Journal Search - issue 2, 2005

full article:

Prevalence of specific cardiovascular disease risk factors in young Newfoundland and Labrador adults living in urban and rural communities
Susan M Kettle, Barbara V Roebothan, Roy West

Introduction: The province of Newfoundland and Labrador has a high rate of cardiovascular disease. Risk factors of cardiovascular disease have not been well studied in young adults. There are reasons to believe that the prevalence of cardiovascular disease risk factors may be higher in young adults residing in rural versus urban settings.
Methods: 540 men and women, ages 18 to 34 years and residing in urban and rural areas of Newfoundland and Labrador were compared for cigarette smoking and for body size. Both body mass index and waist circumference measures were used to indicate body size. Education level and family income were also studied. Data were collected via personal interview as part of a larger study, Nutrition Newfoundland and Labrador.
Results: No difference was noted between the 2 groups in regular smoking or BMI. More female rural residents had a waist circumference above the accepted cut-off compared with female urban residents (32.5% v. 17.0%).
Conclusion: Young adults in urban and rural areas both experience high rates of modifiable risk factors for CVD. Some may be more prevalent in rural areas. Prevention programs should include young adults, especially those residing in rural areas.

Inappropriate use of antibiotics for acute respiratory tract infections in a rural emergency department
Graham Worrall, Barbara Young, Valerie Knight

Introduction: Evidence-based reviews and guidelines recommend lowering antibiotic prescription rates for acute respiratory tract infections (ARIs).
Objective: To determine the number of patients presenting with uncomplicated ARIs at the walk-in emergency department (ED) of a rural community health centre and to determine the antibiotic prescription rate for each type of ARI.
Methods: A one-year retrospective data collection of a rural ED was carried out using MEDITECH and chart review to determine numbers of patients presenting with an ARI; antibiotic prescriptions were recorded according to ARI diagnosis.
Results: ARIs accounted for 22% of all patients seen by the ED doctor. In 57% of the ARIs diagnosed, patients were prescribed an antibiotic. Individual rates ranged from 2% for influenza to 100% for pneumonia. A breakdown of rates for each type of ARI is provided.
Conclusions: Antibiotic prescription rates for ARIs remain high, with some ARIs being more inappropriately managed than others. The rate of patients presenting with ARIs to the study ED was higher than in some other EDs, possibly reflecting the problems of recruiting and retaining family doctors in many rural areas, including ours.

Understanding the role of nurse practitioners in Canada
Andrew Worster, Arlene Sardo, Christine Thrasher, Christopher Fernandes, Elaine Chemeris

The practice of medicine and nursing continues to evolve as a result of changes in knowledge, technology and health care needs. New areas of specialization have developed and, in particular, the roles and duties of registered nurses have been expanded. This expansion has enabled nurses with advanced education and skills to function as independent and interdependent clinicians who practise in partnership with physicians and other health care professionals.

Use of traditional Mi'kmaq medicine among patients at a First Nations community health centre
Sarah Jane Cook

Introduction: The provision of complete, effective, and culturally sensitive health care to First Nations communities requires a familiarity with and respect for patients' healing beliefs and practices.
Purpose: This study addresses one aspect of cross-cultural care by attempting to understand the use of Mi'kmaq medicine among patients at a community health centre and their attitudes toward both Mi'kmaq and Western medicine.
Methods: A questionnaire was completed by 100 patients (14 men, 86 women) at the clinic. The majority (66%) of respondents had used Mi'kmaq medicine, and 92.4% of these respondents had not discussed this with their physician. Of those who had used Mi'kmaq medicine, 24.3% use it as first-line treatment when they are ill, and 31.8% believe that Mi'kmaq medicine is better overall than Western. Even among patients who have not used Mi'kmaq medicine, 5.9% believe that it is more effective than Western medicine in treating illness.
Conclusion: These results have implications for the delivery of health care to First Nations patients, especially in terms of understanding patients' health care values and in meeting the need to provide effective cross-cultural care.

Commercial Insurance vs Community-based Health Plans: Time for a Policy Option With Clinical Emphasis to Address the Cost Spiral
Bruce Amundson

The nation continues its ceaseless struggle with the spiraling cost of health care. Previous efforts (regulation, competition, voluntary action) have included almost every strategy except clinical. Insurers have largely failed in their cost-containment efforts. There is a strong emerging body of literature that demonstrates the relationship between various clinical strategies and reductions in utilization and costs. This article describes the organization of health services, including integration of delivery and financing systems, at the community level as a model that effectively addresses the critical structural flaws that have frustrated control of costs. Community-based health plans (CHPs) have been developed and have demonstrated viability. The key elements of CHPs are a legal organizational structure, a full provider network, advanced care-management systems, and the ability to assume financial risk. Common misconceptions regarding obstacles to CHP development are the complexity of the undertaking, difficulty assuming the insurance function, and insured pools that are too small to be viable. The characteristics of successful CHPs and 2 case studies are described, including the types of advanced care-management systems that have resulted in strong financial performance. The demonstrated ability of CHPs to establish financial viability with small numbers of enrollees challenges the common assumption that there is a fixed relationship between health plan enrollment size and financial performance. Organizing the health system at the community/regional level provides an attractive alternative model in the health-reformdebate. There is an opportunity for clinical systems and state and federal leaders to support the development of community-based integrated delivery and financing system models that, among other advantages, have significant potential to modulate the pernicious cost spiral.

