A shared care model pilot for palliative home care in a rural area:Impact on symptoms, distress, and place of death

Context: Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs. Objectives: To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death. Methods: An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models. Results: Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed. Conclusion: Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration. © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The Effects of Lead Sources on Oral Bioaccessibility in Soil and Implications for Contaminated Land Risk Management

Lead (Pb) is a non-threshold toxin capable of inducing toxic effects at any blood level but availability of soil screening criteria for assessing potential health risks is limited. The oral bioaccessibility of Pb in 163 soil samples was attributed to sources through solubility estimation and domain identification. Samples were extracted following the Unified BARGE Method. Urban, mineralisation, peat and granite domains accounted for elevated Pb concentrations compared to rural samples. High Pb solubility explained moderate-high gastric (G) bioaccessible fractions throughout the study area. Higher maximum G concentrations were measured in urban (97.6 mg kg−1) and mineralisation (199.8 mg kg−1) domains. Higher average G concentrations occurred in mineralisation (36.4 mg kg−1) and granite (36.0 mg kg−1) domains. Findings suggest diffuse anthropogenic and widespread geogenic contamination could be capable of presenting health risks, having implications for land management decisions in jurisdictions where guidance advises these forms of pollution should not be regarded as contaminated land.

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia

Aim: To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications. 

Methods: A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded. 

Results/conclusions: Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p <. 0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed.

Factors influencing the success of rural cataract surgery programs in China:The study of hospital administration and relative productivity (SHARP)

PURPOSE. To explore factors potentially influencing the success or failure of rural Chinese hospitals in increasing cataract surgical output and quality. METHODS. Focus groups (FGs, n = 10) were conducted with hospital administrators, doctors, and nurses at 28 county hospitals in Guangdong Province. Discussions explored respondents' views on increasing surgical volume and quality and improving patient satisfaction. Respondents numerically ranked possible strategies to increase surgical volume and quality and patient satisfaction. FG transcripts were independently coded by two reviewers utilizing the constant comparative method following the grounded theory approach, and numerical responses were scored and ranked. RESULTS. Ten FGs and 77 ranking questionnaires were completed by 33 administrators, 23 doctors, and 21 nurses. Kappa values for the two coders were greater than 0.7 for all three groups. All groups identified a critical need for enhanced management training for hospital directors. Doctors and nurses suggested reducing surgical fees to enhance uptake, although administrators were resistant to this. Although doctors saw the need to improve equipment, administrators felt current material conditions were adequate. Respondents agreed that patient satisfaction was generally high, and did not view increasing patient satisfaction as a priority. CONCLUSIONS. Our findings highlight agreements and disagreements among the three stakeholder groups about improving surgical output and quality, which can inform strategies to improve cataract programs in rural China. Respondents' beliefs about high patient satisfaction are not in accord with other studies in the area, highlighting a potential area for intervention. © 2013 The Association for Research in Vision and Ophthalmology, Inc.

Attitudes of students, parents, and teachers toward glasses use in rural China.

OBJECTIVE:

To use focus groups to understand barriers to glasses use among children in rural China.

METHODS:

Separate focus groups were conducted between December 17, 2007, and August 5, 2008, for the following 3 groups at each of 3 schools in rural China: children aged 14 to 18 years with myopia of less than -0.5 diopters in both eyes, those children's parents, and those children's teachers. Participants were also asked to rank their responses to questions about glasses use. The focus group transcripts were coded independently by 2 investigators using qualitative data management software.

RESULTS:

Respondents of all 3 types indicated that glasses purchase and wear should be delayed in children with early myopia and might be harmful to the eyes. Parents and students reported being uncertain about children's actual myopia status and whether glasses should be worn. Parents ranked their most common reason for not buying glasses as being "too busy with work," whereas "too expensive" ranked low. Inconvenience was ranked as an important reason for not wearing glasses among all 3 student groups. "Accuracy of lens power" was the first-ranked requirement for glasses among all student groups, whereas "new and attractive styles" was ranked last by all. All 3 types of respondents believed that wearing glasses or failing to wear them might worsen myopia.

