This book challenges readers to rethink rural health ethics. Traditional approaches to health ethics are often urban-centric, making implicit assumptions about how values and norms apply in health care practice, and as such may fail to take into account the complexity, depth, richness, and diversity of the rural context. There are ethically relevant differences between rural health practice and rural health services delivery and urban practice and delivery that go beyond (...) the stereotypes associated with rural life and rural health services. This book examines key values in the rural context that have not been fully explored or taken into account when we examine health ethics issues, including the values of community and place, and a need to “revalue” relationships. It also advocates for a greater attention to meso and macro level analysis in rural health ethics as being critical to ethical analysis of rural health care. This book is essential reading for those involved in health ethics, rural health policy and governance, and for rural health providers. (shrink)

Proper utilization of antenatal and postnatal care services plays an important role in reducing the maternal mortality ratio and infant mortality rate. This paper assesses the utilization of health care services during pregnancy, delivery and post-delivery among rural women in Uttar Pradesh and examines its determinants. Data from a baseline survey of UP Community Mobilization project was utilized. A cross-sectional sample of currently married women who delivered a baby 15 months prior to the survey was included. (...) Information was collected from 2208 women spread over five districts of UP. Information on socio-demography characteristics, utilization of antenatal care, delivery and postnatal care services was collected. To examine the determinants of utilization of maternal health services, the variables included were three ANC visits, institutional delivery and PNC within 42 days of delivery. Separate multilevel random intercept logistic regressions were used to account for clustering at a block and gram panchayat level after adjusting for covariates. Eighty-three percent of women had any ANC. Of them, 61% reported three or more ANC visits. Although 68% of women delivered in a health facility, 29% stayed for at least 48 h. Any PNC within 42 days after delivery was reported by 26% of women. In the adjusted analysis, women with increasing number of contacts with the health worker during the antenatal period, women exposed to mass-media and non-marginalized women were more likely to have at least three ANC visits during pregnancy. Non-marginalized women and women with at least three ANC visits were more likely than their counterparts to deliver in an institution. Contacts with health worker during pregnancy, marginalization, at least three ANC visits and institutional delivery were the strong determinants for utilization of PNC services. Self-help group membership had no association with the utilization of maternal health services. Utilization of maternal health services was low. Contact with the health worker and marginalization emerged as important factors for utilization of services. Although not associated with the utilization, SHGs can be used for delivering health care messages within and beyond the group. (shrink)

This study uses data from the Ghana Demographic and Health Survey of 1993 to examine factors determining the use of maternal–child health services in rural Ghana. The MCH services under study are: use of a doctor for prenatal care; soliciting four or more antenatal check-ups; place of delivery; participation in family planning. Bivariate and multivariate techniques are employed in the analyses. The analyses reveal that the use of MCH services tends to be shaped mostly (...) by level of education, religious background and region of residence, and partially by ethnicity and occupation. The implications of these results are discussed. (shrink)

The mortality and morbidity resulting from noncommunicable diseases including cancer in sub- Saharan Africa are predicted to overtake that of infectious diseases by the year 2030. Esophageal cancer is on the increase in Tanzania. This study estimates risk factors for esophageal cancer, ethical issues and the level of awareness of cancer related services among adults in rural Kilimanjaro. A cross sectional descriptive study was conducted of adults aged 18 years and above in three wards, namely, Kahe, mabogini and (...) Arusha Chini, Moshi Rural District, Kilimanjaro region. Face-to-face interviews were conducted with a total of 419 individuals. The mean age was 36.47 =13.49) years. Of those who participated, 211 were male and 60% reported to have completed primary education. A majority of participants were knowledgeable about esophageal cancer risk factors. Overall, 15% and 23% of the participants reported to have been smoking and drinking alcohol, respectively. Male respondents were almost three times more likely to be smokers as compared to female respondents. Moreover, people who were self-employed were about five times more likely to be smokers as compared to those who were unemployed.. Male respondents were almost two times more likely to be drinkers as compared to female respondents. Overall, the level of awareness of cancer related health services was about 70%. The study findings confirm that despite a good level of knowledge about risk factors for esophageal cancer, the practice of exposure to risk factors is alarmingly high. Awareness of where to seek cancer related health services was high with hospitals been mentioned by the majority though there was low understanding on modalities of treatment among adults in Rural Kilimanjaro. Intervention measures should aim at further increasing knowledge of cancer risk factors and reduce the practice of such risks. Ethical matters including truth telling, ageism and autonomy need to be addressed to improve the perception of cancer related health issues and health seeking behaviour. (shrink)

