Neck circumference as a predictor of all-cause mortality in middle-aged and older adults in rural Ecuador

BACKGROUND

Neck circumference (NC) has been associated with mortality secondary to cardiovascular diseases and other conditions. However, information on this association in the population at large is limited. We aimed to assess this association in community dwellers living in rural Ecuador.

METHODS

Individuals aged ≥40 y who were enrolled in the population-based Three Villages Study cohort were prospectively followed to estimate mortality risk according to baseline measurements of NC, after adjusting for relevant confounders.

RESULTS

Analysis included 1521 individuals followed for a mean of 6.4±3.4 y. Mean NC was 36.2±3.7 cm, with 509 (33%) individuals allocated to the first (25-34 cm), 319 (21%) to the second (36-37 cm), 417 (27%) to the third (37-39 cm) and 276 (18%) to the fourth (40-50 cm) quartile. A total of 211 (14%) individuals died during the follow-up. Overall, the crude mortality rate was 2.3 per 100 person-years, which increased to 5.63 for those in the fourth NC quartile. An adjusted Cox-proportional hazards model showed that individuals in the fourth quartile of NC had higher mortality risk compared with the first quartile (HR: 2.98; 95% CI 1.77 to 5.02).

CONCLUSION

Larger NC increases mortality risk in middle-aged and older adults of indigenous ancestry living in rural Ecuador.

Social Capital and Rural Health for Refugee Communities in Australia

Refugee resettlement significantly contributes to Australia's migration programs, with recent policy directives prioritising rural resettlement. As a result, the cultural diversity of populations of several Australian rural towns has substantially expanded. Newcomers may encounter challenges becoming part of closed social networks and accessing the resources they need for a healthy life in resettlement. However, there are also benefits that stem from positive integration for newcomers and for receiving populations. As part of a larger study, which aimed to explore facilitators and barriers to successful resettlement in a rural setting, the objective of this paper was to show how social ties were important for participants' health, both facilitating access to resources, including health services, and connecting people to health-promoting living conditions. In-depth individual interviews with 44 participants from refugee communities originally from Africa and South-East Asia, settled in a rural South Australian town, were conducted. Participants were invited to the study through snowball sampling via known connections between the researchers and key people within the communities. Interview transcripts were analysed using framework thematic analysis. The findings demonstrate how participants drew on connections within their cultural communities, reflecting collectivist cultural values. These social ties were key to enabling access to resources for health. These included emotional resources, such as a sense of belonging, as well as physical and practical resources, including food, housing, and/or accessing services. Several participants were also working towards a career in the health industry. Populations from refugee communities in rural towns are growing, not only with the continuation of new arrivals to these towns, but also as the settled populations expand their families and communities. Effective health service provision in these locations needs to serve these growing communities, and there is scope for services to tap into community networks to assist with this.

Developing fit-for-purpose funding models for rural settings: Lessons from the evaluation of a step-up/step-down service in regional Australia

INTRODUCTION

Sub-acute mental health community services provide a bridging service between hospital and community care. There is limited understanding of the local factors that influence success, and of the funding implications of delivering services in rural areas.

METHODS

This paper draws from quantitative and qualitative evaluation data from a regional Western Australian service to explore these issues.

RESULTS

Consumers satisfaction with the service was high and, overall, admission to the service resulted in positive outcomes. High re-admission rates may be linked to limited community support services following discharge.

DISCUSSION

Our results suggest that outcomes may be enhanced by implementing flexible approaches that address the resource limitations of the rural context, and that the current funding model for sub-acute mental health services in rural Australian may not be fit for purpose. More needs to be understood about how these services can be better integrated with existing support services, and how they can be better funded.

Norwegian Open Fracture Management System: Outcomes After 10 Years Working in Low-Resource Settings in Cambodian Hospitals

INTRODUCTION

The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings.

MATERIALS AND METHODS

A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups.

RESULTS

The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work.

CONCLUSION

The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.

Social determinants of health and cognitive performance of older adults living in rural communities: The Three Villages Study

OBJECTIVES

There is limited information on factors associated with poor cognitive performance in rural settings of Low- and Middle-Income Countries. Using the Three Villages Study Cohort, we assessed whether social determinants of health (SDH) play a role in cognitive performance among older adults living in rural Ecuador.