CONCLUSIONS:

Educational programs are needed to address significant knowledge gaps in families and schools about glasses use in rural China. Cost and the need for attractive styles may not be significant barriers to use in this setting, raising the possibility of paying for such programs through cost recovery.

Understanding barriers to cataract surgery among older persons in rural China through focus groups.

PURPOSE: To utilize focus groups (FGs) to identify barriers to cataract surgery specific to older persons in rural Guangdong, China. METHODS: Three focus groups in separate locations were carried out for persons aged 60 years and above with best-corrected vision <= 6/18 due to cataract, either accepting or refusing surgery. Participants also ranked responses to questions about acceptance of surgery among the elderly. FG transcripts were coded independently by two investigators using qualitative data management software. RESULTS: Twenty participants had a mean age of 72.7 ± 6.1 years, 14 (70.0%) were women and 17 (85.0%) were blind (best-corrected vision <= 6/60) in at least one eye. Cost was ranked by two of three groups as the main barrier to surgery, and all groups listed reducing cost as the best strategy to increase surgical uptake. Many respondents planned to use China's New Cooperative Medical Scheme (NCMS) health insurance to pay for surgery. Participants showed poor understanding of cataract, but ranked educational interventions low as methods of increasing uptake. Though opinions of local service quality were poor, respondents did not see quality as an important barrier to accepting service. Participants frequently depended on family members to pay for surgery. CONCLUSIONS: Contrary to some previous reports, cost may be an important barrier to cataract surgery in rural China, which NCMS may help to alleviate. Educational interventions to increase knowledge about cataract are needed, but may face skepticism among patients. Strategies to promote cataract surgery should target the entire family.

Prevention of Cataract Blindness in Rural China.

China has undergone dramatic economic and social reforms during last 30 years, leading to a notably higher level of living standards and health care access for Chinese citizens. However, China's cataract surgical rate of 780 cases/y per million population trails Asian neighbors with lower income levels such as India and Vietnam. Eye care providers and patients encounter many barriers in gaining access to one another.Hands-on training programs conducted by international nongovernmental organizations and the government have helped to increase the number of qualified cataract surgeons in rural area, but establishing a residency training system that produces ophthalmologists capable of performing independent surgery is the only sustainable way to meet the increasing demand for surgery from an aging population. The New Rural Cooperative Medical System has successfully reduced the financial burden of cataract surgery for the rural population; however, reimbursement for outpatient treatment of leading eye diseases is needed.Community outreach screening combined with education is essential in rural areas' increased demand for surgery. Methods to optimize the yield from such screening must still be devised and proven, however. Improvements in the hospital administration and management structure are also needed to improve the efficiency of China's rural hospitals in delivering high-quality, low-cost cataract surgical services.

Assessing elements of a family approach to reduce adolescent drinking frequency: parent-adolescent relationship, knowledge management, and keeping secrets

AIMS: To estimate 1) the associations between parent-adolescent relationship, parental knowledge and subsequent adolescent drinking frequency and 2) the influence of alcohol use on parental knowledge.

DESIGN: Path analysis of school based cohort study with annual surveys SETTING: Post primary schools from urban and intermediate/rural areas in Northern Ireland PARTICIPANTS: 4,937 post primary school students aged around 11 years in 2000 followed until around age 16 in 2005.

MEASUREMENTS: Pupil reported measures of: frequency of alcohol use; parental-child relationship quality; sub-dimensions of parental monitoring: parental control, parental solicitation, child disclosure and child secrecy.

FINDINGS: Higher levels of parental control (Ordinal logistic OR 0.86 95% CI 0.78, 0.95) and lower levels of child secrecy (OR 0.83 95% CI 0.75 0.92) were associated with less frequent alcohol use subsequently. Parental solicitation and parent-child relationship quality were not associated with drinking frequency. Weekly alcohol drinking was associated with higher subsequent secrecy (Beta -0.42 95% CI -0.53, -0.32) and lower parental control (Beta -0.15 95% CI -0.26, -0.04). Secrecy was more strongly predictive of alcohol use at younger compared with older ages (P=0.02), and alcohol use was less strongly associated with parental control among families with poorer relationships (P=0.04).