Barriers to mental health interventions globally remain a health concern; however, these are more prominent in low- and middle-income countries. The barriers to accessibility include stigmatization, financial strain, acceptability, poor awareness, and sociocultural and religious influences. Exploring the barriers to the utilization of mental health services might contribute to mitigating them. Hence, this research aims to investigate these barriers to mental health service utilization in depth at the Kabutare District Hospital of the Southern Province of (...) Rwanda. The qualitative approach was adopted with a cross-sectional study design. The participants were patients with mental illnesses seeking mental health services at the hospital. Ten interviews were conducted in the local language, recorded, and transcribed verbatim and translated by the researchers. Thematic analysis was applied to analyze the data collected. The results revealed that the most common barriers are fear of stigmatization, lack of awareness of mental health services, sociocultural scarcity, scarcity of financial support, and lack of geographical accessibility, which limit the patients to utilize mental health services. Furthermore, it was revealed that rural gossip networks and social visibility within the communities compounded the stigma and social exclusion for patients with mental health conditions. Stigmatization should be reduced among the community members for increasing their empathy. Then, the awareness of mental disorders needs to be improved. Further research in Rwanda on the factors associated with low compliance to mental health services with greater focus on the community level is recommended. (shrink)

Ethical perspectives on regional, rural, and remote healthcare often, understandably and importantly, focus on inequities in access to services. In this commentary, we take the opportunity to examine the implications of normalizing metrocentric views, values, knowledge, and orientations, evidenced by the recent (2022) New South Wales inquiry into health outcomes and access to hospital and health services in regional, rural and remote New South Wales, for contemporary rural governance and justice debates. To do (...) this, we draw on the feminist inspired approach to rural health ethics involving analysis of power relationships developed by Simpson and McDonald and related ideas from critical health sociology. In presenting this analysis, we extend contemporary thought about spatial health inequities and structural violence. (shrink)

Purpose This study aims to explore how health informatics can underpin the successful delivery of recovery-orientated healthcare, in rural and remote regions, to achieve better mental health outcomes. Recovery is an extremely social process that involves being with others and reconnecting with the world. Design/methodology/approach An interpretivist study involving 27 clinicians and 13 clients sought to determine how future expenditure on ehealth could improve mental health treatment and service provision in the western Murray Darling Basin of (...) New South Wales, Australia. Findings Through the use of targeted ehealth strategies, it is possible to increase both the accessibility of information and the quality of service provision. In small communities, the challenges of distance, access to healthcare and the ease of isolating oneself are best overcome through a combination of technology and communal social responsibility. Technology supplements but cannot completely replace face-to-face interaction in the mental health recovery process. Originality/value The recovery model provides a conceptual framework for health informatics in rural and remote regions that is socially responsible. Service providers can affect better recovery for clients through infrastructure that enables timely and responsive remote access whilst driving between appointments. This could include interactive referral services, telehealth access to specialist clinicians, GPS for locating clients in remote areas and mobile coverage for counselling sessions in “real time”. Thus, the technology not only provides better connections but also adds to the responsiveness of any treatment available. (shrink)

Moates, Anne Most of the Australian population is concentrated in urban areas and larger regional centres. There is a belief that living in rural areas is healthier than city living. However, the opposite is generally true. Contributing factors are lack of access to health care services, attitudes to health care, cost of basic amenities and the degree of remoteness.

Nearly $2 trillion is spent annually in the U.S. treating chronic illness — yet accessibility to quality health care services in rural communities for the chronically ill and dying remains problematic. Unique barriers present special challenges to a meaningful discussion of and subsequent strategies for addressing these issues in the context of increasingly scarce resources.

Verbal autopsy presents the opportunity to understand the disease burden in many low-income countries where vital registration systems are underdeveloped and most deaths occur in the community. Advances in technology have led to the development of software that can provide probable cause of death information in real time, and research considering the ethical implications of these advances is necessary to inform policy. Our research explores these ethical issues in rural Nepal using a public health ethics framework. We considered (...) the burdens and benefits of VA and giving cause of death information to families of the deceased through qualitative research with VA interviewers, community members, national policy stakeholders and international academics. Burdens can be experienced differently, and it is important to balance the emotional burden of VA with utilization of the data to inform planning and increased access to health services. The training, support and supervision of VA interviewers should be prioritized if VA is taken to scale. Initial and ongoing community engagement is recommended in addition to engaging ethical, legal, health and policy personnel in developing protocols and systems. Integrating rigorous research while cautiously moving forward is recommended to ensure systems and responses to concerns are relevant to contexts. (shrink)

Next SectionBackground International and national agencies play a major role in setting HIV care-and-treatment priorities in low-income-countries. Little is known about priority setting at lower health-system levels. The objective of this article is to explore experiences of HIV priority decisions, at what levels these decisions are made and how they might influence the distribution of health benefits in a high-endemic region in Tanzania. Methods This is a qualitative study using observations, key documents and semistructured focus-group and individual interviews (...) (43) with health workers, patients and administrators at one regional and one district hospital. The analysis was based on an editing analysis style. Results Health workers did not perceive themselves as bedside rationing agents and they reported following national recommendations and felt they have little impact on important priority decisions. Health benefit distributions were largely determined by priority decisions made at a national level. External factors, such as eligibility criteria, inadequate funding and barriers to access seemed to play a major role in the actual distribution of health services and benefits in the region. Patient groups who were actually given high priority were the sickest patients, those living near a facility and those who could afford long journeys and frequent visits. Low-priority groups were those experiencing other co-morbidities or treatment failure, children, asymptomatic patients and the poorest. Conclusions/significance The interaction of priority setting across health-system levels and their impact on distribution of health outcomes in the population has been underestimated. The distributional pattern of health outcomes calls for further normative assessment. (shrink)