METHODS

Atahualpa, El Tambo and Prosperidad residents aged ≥60 years received measurement of SDH by means of the Gijon Scale together with a Montreal Cognitive Assessment (MoCA). The association between SDH and cognitive performance (dependent variable) was assessed by generalized linear models, adjusted for demographics, years of education, cardiovascular risk factors, symptoms of depression and biomarkers of structural brain damage.

RESULTS

We included 513 individuals (mean age: 67.9 ± 7.3 years; 58% women). The mean score on the Gijon scale was 9.9 ± 2.9 points, with 237 subjects classified as having a high social risk (≥10 points). The mean MoCA score was 19.6 ± 5.4 points. Locally weighted scatterplot smoothing showed an inverse linear relationship between SDH and MoCA scores. SDH and MoCA scores were inversely associated in linear models adjusted for clinical covariates (β: -0.17; 95% C.I.: -0.32 to -0.02; p = 0.020), neuroimaging covariates (β: -0.17; 95% C.I.: -0.31 to -0.03; p = 0.018), as well as in the most parsimonious model (β: -0.16; 95% C.I.: -1.30 to -0.02; p = 0.026).

CONCLUSIONS

Study results provide robust evidence of an inverse association between SDH and cognitive performance. Interventions and programs aimed to reduce disparities in the social risk of older adults living in underserved rural populations may improve cognitive performance in these individuals.

Patient Assessment: Using the Oncology Nurse Navigator Patient Assessment for Rural and Other Resource-Poor Settings

Oncology nurse navigators (ONNs) rely on assessment tools to identify patient priorities so that care may be expedited along the cancer continuum. Few nonproprietary assessment tools exist for ONNs who work in rural and other resource-poor settings to reliably identify and track patient needs and barriers for seamless and timely oncology care.

Behavioral Health Needs, Barriers, and Parent Preferences in Rural Pediatric Primary Care

OBJECTIVE

The goal of this study was to examine modifiable factors related to health disparities by exploring the role of predisposing, need, and enabling characteristics on mental/behavioral health treatment-seeking behaviors in a rural sample. Parental treatment preferences and knowledge about treatment options were also examined.

METHODS

One hundred eighteen parents completed questionnaires assessing demographics, child prior psychological treatment, child psychological symptoms, barriers to care, mental health stigma, and willingness to seek services across settings. Questions also assessed preferences for treatment, awareness of behavioral/mental health services, and knowledge of community treatment options.

RESULTS

Prior treatment use and stigma significantly predicted willingness to seek services in a doctor's office after controlling for predisposing (demographic) and need characteristics (psychological symptoms). Symptom severity and barriers significantly differentiated between parents who previously sought treatment or reported an unmet treatment need from those who reported no prior treatment and no treatment need. Families overwhelmingly (94%) reported a preference for individual versus group treatment, and up to 10 sessions were most commonly reported (38%) as the ideal number of sessions. Forty percent of respondents reported no knowledge of treatment options in their community.

CONCLUSIONS

These results highlight the role of enabling characteristics (i.e., stigma, barriers to care, psychological symptoms) and prior service use in understanding parental treatment seeking in a rural sample. Overall, these results support integrated behavioral health in rural settings. Understanding modifiable factors and parent treatment preferences and knowledge may be important to increase access to services and reduce health disparities in rural areas. Future research directions are discussed.

Location Matters: Geographic Disparities and Impact of Coronavirus Disease 2019

The COVID-19 pandemic in the United States has revealed major disparities in the access to testing and messaging about the pandemic based on the geographic location of individuals, particularly in communities of color, rural areas, and areas of low income. This geographic disparity, in addition to deeply rooted structural inequities, have posed additional challenges to adequately diagnose and provide care for individuals of all ages living in these settings. We describe the impact that COVID-19 has had on geographic disparate populations in the United States and share our recommendations to what might be done to ameliorate the current situation.

