Training and education in rural health: perspectives in Europe

I. INTRODUCTION

Nowadays, there is an evident gap in health status and socio-economic conditions between rural and urban dwellers and the problem is particularly clear in Asian and African developing countries. There is a lack of access to appropriate public health services with its consequences of lower health status of the rural population. An impressive example for the rural health inequity is given by comparative data concerning the rate of antenatal check-ups (Tab. 1) and child survival rate (Tab. 2) in rural and urban areas which was delivered by the National Family Health Survey of India [3].

Table 1. Antenatal check up-rate urban vs. rural

Antenatal check-up	Urban (%)	Rural (%)
No check-up	13.6	39.8
Doctor	74.8	41.2
Health worker	2.0	6.6
Others	9.0	11.8

Table 2. Child survival rates

Rates	Rural	Urban	Total
Perinatal mortality	47.9	31.4	44.2
Neo-natal mortality	52.3	28.9	47.1
Infant mortality	82.0	47.6	72.0

To reduce the rural health inequity, achievable goals have to be set. The first one is building a network of rural health professionals able to facilitate the development, the planning and the implementation of Rural Health programs taking. They should be focused on three main fields of interventions:

- Health of the General population

- Rural occupational health

- Environmental health

These training and education programmes dealing with the main local environmental and health problems to local technical staff. Only personnel technically qualified and knowledgeable about local issues will be adequate to face problems and promote a sustainable health development.

In highly developed countries such as Australia, United States or Canada universities already offer elaborative training concepts of educating rural health experts. Compared to them, the development in this field is much more behind in Asia and Africa and even in Europe. So, since a broad experience in this field of training and education in rural areas is not available yet in these regions, the main topics of such training courses for rural health experts are to be presented in the following.

II. EDUCATIONAL OBJECTIVES OF RURAL HEALTH PROGRAMMES

Their general aim is promoting a sustainable health development for local population. Therefore, local rural health experts have to be created who deal with the main local environmental and health problems. They should be enabled to face, at any level, the different problems related to “Rurality” and to act, in this way, as changing agents for health in their local surrounding. In this way, the access of the entire population to the basic elements of promotive, preventive and treatment services should be facilitated.

This general objective implies certain core competencies the rural health experts have to attain in the education. He/she has to become

Medical Expert for population-relevant diseases,

Humanist with a sense of caring, sensitivity and concern for the problems of the people,

Epidemiologist who is able to assess the health needs of the population by means of epidemiological methods,

Expert in Risk Assessment by analysing the risk-factors for health in the rural environment and by setting priorities for actions,

Health promoter for healthy life-styles in the community,

Communicator who is able to listen to the people, to understand their needs and who can contribute to possible solutions,

Collaborator who is aware of an interdisciplinary approach to health care and can integrate oneself efficiently in an interdisciplinary team,

Learner with an orientation of life-long learning which keeps the expert up to date with the advances in health related knowledge and its application in responding to the health needs of people and communities. Appropriate learning-skills are to develop and to be applied during the whole professional life.

And, last but not least,

the rural expert too!! That means that he/she should be aware of the personal stress caused by the demands of the professional life. It is important to develop strategies for coping with these sources of stress.

This short description shows the variety of tasks of a rural health expert. He/she has to develop both - competencies as a `generalist´ and as a `specialist´ as well.

Education and training programmes have to face the complexity of this profile. By setting priorities they have to decide about the main topics of teaching. That leads to the next questions concerning the contents of learning.

III. DOMAINS OF LEARNING

As rural health problems vary a lot among countries, a specific country/area profile has to describe the local needs concerning

- Health of the general population,

- Rural occupational health,

- Environmental health.

An example from Europe clarifies that this country/area profile is the decisive basis not only for intervention but also for teaching by determining its focus: in Hungary, the country profile identifies the extension of life expectancy as an important issue (JAKAB, 2004). Due to this priority, health aspects of the general population (such as nutrition, tobacco/alcohol control, physical activities) have to be focussed by rural health experts. And they have to be preferable trained in identifying and reducing risk-factors and promoting healthy life-styles for the population. In a different country, child labour, accident prevention or environmental pollution could be on top of the agenda and therefore mainly to be dealt with in intervention planning and teaching.

To ensure a comprehensive learning process theoretical knowledge about general and local rural health issues and practical skills have to be learned. Both elements – knowledge and skills - are indispensable for meeting the above-mentioned rural health expert profile.

Related to knowledge about health of the general population, Collosio et al. [1] propose following main topics to be taught:

- Quality of life in rural areas,

- Health delivery and health promotion,

- Diet and nutrition,

- Food safety assurance,

- Food quality surveillance and monitoring,

- Child food safety and nutrition,

- Prevention of vector-born disease,

- Immunisation against vaccine preventable diseases.