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in (...) rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children’s care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations. (shrink)

A considerable section of the population in India accesses the services of individual private medical practitioners (PMPs) for primary level care. In rural areas, these providers include MBBS doctors, practitioners of alternative systems of medicine, herbalists, indigenous and folk practitioners, compounders and others. This paper describes the profile, knowledge and some practices of the rural doctor in India and then discusses the reasons for lack of equity in health care access in rural areas and possible (...) solutions to the problem. (shrink)

The notion of social capital focuses attention on social connectedness within communities and the ways that this connectedness may affect health and well-being. There are many competing definitions of social capital but most suggest that it involves trust, social networks and reciprocity within communities, not necessarily geographically defined. The usefulness of social capital and related theories that help in understanding the function of nurses in rural communities are explored in this paper. Nurses and health service planners are (...) becoming increasingly aware of the potential contribution of community nurses in rural and/or remote areas, as evidenced in the development of nurse practitioners. Through their interrelational role and status in rural communities, nurses are often ‘immersed’ or ‘embedded’ in the social networks that make up the fabric of rural life and may therefore be important contributors to social capital. For a concept such as social capital to be useful in nursing research, it must have distinct attributes, delineated boundaries, and well-described preconditions and outcomes in multiple contexts. (shrink)

Increasingly, palliative care is being referred to as an essential programme and in some cases as a human right. Once it is recognized as such, it becomes part of the lexicon of social justice in that it can be argued that all members of society should have access to such care. However, this begs the question of how that care should be enacted, particularly in rural and remote areas. This question illustrates some of Friedrich Hayek's critiques of social justice. (...) Hayek has likened social justice to a ‘moral stone’ arguing that social justice is meaningless to the extent that society is impersonal and as such cannot be just, only those individuals who make up that society can be just. When responsibility for justice is assigned to an impersonal society, ideas of social justice can become a clarion call for whom no one is directly accountable. This opens the door for questionable macro‐level political agendas that have no capacity to enact the ideal, and worse, may suppress individual moral acts towards the desired end. Further, acts of interference at the macro level with the ideal of equal opportunity run the risk of disadvantaging other members of society. Instead, he has argued that a better approach lies in finding ways to induce and support individual moral acts that promote the human good. Hayek's arguments are particularly compelling for rural palliative care. In this paper we draw upon data from an ethnographic study in rural palliative care to illustrate the potential misfit between the ethical ideal of palliative care as expressed by rural participants and the narratives of social justice. (shrink)

Religion holds unique importance in peoplereligious factor effectiveness in rural areas. They thought that religious leaders could contribute positively to community education, and suggested ways in which they could educate the community in reproductive health issues. They also suggested various channels through which religious leaders could be approached to convince them to cooperate in reproductive health programmes. The study concludes that involving religious leaders in rural settings could enable reproductive health programmes and services to (...) reach more conservative groups in society, and thus contribute effectively to bringing about positive change in the attitudes of Pakistani society towards reproductive health. (shrink)

This article tells the empirical story of women from seven villages of Kwale, the most southeastern county in the Coast Province of Kenya that borders with Tanzania—Lunga Lunga, Godo, Perani, Umoja, Maasailand, Mpakani and Jirani—as they searched for community health, equity, gender equality and peace on their own terms. This article shows that creative health initiatives can be successfully used as mechanisms for peace building. Since 2010, the Nikumbuke-Health by All Means projects from the University of Madison-Wisconsin (...) in the United States, have trained 57 health promoters and 32 female actors on disease prevention and health promotion that have outreached approximately 120,000 inhabitants around the county enhancing unity in diversity, and breaking down the walls of ethnic hostilities and prejudice. Because of its low cost and high effectivity, the United Nations awarded N-HbAM[1] the 2013 Public Service Award as a model of best practice in gender, community development and sustainable wellbeing. [1] In 2013, at the time of the UNPS Award the projects were still called Nikumbuke-Health by Motorbike. The name was changed in 2018 as the projects broadened in scope and geographical location. (shrink)

The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional–patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional–patient relationship and allocation of resources. To (...) date, there exists a limited focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad-ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence—informed, rural-attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population. (shrink)

Publication date: 15 October 2018 Source: Author: Ehiosun O. Marvel NHIS was launched officially on 6th of June 2005. The Scheme is designed to provide comprehensive health care at affordable costs, covering employees of the formal sector, self-employed, as well as rural communities, the poor and the vulnerable groups. However, client satisfaction of services rendered continues to be a major concern for the improvement of NHIS. This study is designed to determine the level and causes of dissatisfaction (...) of clients accessing NHIS clinic at the Kubwa General Hospital, Kubwa, FCT, Abuja. This study employed a descriptive cross sectional survey. 279 NHIS enrollees were recruited for this study at the Kubwa General Hospital. Questionnaires were administered and the level of dissatisfaction and satisfaction of NHIS services were analyzed. The satisfaction rate was 69.2% while the dissatisfaction rate was 22.9%. The respondents were satisfied with the attitude of health workers in NHIS clinic, Kubwa. However, they were dissatisfied with waiting time, attitude of record officers and those in pharmacy department. This study found that the level of dissatisfaction with NHIS services is high despite a high satisfaction level. The Attitude of health workers may influence the dissatisfaction of enrollees. NHIS is still limited to the formal sector. (shrink)

