Health Services Administration/Management

The ways in which disability impacts people and their health in rural places are a result of the interaction between the person and the rural environment in which they live. Disability is defined as ongoing difficulties engaging in daily activities and social roles due to physical or mental conditions. The United Nations Convention on the Rights of People with Disabilities (UN-CRPD) implemented policy in 2008 that recognized that disabled people are worthy of autonomy and dignity. The social and physical environment are constructed in ableist ways that make it difficult for people with disabilities to realize their independence and this is particularly true in many rural places. Person–environment fit and urbanormativity (the favoring of urban spaces at the expense of rural ones) are important concepts in understanding the experiences of rural disabled people. There is little existing research regarding the epidemiology of disability and rural health, but rural people report higher and earlier rates of disability than urban people and rural places have higher rates of older adults with higher rates of disability. Furthermore, rural people with disabilities experience various secondary health conditions and higher rates of mortality compared to urban people with disabilties. The lack of access to health care and advocacy help explain some of the differences in health outcomes when comparing rural and urban people. The disability rights movement led to the creation of different types of advocacy and service organizations across the globe to address these disparities. An important way to improve the experiences and health of rural people with disabilities is to ensure they have access to quality and dependable in-home services and community-based rehabilitation, which currently tend to be under-funded with dramatic worker shortages in many rural places. A final promising approach to improving the health of rural disabled people is through evidence-based health promotion programming that targets early indicators of health problemsand recovery and health-sustaining efforts following a health problem.

Many seniors needing social and clinical care come from vulnerable populations that have difficulty accessing services, a great need for those services, and/or potentially impaired decision-making skills. At the same time, when seniors use services on a routine basis, they become increasingly dependent on the individual service provider. The aged care sector has a duty to provide “public value”—that is, to provide a valuable contribution to society within existing resource constraints. This requires more than simply addressing the basic individual needs of care recipients. Ethical factors must be considered in policies around services to vulnerable seniors and potential issues in addressing suboptimal quality of care, neglect, and abuse of seniors, as demonstrated by continuing public news of poor care provided to seniors in nursing homes, social care, and residential care settings.

Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.

The health status of refugees and asylum seekers varies significantly across the European region. Differences are attributed to the political nature of the legal categories of “asylum seeker” and “refugee”; the wide disparities in national health services; and the diversity in individual characteristics of this population including age, gender, socioeconomic background, country of origin, ethnicity, language proficiency, migration trajectory, and legal status. Refugees are considered to be at risk of being or becoming relatively “unhealthy migrants” compared to those migrating on the basis of economic motives, who are characterized by the “healthy migrant effect.” Refugees and asylum seekers are at risk to the drivers of declining health associated with settlement such as poor diet and housing. Restricted access to health care whether from legal, economic, cultural, or language barriers is another likely cause of declining health status. There is also evidence to suggest that the “embodiment” of the experience of exclusion and marginalization that refugee and asylum seekers face in countries of resettlement significantly drives decrements in the health status of this population.

Falls in hospital and residential care settings are common events that can have major impacts for the older person, their families, and staff and also at an organizational level. They are a major trigger event for those with chronic health problems to advance to greater levels of care because they often result in traumatic injuries while they provide a signal event for declining health that may have gone unobserved before injury. Falls among older people in hospital and residential care settings are often caused by a complex mix of risk factors and have proved difficult to prevent. There is growing research evidence that a mix of universal falls prevention interventions that are applied to all patients or residents, as well as targeted interventions addressing one or more identified personal and environmental falls risk factors (often based on a falls risk factor assessment and environmental assessment) can help to reduce risk of future falls in hospitals and residential care. Preventing falls among older people in hospitals and residential care settings requires a complete staff and organizational focus.

This article describes how the State of Bahia Water and Sanitation Company (Empresa Baiana de Águas e Saneamento [EMBASA]) expanded sewerage coverage in the city of Salvador, in the state of Bahia, Brazil. In 2021, the city had a sewerage network that served over 80% of its population, despite the fact that at least 70% of the city was composed of informal settlements. To overcome the enormous challenges of installing sewerage systems in areas with informal settlements, EMBASA decided to use the condominial sewerage model, a methodology that combines technical changes in the design of the collection systems coupled with a strong community participation component. The principal technical changes in the collection system were adapting the solution to local circumstances in each neighborhood, universalization of service, the use of the concept of microsystems (subbasins), and the use of the urban block as the basic collection unit. The methodology was first used during a program to expand the sanitary sewerage system of Salvador between 1995 and 2004, when household connections to the sanitary sewage system increased from 26% to 60% in the municipality. The condominial sewerage methodology was adopted because it was the only system capable of solving the enormous problems of informal occupation, community participation, and social inequality, among other things. With the success of the program, investments in sanitary sewerage were continued, and in 2021, the connection rate was 81%. Many challenges to increasing coverage remained, especially those related to the occupation of urban land, which continued in a disorderly manner; social inequalities; and changes in the sanitation regulatory framework.