For occupational health they propose

- health prevention of agricultural workers - medical surveillance,

- information and training,

- occupational health priorities in rural areas,

- non-communicable resp. communicable diseases related to rural occupation.

Teaching environmental health includes:

- Environmental monitoring and risk assessment for different environmental targets (e.g. sanitation, water supply)

- Pollution (air, water, soil),

- Waste management,

- Other risks ( e.g. natural presence of asbestos)

Furthermore, a behavioural perspective should be added to the education. As the rural health expert is concerned with people and acts as changing agent, teaching should also aim at the

- improvement of the understanding of human behaviour by regarding cultural and psychosocial aspects of the rural population,

- behavioural aspects of health promotion,

- determinants for the change of health behaviour in the rural population.

Skills to be trained are professional skills, such as:

- decision-making skills,

- data collection skills,

- evidence-based risk assessment and risk management skills,

- skills for strategic planning and intervention,

- (inter-professional) communication skills.

Learning skills, including the ability:

- to ask the appropriate questions,

- to set priorities,

- to use various health information systems (e.g. people, textbooks, internet etc.),

- to present information orally and in writing in a clear way.

Specific skills like:

- first aid treatment,

- training in emergency and trauma (especially for rural GPs).

As rural health means multidisciplinary interaction the training should be addressed to different groups of health professionals. The target groups are:

- medical doctors,

- occupational health physicians,

- rural practitioners,

- technical staff,

- nurses,

- public health organisation personnel,

- medical students (especially from rural areas),

- social workers.

IV. ORGANIZATIONAL AND INSTITUTIONAL ASPECTS OF THE TEACHING PROGRAMMES

It is clear that only a multidisciplinary approach of different scientific disciplines from Medicine, Natural and Social Sciences can meet the great demands on such a project. So, due to the complexity of the topics, a network of high level educational institutions specialized in the different fields of the rural health issues is to establish. Preferable universities should be invited to offer their expertise to local rural health experts so that they can get the chance to obtain the most advanced information. Further support seems necessary by Health associations and Ministries of Health.

An important characteristic for teaching must be its output instead of input orientation. The professional qualification of the participants for local rural health problems is its basis. For this purpose, studies must be offered in a modularized and consecutive way that opens different levels of teaching activities.

On a basic level, so-called micromodules can consist of short intensive courses (with a duration of three days to a week) which seem to be appropriate

- to face very specific problems,

- in a well defined rural area and,

- to train local staff specifically.

The teaching can also serve as refresher courses to update the rural health personnel.

So-called mesomodules consist of several different micromodules. This option enables the user to face more complex problems by covering a greater variety of topics. They should last about one month and should involve a staff of teachers from different fields of knowledge such as:

- environmental health personnel,

- staff of ministeries and regulatory bodies,

- rural practitioners and medical doctors,

- occupational health physicials,

- technicians.

A Master-Programme on rural health is a macromodule to be studied consecutively. It is the most complex option. It should last at least for one academic year with a total of 1500 teaching hours. By comprising micro- and mesomodules these activities should be equally subdivided in teaching training, practical training and individual learning. The target group to be addressed to are:

- university researchers and teachers,

- environmental protection and national prevention personnel,

- rural physicians,

- occupational health physicians.

For the realization of the teaching activities, the use of e-learning is a precondition to overcome the problem of distance. Most of their parts (such as the contact with tutors, written examinations or even the preparation of a thesis) can be carried out via web or via conference calls. There are some extend experiences with e-learning especially from Australia. For example, a so-called e-mentor programme from James Cook University shows that this approach can provide an efficient and effective low-cost model for linking rural health teachers in a non-rural location with their students in a remote area [2].

In the process of establishing rural health teaching programmes there are still many obstacles to overcome. A major problem is funding. So, creating a solid financial fundament for these programmes will be the challenge of the near future.

REFERENCES

1. Collosio C., Patil A.V., Goyal R.C., Tiramani M., Mammone T., Maroni M., 2003. A Training and Education Programme in Rural health in Developing Countries. Lecture held at the 15^thIntern. Congr. of Agr. Med. and Rural Health, Ayudhaya, Thailand.

2. Gupta T.S., Grant M., Mc Kenzie A, 2003. Bringing the Bush into the city: The e-mentor Programme at the James Cook University School of Medicine. Poster presented at 6^th Wonca Rural Health Conf., Santiago de Compostela, Spain.

3. International Institute for Population Sciences, 1999. National Family Health Survey. www.nfhsindia.org/data1.html.

4. Jakab S., 2004. Health care challenges in rural areas of Hungary. Agricultural Medicine and Rural Health, 23/ 1 : 3- 8. Hungary.