The sudden outbreak of coronavirus disease 2019 has caused a huge impact on the Chinese residents' health and economic level. In the pandemic background, the country and its institutions have introduced pandemic-related insurance to stabilize the national situation. At this stage, insurance has played an increasingly important role in social life. With the popularization of insurance, the idea of buying insurance to avoid risk has gradually become popular among people. Among them, the New Rural Cooperative Medical System has (...) been farmers' common choice. The NRCMS, a mutual aid system created by farmers spontaneously in the country, plays a great role in guaranteeing farmers access to basic health services, alleviating poverty caused by disease and returning to poverty due to disease, and promoting poverty alleviation and rural revitalization. Given this backdrop, we study the efficiency of the NRCMS that can effectively promote poverty alleviation and rural revitalization and ensure the people's happy life. Implementing the Data Envelopment Analysis, we find that technological progress is one of the main factors influencing the efficiency of the NRCMS. Therefore, it is important to improve the technology for providing the efficiency of the NRCMS and promoting the happiness of the society. (shrink)

People living in rural areas make up 20 percent of the U.S. population, but only 9 percent of physicians practice there. This uneven distribution is significant because rural areas have higher percentages of people in poverty, elderly people, people lacking health insurance coverage, and people with chronic diseases. As a way of ameliorating these disparities, e-health initiatives are being implemented. But the rural e-health movement raises its own set of distributive justice concerns about the (...) digital divide. Moreover, even if the digital divide is overcome, e-health services may be of an inferior quality compared to face-to-face medical encounters. In this paper, I argue that before we can fully understand the distributive justice implications of e-health, we must first understand what distributive justice means. I argue that five elements—fairness, quality, accessibility, availability, and efficiency—constitute a general conception of justice and that all of these elements must be considered when evaluating e-health for rural health profession shortage areas. In doing so, it may be necessary to make important tradeoffs among these elements. I then examine the development of e-health programs in light of Rawls’s principle of equal opportunity and Daniels’s notion of species-typical functioning. I conclude that in the context of e-health, Rawls’s principle should be expanded to include geography as a prima facie morally relevant criterion for allocating healthcare benefits. I also conclude that Daniels’s notion of species-typical functioning provides grounds for thinking of health and some healthcare services as special goods. (shrink)

Background: Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives. Methods: We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour (...) travelling distance by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo. Results: This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change. Conclusions: The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Global Health Careers:Serving the Navajo CommunityMaricruz Merino, Jonathan Iralu, and Sonya ShinGallup Indian Medical Center (GIMC) sits on a hilltop in Gallup, New Mexico, a town of 20,000 in the four corners region of the Southwestern United States. From its third story windows one can see the red cliffs of the nearby Navajo Nation, a 27,000 square mile reservation that reaches into Arizona, northern New Mexico, and the (...) southern edges of Utah. It is a vast, rural landscape that houses more than 350,000 Navajos. For many on the reservation, healthcare is provided by Indian Health Service hospitals such as GIMC."Are you going to stay?" is a common question for new doctors at GIMC. The Navajo know that their geographic location, while beautiful and attractive to many young providers, will also be the reason they leave. It is hard for doctors to be away from their own homelands. Aging parents get sick, [End Page 86] educational opportunities arise, and children who need to be near extended family are born. But to the Navajo, the story of an individual provider is not so important or memorable. All they know is that providers come and go."Are you here to experiment on us?" is yet another question. Years of exploitation and efforts to destroy traditional ways and language have made many Navajo wary of healthcare providers, no matter how genuine their intentions. Many are so fearful of the hospital—they regard it as "the place to go die."Yet despite this initial suspicion, the Navajo are welcoming people at heart, and tend to develop relationships of trust with their providers. Parents will begin to talk about their grief over a son that has committed suicide or a daughter who died from alcoholic cirrhosis. The elderly will tell you how they care for their five orphaned grandchildren while they can barely take care of their own diabetes. A carpenter tells you he has not worked in a year and feels worthless. An HIV-positive woman will tell you she has been sleeping in a dry river bed because she has no place to go. It quickly becomes apparent that as a physician you will be treating patients with enormous social challenges in addition to complex medical conditions.The origins of the Federal Government's involvement in the healthcare of American Indians and Alaskan Natives (AI/ANs) in the 19th century arose out of both legal obligation and concern for self- preservation. Health services were promised to AI/ ANs in exchange for land, settlements, and agreements. In addition, infectious diseases endemic on reservations as a consequence of crowding and abject poverty, including smallpox and tuberculosis, were seen as a major public health concern. The responsibility of Native American health was first granted to the War Department, then to the Bureau of Indian Affairs, and finally to the Public Health Service in 1955 under the heading of the IHS, or Indian Health Service (U.S. Commission on Civil Rights, 2004; National Library of Medicine, 1994).Since then, the IHS has had many successes. Vaccination rates have gone up, and rates of pneumonia and tuberculosis have gone down significantly. Maternal and infant mortality have declined, and life expectancy has increased (Indian Health Services, 1999). Nonetheless, these improvements remain overshadowed by glaring health disparities among AI/ANs across a broad spectrum of diseases, both communicable and non-communicable, acute and chronic. Native Americans experience higher rates of obesity, diabetes, and cardiovascular disease than the general United States population. They are also more likely to die from alcohol-related causes and in accidents. Life expectancy remains more than five years less than that of the general U.S. population (U.S. Commission on Civil Rights, 2004; U.S. Department of Health and Human Services, 2000).Underlying these health indicators is the continued impoverished status of most AI/ANs. In Navajo, almost half of the population lives below the poverty line. According to the Navajo Nation, the current unemployment rate is 42% (Navajo Nation Department of Economic Development, 2011). Many Navajo on the reservation do not have running water or electricity. They heat with wood, which they chop and haul themselves—regardless... (shrink)