Prevalence of Maternal Postpartum Depression, Health-Seeking Behavior and Out of Pocket Payment for Physical Illness and Cost Coping Mechanism of the Poor Families in Bangladesh: A Rural Community-Based Study

The burden of depression is high globally. Maternal depression affects the mother, the child, and other family members. We aimed to measure the prevalence of maternal postpartum depressive (PPD) symptoms having a child aged 6–16 months, health-seeking behavior for general illness of all family members, out of pocket (OOP) payments for health care and cost coping mechanisms. We conducted a cross sectional study with 591 poor families in rural Bangladesh. The survey was conducted between August and October, 2017. Information was collected on maternal depressive symptoms using the Self Reporting Questionnaire (SRQ-20), health-seeking behavior, and related costs using a structured, pretested questionnaire. The prevalence of depressive symptoms was 51.7%. Multiple logistic regression analysis showed that PPD symptoms were independently associated with maternal age (p = 0.044), family food insecurity (p < 0.001) and violence against women (p < 0.001). Most (60%) ill persons sought health care from informal health providers. Out of pocket (OOP) expenditure was significantly higher (p = 0.03) in the families of depressed mothers, who had to take loan or sell their valuables to cope with expenditures (p < 0.001). Our results suggest that postpartum depressive symptoms are prevalent in the poor rural mothers. Community-based interventions including prevention of violence and income generation activities for these economically disadvantaged mothers should be designed to address risk factors. Health financing options should also be explored for the mothers with depressive symptoms

Cerebrovascular Correlates of Dementia in Community-Dwelling Older Adults Living in Rural Communities - The Three Villages Study. Rationale and Protocol of a Population-Based Prospective Cohort Study

BACKGROUND

Despite the assumption that dementia is increasing in rural areas of Latin America, there is no information on the burden and risk factors leading to dementia in these settings.

AIMS

To assess prevalence and incidence of dementia, and its cerebrovascular correlates in an established cohort of community-dwelling older adults living in rural Ecuador, and to explore the impact of dementia on functional disability and the role of the social determinants of health in the above-mentioned relationships.

DESIGN

Population-based, cohort study with cross-sectional and longitudinal components. Baseline clinical interviews will focus on the assessment of cognitive performance and dementia by means of the clinical dementia rating scale (CDRS). Functional disability and social determinants of health will be correlated with CDRS scores. In addition, participants will undergo interviews and procedures to assess cardiovascular risk factors and signatures of brain damage, cerebral small vessel disease, and other stroke subtypes. The CDRS and the Functional Activities Questionnaire will be administered every year to assess the rate of incident dementia and the severity of functional disability. Neuroimaging studies will be repeated at the end of the study (5 years) to assess the impact of newly appeared cerebral and vascular lesions on cognitive decline.

COMMENT

This study will allow determine whether cerebrovascular diseases are in the path of dementia development in these rural settings. This may prove cost-effective for the development of preventive strategies aimed to control modifiable factors and reduce disability in patients with dementia living in underserved populations.

Changing patterns of mental health knowledge in rural Kenya after intervention using the WHO mhGAP-Intervention Guide

BACKGROUND

Despite the high prevalence of mental disorders, mental health literacy has been comparatively neglected. People's symptom-management strategies will be influenced by their mental health literacy. This study sought to determine the feasibility of using the World Health Organization mhGAP-Intervention Guide (IG) as an educational tool for one-on-one contact in a clinical setting to increase literacy on the specified mental disorders.

METHODS

This study was conducted in 20 health facilities in Makueni County, southeast Kenya which has one of the poorest economies in Kenya. It has no psychiatrist or clinical psychologist. We recruited 3267 participants from a community that had already been exposed to community mental health services. We used Mental Health Knowledge Schedule to measure the changing patterns of mental health knowledge after a period of 3 months, following a training intervention using the WHO mhGAP-IG.

RESULTS

Overall, there was a significant increase in mental health related knowledge [mean range 22.4-23.5 for both post-test and pre-test scores (p < 0.001)]. This increase varied with various socio-demographic characteristics such as sex, marital status, level of education, employment status and wealth index.

CONCLUSIONS

mhGAP-IG is a feasible tool to increase mental health literacy in low-resource settings where there are no mental health specialists. Our study lends evidence that the WHO Mental Health Action Plan 2013-2020 and reduction of the treatment gap may be accelerated by the use of mhGAP-IG through improving knowledge about mental illness and potentially subsequent help seeking for early diagnosis and treatment.

Clinical and neuroimaging risk factors for cognitive decline in community-dwelling older adults living in rural Ecuador. A population-based prospective cohort study

OBJECTIVE

There is limited information on factors influencing cognitive decline in rural settings from low- and middle-income countries. Using the Atahualpa Project cohort, we aimed to assess the burden of cognitive decline in older adults living in a rural Ecuadorian village.

