided by the public employment service (PES). However, the study also found that a 'digital divide' was evident within the unemployed client group. Those with low educational attainment, the long-term unemployed, young people and those perceiving their ICT skills to be 'poor' were less likely to use the Internet. Although respondents in rural areas were more likely to use ICT to look for work, they also pointed to the overriding importance of informal, social networks as a means of sharing job information in remote communities. We conclude that ICT may have a future role in the delivery of services for jobseekers, especially in rural areas. However, policies are required to ensure that information provided through ICT-based services is locally relevant, and disadvantaged groups have access to the facilities and training they require.