In this article, the author explores a model of alternative medical education being pioneered at Loyola University Chicago Stritch School of Medicine. The five-year Global Health Fieldwork Fellowship track allows two students per year to complete an extra year of medical education while living and working in a free rural clinic in the jungle lowlands of Bolivia. This alternative curricular track is unique among other existing models in that it is longitudinally immersive for at least one full additional (...) year of medical education, grounded in clinical and service learning, and heavily focused upon global health and the social components of medicine. Studies have shown that both longitudinal alternative medical curricular tracks and short-term global health electives have long-term benefits upon the professional development of participants, suggesting that the GHFF is likely to do the same. The author also argues that the GHFF is an advantageous model of global health education compared to standard offerings and provides a unique curricular model by which to foster the development of social values—such as professionalism, advocacy, and social justice—that are widely considered lacking in today’s medical education. (shrink)

Purpose This paper aims to assess the usage pattern of telecentres, how rural women frame telecentres and barriers that limit use of telecentres. Further, the study examined the effects of demographic characteristics and location on telecentre usage. Design/methodology/approach The study used a sequential mixed research design in three rural districts surrounding telecentres: Kongwa, Sengerema and Kilosa districts. The study population comprised rural women who were users and non-users of telecentres. The study conducted six focus group discussions with (...) 37 users and six FGDs with 36 non-users in the first phase of the study in 2014; questionnaires were administered to 90 users and 90 non-users in the second phase of the study in 2015. Findings The primary use of telecentres among users was to access internet, followed by information and communication technology training courses and secretarial purposes. Rural women used internet for educational purposes, followed by news, information on health issues, job opportunities, social and entertainment issues. Rural women currently using internet were more likely to be better educated and have higher incomes at both bivariate and multivariate analysis. Users indicated that they faced the following barriers towards using telecentre: short duration of ICT training, frequent power outages, low speed of internet and few computers at the telecentres. Non-users were not using telecentres because of lack of ICT skills and language barriers. Originality/value This study provides empirical evidence to telecentres, libraries and other rural ICT initiatives to design rural ICT services that are gender-sensitive and demand-driven. (shrink)

Introduction. The problems of state and local governance in sparsely populated and rural areas is relevant for the Russian Federation due to the presence of depressed areas, depopulation of the countryside, small towns, monotowns, migration of the rural population to large cities, regional capitals, other regions and abroad. These processes are typical for many other modern states. Solving the problems of rural and sparsely populated areas includes providing socially significant services, protecting the health and safety (...) of residents, developing education, creating and maintaining social infrastructure, and creating jobs. The purpose of the article is to identify the most important management problems in rural and sparsely populated areas and reveal possible solutions to these problems using the example of Great Britain. Methods. The research is based on a systematic approach to management in rural and sparsely populated areas. Analysis of factual data, legal sources, published survey results, foreign Internet sources. Comparative analysis of problems and measures of state policy in different states. Scientific novelty of the research. The author highlights the current measures taken in the UK at the central, local levels in order to overcome the problems of rural and sparsely populated areas. These activities as a basis for developing practical recommendations may be important for solving similar problems in Russian regions, including in the context of the COVID-19 epidemic and economic problems in the near future. Results. As a result the author identifies problems in the field of management in rural and sparsely populated and hard-to-reach areas, as well as possible directions of state policy in the UK and Russia to overcome these problems. Conclusions. The most important direction of state policy for solving the problems highlighted in the study is the development of local interests of the community, the integration of state support measures and local events. As measures aimed at solving social and infrastructural problems of sparsely populated areas in the UK, one can single out government programs implemented at the national and regional levels with the participation of industrial enterprises and businesses, a grant mechanism for the implementation of financial support, combined with the empowerment of local communities. There is no such policy in Russia yet. (shrink)