METHODS

The study included Atahualpa residents aged greater than or equal to 60 years who had a follow-up Montreal Cognitive Assessment (MoCA) repeated at least 1 year after baseline. MoCA decline was assessed by multivariable longitudinal linear models, adjusted for demographics, days between MoCA tests, cardiovascular risk factors, and neuroimaging signatures of structural brain damage.

RESULTS

We included 252 individuals who contributed 923.7 person-years of follow-up (mean: 3.7 ± 0.7 years). The mean baseline MoCA was 19.5 ± 4.5 points, and the follow-up MoCA was 18.1 ± 4.9 points (P = 0.001). Overall, 154 individuals (61%) had lower MoCA scores at follow-up. The best fitted longitudinal linear model showed a decline of follow-up MoCA from baseline (β: 0.14; 95% CI, 0.0-0.21; P < 0.001). High glucose levels, global cortical atrophy, and white matter hyperintensities were independently and significantly associated with greater MoCA decline.

CONCLUSION

This study provides evidence of cognitive decline in older adults living in a rural setting. Main targets for prevention should include glucose control and the control of factors that are deleterious for the development of cortical atrophy and white matter hyperintensities.

Care Coordination: Overcoming Barriers to Improve Outcomes for Patients With Hematologic Malignancies in Rural Settings

BACKGROUND

Most patients with cancer experience financial, emotional, and logistical barriers to care that significantly affect their adherence to and successful completion of treatment. However, patients with hematologic malignancies, particularly those who live in rural settings, must also contend with additional challenges.

OBJECTIVES

This article aims to synthesize the literature about barriers to timely access to care and to coordination of this care for patients with hematologic malignancies, particularly those in rural settings, as well as identify strategies to improve cancer care delivery for those patients.

METHODS

A search of the literature from 2008-2018 pertaining to rural health disparities for patients with hematologic malignancies, along with ways to overcome these disparities, was conducted.

FINDINGS

Patients with hematologic malignancies, particularly those who reside in rural settings, face complex barriers to care. These barriers cause emotional and physical distress. A team approach to care coordination that is focused on eliminating these barriers and improving outcomes is needed.

Using Ethnography to Identify Barriers and Facilitators to Optimal Infant and Young Child Feeding in Rural Ghana: Implications for Programs

BACKGROUND

Understanding the context of infant and young child feeding (IYCF) is recognized as essential for designing appropriate complementary feeding interventions.

OBJECTIVE

Our objective was to study household IYCF behaviors in 2 districts in southern and northern Ghana to identify opportunities to improve existing nutrition programs.

METHODS

We interviewed 80 caregivers of children aged 6 to 23 months using ethnographic methods, including free listing, guided discussions and cognitive mapping techniques, and 24-hour dietary recall. Descriptive statistics and thematic content analysis were used to analyze quantitative and qualitative data.

RESULTS

In both settings, children's diets were predominantly maize based. Fish, the main animal source food, was consumed daily but in very small quantities. Milk was consumed by only a few children, in tea and porridge. Fruits were seldom consumed. Household food production did not meet requirements, and the markets were heavily relied on for staples and other key ingredients. Most caregivers demonstrated basic knowledge and understanding of key health and nutrition concepts. Barriers to optimal child feeding identified were lack of money to purchase the nutritious foods recommended for children, seasonal food insecurity, and some caregiver beliefs, practices, and nutrition knowledge gaps. Positive contextual features include caregiver recognition of the dietary needs of young children and commitment to provide foods to meet these needs.

CONCLUSION

Our findings suggest that complementary feeding in these rural settings can be improved through reinforcement or modification of strategic components of local health and nutrition education in light of existing barriers and enablers to optimal IYCF.

Water and sanitation hygiene knowledge, attitude, and practices among household members living in rural setting of India

Background:

Rural population in developing countries face water, sanitation, and hygiene-related health issues. To objectively highlight these issues, we studied the knowledge, attitude, and practices-related to drinking water and sanitation facilities among the rural population of Chennai, India.

Materials and Methods:

A cross-sectional study was designed involving individuals over 18 years of age living in Thandalam village, Chennai, India. Basic information about sociodemographic profile and existing drinking water and sanitation related knowledge, attitude, and practices was collected using a modified version of previously validated questionnaire and analyzed.