CONCLUSIONS: Adolescent alcohol use appears to increase as parental control decreases and child secrecy increases. Greater parental control is associated with less frequent adolescent drinking subsequently, while parent-child attachment and parental solicitation have little influence on alcohol use. 

Stakeholder participation in sustainable forest management in fire-prone areas

Os incêndios florestais, associados ao abandono do espaço rural, a pequena propriedade florestal e o desinteresse e o absentismo dos proprietários florestais têm sido apontados como fatores que têm afetado a sustentabilidade das florestas em Portugal. Apesar da formulação de políticas e de instrumentos de planeamento e de gestão florestal para lidar com estes constrangimentos, são ainda escassos os progressos para uma Gestão Florestal Sustentável. A nível internacional e europeu, a participação dos agentes já representa um aspeto-chave no processo de definição e de implementação de estratégias que promovam a multifuncionalidade da floresta, mas também se adeqúem às necessidades e aos interesses dos agentes locais. A temática da tese esteve focada nesta discussão, argumentando que existe uma escassa participação dos agentes nos processos de tomada de decisão relativos ao setor florestal. O principal objetivo da investigação foi o desenvolvimento de uma metodologia participativa para a discussão e negociação de estratégias locais para a Gestão Florestal Sustentável, que maximizem o potencial produtivo e o papel sócio-ambiental das florestas, diminuam o risco de incêndio e promovam o crescente interesse e participação dos agentes locais na gestão florestal. A tese está estruturada em três partes. A primeira parte apresenta uma avaliação do sector florestal nacional, com base numa revisão bibliográfica e numa comparação de indicadores, políticas e instrumentos de planeamento e gestão florestal (Capítulo 2) e com base num estudo de perceção social desenvolvido numa área de estudo localizada na região Centro de Portugal. Este estudo analisa as perceções técnicas (decisores políticos e técnicos) e sociais (proprietários florestais e outros membros da comunidade local) sobre as florestas, a gestão florestal e os incêndios florestais (Capítulo 4). As ‘Zonas de Intervenção Florestal’, enquanto ferramenta recente para a cooperação e organização dos proprietários e produtores florestais, foram também analisadas (Capítulo 3). A segunda parte da tese é dedicada à análise de processos de participação pública, com base numa revisão bibliográfica sobre os benefícios, níveis, abordagens e métodos de participação (Capítulo 5) e numa avaliação de processos de participação pública desenvolvidos em Portugal (Capítulo 6). A terceira parte da tese foca-se no desenho e no teste da metodologia participativa proposta no âmbito desta tese (Capítulo 7) e na formulação de algumas orientações para melhoria dos processos participativos na gestão florestal (Capítulo 8). Os resultados confirmaram a centralidade dos incêndios florestais e dos fatores associados ao contexto socioeconómico (e.g. despovoamento e envelhecimento populacional, absentismo, falta de gestão florestal, estrutura fundiária) como os principais problemas que afetam a floresta na região Centro de Portugal. A organização e cooperação dos proprietários florestais emergiu como solução possível para lidar com estas ameaças e promover a multifuncionalidade da floresta, sendo essencial aumentar o conhecimento e a participação dos agentes nas decisões associadas à floresta. É proposta uma ferramenta para esta participação, centrada no contexto local e facilmente utilizável por todos os agentes. A implementação da metodologia participativa revelou o seu potencial no desenvolvimento de uma participação equitativa e inclusiva dos múltiplos agentes.

Beach quality assessment and management in the Sotavento (Eastern) Algarve, Portugal

The purpose of this study on beach quality assessment and management was to evaluate the quality of five beaches in the Algarve Sotavento region of Portugal and to identify beach users’ preferences and priorities regarding their visit to a beach. The Algarve is one of the country’s most internationally known regions and it is generally perceived as a major tourist destination. Because of the increasing level of tourists, there is a specific need to address beach quality, as overcrowding can result in excessive litter, reduce water quality and consequently reduce the socio-economic value of the area. The main methodology for the evaluation of the beach quality in this pilot project was the Bathing Area Registration and Evaluation framework (BARE), which recognizes five beach types (rural, remote, resort, urban and village) through five main priority issues of concern to beach users (water quality, scenery, litter, safety, facilities) and evaluates the beach quality, ranging from one (low) to five (high) stars. After overall bathing area classification, Quarteira-Vilamoura, Ilha do Farol, Ilha Deserta and Ilha da Armona received three-star rating and Quinta do Lago site obtained a one-star rating. The quantitative research data on beach users’ preferences and priorities was obtained through administration of 50 questionnaires per beach and showed that beach users at all sites expressed the need for improved cleanliness, safety and facilities on the beach. The BARE framework, together with the questionnaire surveys, allowed the identification of management priorities required to improve the quality of individual beaches and therefore increase income from tourism.