The stigmatisation of the gecekondu in post-1945 Turkey is a common theme in the literature. However, these studies have drawn little connection with health issues, even though these are known to be important in the mechanisms of stigmatisation. Policies for tuberculosis (TB) control—then Turkey's “number one health issue”—have tended to focus on individual and biological factors, to the detriment of social or environmental ones that could contribute to making TB a matter of politics and not only of policies. (...) A close study of the practices of the numerous TB-control actors nevertheless reveals an entanglement of the social, the environmental, and the medical questions. Through the emblematic but unknown case study of the TB-control pilot area created in Zeytinburnu in 1961, this article studies discourses, but also graphic representations, portraying the gecekondu as unhealthy, revealing an underlying environmental conception of TB among Turkish public health actors. The choice of Istanbul's biggest gecekondu neighbourhood to be a pilot area originated from a common conception of the gecekondu areas as pathogenic, but also contributed to reinforcing this vision and adding it to the very definition of the gecekondu. It thus participated in the stigmatisation of these areas and their inhabitants, even if some of the study's conclusions undermined the common vision of the gecekondu as populated by poor, rural migrants. However, the pilot project was also conceived as a way to integrate the inhabitants into the modern city. The “pilot” character of the area, if characteristic of the vocabulary of the 1960s, which were also the time of the attempt to “socialise the health services” in Turkey, is questionable. The project displayed a desire to know and control this specific territory rather than a genuine promotion of broader environmental changes to be replicated on a national scale. (shrink)

Background: Health researchers must weigh the benefits and risks of publishing their findings.Objective: To explore differences in decision making between rural health researchers and managers on the publication of research from small identifiable populations.Method: A survey that investigated the attitudes of Australian rural general practitioners to nurse practitioners was explored. Decisions on the study’s publication were analysed with bioethical principles and health service management ethical decision-making models.Results: Response rate was 78.5% . 84–94% of GP responders (...) considered it to be undesirable for nurse practitioners to initiate referrals to medical specialists , to initiate diagnostic imaging and to prescribe medication .Bioethical analysis: It was concluded that the principle of beneficence outweighed the principle of non-maleficence and that a valid justification for the publication of these results existed.Decision-making models of health service managers: On the basis of models of ethical decision making in health service management, the decisions of the area’s health managers resulted in approval to publish this project’s results being denied. This was because the perceived risks to the health service outweighed benefits. Confidentiality could not be ensured by publication under a regional nom de plume.Conclusions: A conflict of interests between rural researchers and health managers on publication of results is shown by this case study. Researchers and managers at times owe competing duties to key stakeholders. Both weigh the estimated risks and benefits of the effect of research findings. This is particularly true in a rural area, where identification of the subjects becomes more likely. (shrink)

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few (...) women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women’s experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwive (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery. (shrink)

Partially because of the high cost of developing and maintaining cold chains, systems needed to keep heat-labile vaccines under adequate refrigeration from their points of manufacture to their administration in the field, the Joint WHO/FAO Expert Committee on Zoonoses (i.e., the approximately four fifths of all described human infections that people share with other vertebrate animals) recommended in 1982 operation of common cold chains by health and veterinary services in rural areas. Following this recommendation, a 1984 pilot (...) level initiative in medical-veterinary intersectoral cooperation should be regarded as a practical way to deliver human primary health care to currently neglected African pastoralists, and as a potential core program for development efforts overall within arid and semiarid areas of the African continent. (shrink)

The complexities of professional ethics are best understood and interpreted within their sociohistorical context. This paper focuses on the experience of 20 rural psychologists from across Canada, a context rife with demographic and practice characteristics that may instigate ethical issues. Employing hermeneutic phenomenology, these qualitative research results are indicative of professional struggles that impacted the participants’ experience of professional ethics and raised key questions about policy and practise. Concerns regarding competition highlight potential professional vulnerability, beget the idea of fostering (...) general psychological practice, and question the role of professional bodies in addressing rural shortages. Dependency on government funding models and decisions highlights the benefits and medical cost-offset effect of psychological services’ role in funded medical care. The controversial prescriptive authority debate for psychologists raises myriad concerns that are particularly salient to rural practitioners. These include changes to training and practice, with risks of psychopharmacology gaining prominence over behavioural health interventions. National inconsistencies in level of registration add to the growing shortage of practitioners. Finally, the results illuminate the need for advocacy to move beyond the literature and into public policy to increase public awareness, decrease the stigma of mental illness, and develop rural Canadian psychology. Although limited to this study, these results allowed for a fuller and more robust understanding of rural practice in consideration of professional ethics, which may inform policy, science, or ethical clinical practice. (shrink)