Results:

Forty-five percent of the participants were not following any methods of water treatment and among them half of the participants felt that water available to them was clean and did not require any additional treatment. Twenty-five percent of the participants surveyed did not have access to toilets inside their household.

Conclusion:

There is a need for intervention to educate individuals about drinking water treatment methods, sanitation, and hand washing practices.

Health-promoting practices and the factors associated with self-reported poor health in caregivers of children orphaned by AIDS in southwest Uganda

Informal caregivers worldwide are faced with the dilemma of maintaining their health and meeting the caregiving demands of their loved ones. This study explores the health outcomes of caregiving, caregivers' health-promoting practices and the challenges to providing care among caregivers to children orphaned by AIDS in southwest Uganda. A descriptive design and interview questionnaires were used to collect data from 204 caregivers. The average age of the caregivers was 41.36 (±10.9) years and most of them (53%) were grandmothers to the orphans. The majority (65%) of the caregivers were caring for at least three orphans, had been in the caregiver role for more than five years (61%), and stated that their health had been negatively impacted by caregiving (61%). According to self-reports, the most common new health problems since taking up the caregiving role were chronic ill health (97%), social isolation (95%) and mental stress (92%). The health-promoting practices most often engaged in were eating a balanced diet (67%), seeking spiritual support (58%), and performing self-care activities (44%). The challenges to caregiving most often reported were poverty (88%) and a lack of time to seek personal medical care (59%). The predictors of self-reported poor health among the caregivers were stress (odds ratio [OR] = 3.43; p ≤ 0.01), caring for three or more orphans (OR = 2.19; p ≤ 0.01), female gender (OR = 1.77; p ≤ 0.01), and having spent more than five years as a caregiver to an orphan (OR = 1.35; p ≤ 0.01). The findings suggest that caregivers commonly experience poor health and their health-promoting practices are inadequate. There is a need for organised and formal health-promotion programmes for caregivers of children orphaned by AIDS, especially in rural areas of developing countries. Interventions for health promotion can be achieved through integrated programmes that provide health education, social services, respite from caregiving and counselling.

[HIV/TB co-infection in rural settings of Benin: case of the Djougou-Ouake-Copargo sanitary district (north-west Benin)]

AIMS

we measured the burden of TB/HIV co-infection in a rural setting of Benin, and assessed the outcome of tuberculosis treatment at the end of the intensive phase of TB treatment.

METHODS

This is a retrospective, cross-sectional, descriptive study, covering January 2006 to December 2011.

RESULTS

A total of 256 patients were included, 67 (26.1%) were HIV +. A minority, 25% of co-infected HIV / PTB, had TB bacilli high density (+++) versus 45% of mono-infected (P = 0.005). The smear conversion was obtained in 96% of coinfected versus 93% in HIV- at the end of the intensive phase (P = 0.5). The cure rate was 86% and 93.1% respectively in co-infected and HIV-. A proportion of 13.5% of co-infected died versus 3% in HIV- (P = 0.005). 21% of co-infected with CD4 <200 died versus 3.6% of those with CD4> 200 (P = 0.041).

CONCLUSION

This work underlines the high prevalence of HIV / TB co-infection in this region. Co-infected patients respond well to treatment, but their mortality is high when they are very immunocompromised.

[HIV/TB co-infection in rural settings of benin: case of Djougou-Ouake-Copargo district (north-west Benin]

AIMS

We measured the burden of HIV/tuberculosis (HIV/TB) co-infection in people infected by TB in rural settings of Benin, and assessed the outcome of TB treatment at the end of the intensive phase.

METHODS

This is a retrospective, cross-sectional, descriptive study, covering January 2006 to December 2011.

RESULTS

A total of 256 patients were gathered, 67 (26.1%) were HIV +. A proportion of 25% of co-infected HIV / PTB had TB bacilli high density (+++) versus 45% of mono-infected (P = 0.005). The smear conversion was obtained in 96% of coinfected versus 93% in HIV- at the end of the intensive phase (P = 0.5). The cure rate was 86% and 93.1% respectively in co-infected and HIV-. A proportion of 13.5% of co-infected died versus 3% in HIV- (P = 0.005). 21% of co-infected with CD4 <200 died versus 3.6% of those with CD4> 200 (P = 0.041).

CONCLUSION

This work underlines the high prevalence of HIV / TB co-infection in this region. Co-infected patients respond well to treatment, but their mortality is high when they are very immunocopromissed.