Water quality in lakes and reservoirs in China

Dissertation elaborated for the partial fulfilment of the requirements of the Master Degree in Civil Engineering in the Speciality Area of Hydarulics

How to attract central and Northeneuropeans to a rural tourism establishment in the center of Portugal

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Personal Support Workers' Experience of Collaboration in a Long-Term Care Facility in Rural Ontario

The growing complexity of healthcare needs of residents living in long-term care necessitates a high level of professional interdependence to deliver quality, individualized care. Personal support workers (PSWs) are the most likely to observe, interpret and respond to resident care plans, yet little is known about how they experience collaboration. This study aimed to describe PSWs’ current experiences with collaboration in long-term care and to understand the factors that influenced their involvement in collaboration. A qualitative approach was used to interview eight PSWs from one long-term care facility in rural Ontario. Thematic analysis revealed three themes: valuing PSWs’ contributions, organizational structure, and individual characteristics and relationships. Collaboration was a difficult process for PSWs who felt largely undervalued and excluded. To improve collaboration, management needs to provide opportunities for PSWs to contribute and support the development of relationships required to collaborate.

Exploración y análisis de las políticas educativas relativas a la educación rural en Centroamérica : casos de Costa Rica y Nicaragua

Différents organismes internationaux se sont penchés sur l’école rurale des pays en émergence. La plupart de ces travaux de recherche montrent que ces écoles n’offrent pas une éducation adaptée au milieu dans lesquelles elles sont situées, du fait essentiellement qu’on y a implanté la structure administrative et pédagogique des écoles urbaines sans tenir compte des caractéristiques de la population infantile des zones rurales. Afin de tenter de remédier aux difficultés identifiées, ces organismes ont proposé diverses solutions ou préconisé des politiques adaptées à ce contexte particulier. Le but de cette recherche est d’étudier comment ces recommandations convergent-elles avec les politiques éducatives et dans le quotidien des écoles en milieu rural de deux pays de l’Amérique centrale, le Costa Rica et le Nicaragua. À cette fin, comme cadre d'analyse, nous avons établi six catégories : condition socio-économique, plan d'études et pédagogie, relation école et communauté, enseignants, technologie et finalement, gestion et gouvernance. Pour ce faire, nous analysons les recommandations globales formulées par diverses organisations internationales et d’autres organismes des pays développés à propos de l'éducation rurale. Nous comparons ensuite ces informations avec les décisions politiques prises ces dernières vingt années, dans les deux pays sélectionnés afin de favoriser le développement éducatif des zones rurales. Pour finir, nous observons sur le terrain le quotidien de quelques écoles rurales des deux pays retenus. En partant de l’hypothèse qu’il existe suffisamment d’information et de recommandations permettant l’élaboration des politiques éducatives appropriées pour améliorer les conditions des écoles rurales, le travail présente une analyse multiniveaux (recommandations globales, politiques nationales et pratiques scolaires) en établissant la convergence ou la divergence dans chacune des catégories. Les principaux résultats de la recherche démontrent qu'il existe une convergence entre les pratiques scolaires et les politiques éducatives émises par les pays étudiés, avec quelques exceptions. Quant à la convergence entre les recommandations globales et les politiques émises par ces pays, on ne peut pas parler de convergence de façon générale. La recherche propose l'élaboration de profil de politiques nationales pour chaque pays, en fonction de la manière par laquelle ils abordent la problématique de l'éducation rurale : soit par l’assignation des ressources pour étendre les services éducatifs normalisés pour tous les enfants, ou en produisant des politiques focalisées, créant des programmes spécifiques, faisant remarquer la différence du monde rural.