In May 1973 a new collaboration between NASA, the Indian Health Service, and the Lockheed Missiles and Space Company promised to transform the way members of the Papago (now Tohono O’odham) Tribe of southern Arizona accessed modern medicine. Through a system of state-of-the-art microwave relays, slow-scan television links, and Mobile Health Units, the residents of the third-largest American Indian reservation began to access physicians remotely via telemedical encounters instead of traveling to distant hospitals. Examining the history of the (...) STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) project from the perspective of NASA and its contractors, from the perspective of the Indian Health Service, and from the perspective of O’odham engineers and health professionals offers a new focus, emphasizing the American Indian reservation as a site of medical research and technological development in the late twentieth century, with specific attention to the promise of information technology to address health disparities and the role of American Indians as actors in the late twentieth-century history of science, technology, and medicine. (shrink)

While caregiving in northern, rural and remote communities takes place in the context of conditions unique to smaller communities, caregivers live with social policies that are shaped by urban norms rather than rural realities. In times of economic decline and government cuts rural issues of limited services and infrastructure as well as dependency on a single industry can lead to unemployment, community and family instability, and a decline in health and well-being. During these times caregivers (...) face increased pressure to voluntarily fill the gaps left by service cuts. Research with women caregivers in four communities in northern British Columbia (BC), Canada explores the experiences of caring and the social, geographic, economic and political contexts within which the caregiving occurs. The discourse of economic efficiencies that speaks solely to the monetary value of care is contrasted with the human condition of connectedness and relationships. These two contradictory perspectives are uncovered during interviews with women caregivers and analyzed in the framework of Olena Hankivsky's discussion of an ethic of care. (shrink)

The geographically inequitable distribution of physicians has long posed a serious social problem in Japan. The government tackled this problem by establishing and managing Jichi Medical University (JMU) and regional quotas (RQs) for medical schools. JMU/RQs recruit local students who hope to work as physicians in rural areas, educate them for 6 years without tuition (JMU) or with scholarship (RQs), and after graduation, assign them to their home prefectures for 9 years, including 4–6 years of rural service. JMU/RQs (...) entrants now occupy 11.6% of all medical school entrants. While JMU/RQs have been shown to be highly effective in securing physicians for rural areas, ethical issues related to these policies have been raised, such as whether the government truly needs to implement these policies using tax money, and whether it is acceptable to limit the personal freedoms of the physicians. In this paper, we discuss these issues from the perspectives of social justice, utilitarianism, luck egalitarianism, liberty, medical professionalism and consistency with national health insurance and the Japanese Constitution. We conclude that JMU/RQs are necessary and ethically valid policies, and also propose some institutional improvements to better secure the integrity and maturity of these systems. (shrink)

To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications (...) were original research articles while (12) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues. (shrink)

Background The world is urbanizing rapidly; more than half the world’s population now lives in urban areas, leading to significant transition in lifestyles and social behaviours globally. While offering many advantages, urban environments also concentrate health risks and introduce health hazards for the poor. In Bangladesh, although many public policies are directed towards equity and protecting people’s rights, these are not comprehensively and inclusively applied in ways that prioritize the health rights of citizens. The country is thus (...) facing many issues that raise moral and ethical concerns. Methods A narrative literature review was conducted between October 2016 and November 2017 on issues related to social justice, health, and human rights in urban Bangladesh. The key questions discussed here are: i) ethical dilemmas and inclusion of the urban poor to pursue social justice; and ii) the ethical obligations and moral responsibilities of the state and non-state sectors in serving Bangladesh’s urban poor. Using a Rawlsian theory of equality of opportunity to ensure social justice, we identified key health-related ethical issues in the country’s rapidly changing urban landscape, especially among the poor. Results We examined ethical dilemmas in Bangladesh’s health system through the rural–urban divide and the lack of coordination among implementing agencies. The unregulated profusion of the private sector and immoral practices of service providers result in high out-of-pocket expenditures for urban poor, leading to debt and further impoverishment. We also highlight policy and programmatic gaps, as well as entry points for safeguarding the right to health for Bangladeshi citizens. Conclusions The urban health system in Bangladesh needs a reform in which state and non-state actors should work together, understanding and acknowledging their moral responsibilities for improving the health of the urban poor by engaging multiple sectors. The social determinants of health should be taken into account when formulating policies and programs to achieve universal health coverage and ensure social justice for the urban poor in Bangladesh. (shrink)

BackgroundHealth service delivery should ensure ethical principles are observed at all levels of healthcare. Working towards this goal requires understanding the ethics-related priorities and concerns in the day-to-day activities among different health practitioners. These practitioners include community health workers (CHWs) who are involved in healthcare delivery in communities in many low-and middle-income countries such as Uganda. In this study, we used photovoice, an innovative community based participatory research method that uses photography, to examine CHWs' perspectives on ethical concerns (...) in their work.MethodsWe explored perspectives of 10 CHWs (5 females and 5 males) on ethical dimensions of their work for 5 months using photovoice in a rural community in Wakiso district, Uganda. As part of the study, we: 1. Oriented CHWs on photovoice research and ethics; 2. Asked CHWs to take photographs of key ethical dimensions of their work; 3. Held monthly meetings to discuss and reflect on the photos; and 4. Disseminated the findings. The discussions from the monthly meetings were audio recorded, transcribed, and emerging data analysed using conventional content analysis with the help of Atlas ti version 6.0.15.ResultsCHWs were aware of and highly concerned about the need to observe ethical principles while carrying out their roles. The ethical principles CHWs were aware of and endeavoured to observe during their work were: maintaining professional integrity and abiding by ethical principles of practice; ethical responsibility in patient care; maintaining confidentiality while handling clients; respect for persons and communities; and enhancing their knowledge and skills for better practice. However, CHWs also identified challenges concerning their observance of ethical principles including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings.ConclusionsCHWs were aware of and keen to discuss ethical issues in their work. However, there is need to address the challenges they face so as to facilitate observing ethical principles during the course of their work in communities. (shrink)

With the growing call for private sector actors to address global challenges, it is necessary to first assess whether regions with the greatest needs are accessing corporate philanthropy. In this paper, we ask whether corporate philanthropy is reaching those with the greatest health-care needs. Drawing on economic geography and corporate homophily, we argue that corporate philanthropy tends to exacerbate health inequality as grants are destined for counties with fewer health problems. We test and find support for this (...) hypothesis using data on health grants made by US corporate foundations and county-level health data. Our results that corporate health grants are less likely to go to counties which have a lower proportion of medical service providers and insured citizens suggest that corporate foundations are unwittingly complicit in worsening the resource gap between small, poor, rural counties and large, wealthy, urban counties. From an ethical perspective, we provide some guidance as to how this may be corrected. (shrink)

The provision of mental health services to women has come sharply into focus for providers of secure psychiatric services in the UK. Women's services are being developed in response to the known risks of mixed-sex provision, and a growing appreciation of the ways that women in secure services can be further disadvantaged by their minority status. Our intention here is to present evidence and reflections to help inform this development. The evidence is drawn from our (...) recent work in this field, which includes carrying out a review of local mental health services for ‘difficult’ women, and developing and piloting a national training programme for staff working with women in secure services. The reflections we offer are informed by the conviction that taking social inequalities into account is central to making sense of women's mental health difficulties, and improving service responses to women's needs. While there are signs that many mental health workers in secure services are beginning to share these convictions, the challenge now is to provide the necessary authorization, training and support that will enable them to translate these understandings into empowerment practice with women. (shrink)

Involuntary commitment links the healthcare, public health, and legislative systems to act as a “carceral health-service.” While masquerading as more humane and medicalized, such coercive modalities nevertheless further reinforce the systems, structures, practices, and policies of structural oppression and white supremacy. We argue that due to involuntary commitment’s inextricable connection to the carceral system, and a longer history of violent social control, this legal framework cannot and must not be held out as a viable alternative to the criminal (...) legal system responses to behavioral and mental health challenges. Instead, this article proposes true alternatives to incarceration that are centered on liberation that seeks to shrink the carceral system’s grasp on individuals’ and communities’ lives. In this, we draw inspiration from street-level praxis and action theory emanating from grassroots organizations and community organizers across the country under a Public Health Abolition framework. (shrink)

Protection of human participants is a fundamental facet of biomedical research. We report the activities of a health service research study in which there were three institutional review boards (IRBs), three legal departments and one research administration department providing recommendations and mandating changes in the study methods. Complying with IRB requirements can be challenging, but can also adversely affect study outcomes. Multiple protocol changes mandated from multiple IRBs created a research method that was not reflective of how substance use (...) screening would be performed in a clinical setting. There was direct conflict between the IRBs' perceptions of participants' protection with the researchers' need to use research methodology that assures the clinical relevancy of results. (shrink)

It is nearly 20 years since Tony Hope wrote an editorial in this journal on Empirical Medical Ethics,1 arguing for both a recognition of the increasing amount of work being done in ‘empirical ethics’ and for its importance as a new direction for medical ethics research. Since then empirical ethics has flourished, with debates over the role of ‘empirical’ data in ethical reasoning producing a growing body of literature and the JME and other bioethics journals regularly publishing empirical studies. While (...) bio/medical ethics has grappled with ‘incorporating’ or using more empirical data in ethical analysis, with varying degrees of success, and some criticism, there has not been a corresponding willingness of more empirical disciplines to embrace ethical analysis. This is a particular lack for applied research areas that see their role as predominately influencing policy and practice, such as health services research. Health services research ‘is the integration of epidemiological, sociological, economic, and other analytic sciences in the study of health services.’ Whose ‘main goals … are to identify the most effective ways to organize, manage, finance, and deliver high quality care; reduce medical errors; and improve patient safety’.2 Health services research brings together a wide variety of disciplines and would seem ideally placed to include ethics. However, if you search health services research journals and conference programmes there is very little consideration of ethics as a substantive topic and often scant attention paid to the ethical issues that might be raised by an intervention or policy. Ethics and ethical issues are generally confined to discussions over priority setting, and occasionally health technology assessment, with other areas of health service research seldom engaging in ethical debate. In the Encyclopaedia of Health Services Research,3 ethics …. (shrink)