Assisted Living in Rural America: Results From a National Survey
Catherine Hawes, Charles D. Phillips, Scott Holan, Michael Sherman, Linnae L. Hutchison

Context: Expanding the availability of long-term care (LTC) services and making them more responsive to consumer preferences is an important goal, particularly for elderly people living in rural areas who tend to be older and have greater functional limitations but less access to the range of LTC options available in metropolitan areas. One option that has been growing in popularity is assisted-living facilities (ALFs).
Purpose and Methods: This paper describes rural ALFs and compares them with metropolitan ALFs. Data were collected using a multistage sample design that yielded a nationally representative sample of ALFs. Telephone interviews were completed with administrators of 1,251 ALFs in 1998.
Findings: Nationwide, assisted living was largely administered by private payment, and there was an undersupply in rural areas. Compared with metropolitan ALFs, rural ALFs were smaller and less likely to offer the types of services and accommodations associated with the philosophy of assisted living. They were more likely to offer accommodations with little privacy, and while similar in the services they offered, rural ALFs were less likely to have nurses on staff, particularly licensed practical nurses. Moreover, they were less likely to offer a combination of high services and high privacy. Finally, rural ALFs charged lower prices than urban ALFs; however, the average price was still unaffordable for most elderly rural residents.
Conclusions: These findings suggest that assisted living, as currently structured, will make only a marginal contribution to meeting the needs of frail elders in rural areas.

A National Study of Obesity Prevalence and Trends by Type of Rural County
J. Elizabeth Jackson, Mark P. Doescher, Anthony F. Jerant, L. Gary Hart

Context: Obesity is epidemic in the United States, but information on this trend by type of rural locale is limited. Purpose: To estimate the prevalence of and recent trends in obesity among US adults residing in rural locations.
Methods: Analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 1994-1996 (n Π342,055) and 2000-2001 (n Π385,384). The main outcome measure was obesity (body mass index [BMI] _30), as determined by calculating BMI from respondents' self-reported height and weight.
Results: In 2000-2001, the prevalence of obesity was 23.0% (95% confidence interval [CI] 22.6%-23.4%) for rural adults and 20.5% (95% CI 20.2%-20.7%) for their urban counterparts, representing increases of 4.8% (95% CI 4.2%-5.3%) and 5.5% (95% CI 5.1%-5.9%), respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties in Louisiana, Mississippi, and Texas; obesity prevalence increased for rural residents in all states but Florida over the study period. African Americans had the highest obesity prevalence of any group, up to 31.4% (95% CI 29.1%-33.6) in rural counties adjacent to urban counties. The largest difference in obesity prevalence between those with a college education compared with those without a high school diploma occurred in urban areas (18.4% [95% CI 17.9%-18.9%] vs 23.5% [95% CI 22.5%-24.5%], respectively); the smallest difference occurred in small, remote rural counties (20.3% [95% CI 18.7%-21.9%] versus 22.3% [95% CI 20.7%-24.0%], respectively).
Conclusions: The prevalence of obesity is higher in rural counties than in urban counties; obesity affects some residents of rural counties disproportionately.

Geographic Disparities in Cervical Cancer Mortality: What Are the Roles of Risk Factor Prevalence, Screening, and Use of Recommended Treatment?
K. Robin Yabroff, William F. Lawrence, Jason C. King, Patricia Mangan, Kathleen Shakira Washington, Bin Yi, Jon F. Kerner, Jeanne S. Mandelblatt

Context: Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.
Methods: This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality-high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.
Findings: Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.
Conclusions: At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Delivery Complications Associated With Prenatal Care Access for Medicaid-Insured Mothers in Rural and Urban Hospitals
Sarah B. Laditka, James N. Laditka, Kevin J. Bennett, Janice C. Probst

Context: Pregnancy complications affect many women. It is likely that some complications can be avoided through routine primary and prenatal care of reasonable quality.
Purpose: The authors examined access to health care during pregnancy for mothers insured by Medicaid. The access indicator is potentially avoidable maternity complications (PAMCs). Potentially avoidable maternity complications are often preventable through routine prenatal care, such as infection screening and treatment. The authors examined the risks of potentially avoidable maternity complications among rural and urban hospital deliveries for groups of mothers defined by race or ethnicity.
Methods: Data are from the year 2000 Nationwide Inpatient Sample (NIS). The stratified sample represents all discharges from 20.5% of community hospitals in the United States. The Nationwide Inpatient Sample identifies hospital locations, but not patients' areas of residence. Analyses, which accounted for the sample design, included calculation of potentially avoidable maternity complication rates by race or ethnicity, v2, t tests, and multivariate logistic regression.
Findings: Within groups defined by race or ethnicity, unadjusted rates for potentially avoidable maternity complications did not differ significantly by hospital location. Holding other factors constant, potentially avoidable maternity complications were less common in rural hospitals than in urban hospitals (odds ratio, 0.78; CI, 0.62 to 0.99). In rural hospitals, African Americans had notably higher risk for potentially avoidable maternity complications than did non-Hispanic whites (odds ratio, 1.72; CI, 1.26 to 2.36). In urban hospitals, risk of potentially avoidable maternity complications was not significantly higher for African Americans. Hispanics and Asians had notably lower risks of potentially avoidable maternity complications in urban hospitals than did non-Hispanic whites.
Conclusions: Providers and policymakers should work to reduce the risks of potentially avoidable maternity complications for African American women in rural areas who are insured by Medicaid.

Improvements in Care and Reduced Self-management Barriers Among Rural Patients With Diabetes
Nancy Dettori, Benjamin N. Flook, Erich Pessl, Kim Quesenberry, Johnson Loh, Colleen Harris, Janet M. McDowall, Marcene K. Butcher, Steven D. Helgerson, Dorothy Gohdes, Todd S. Harwell

Context: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes.
Purpose: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care.
Methods: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management.
Findings: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%).
Conclusions: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.

Perceived Barriers to Nurse Practitioner Practice in Rural Settings
Linda Lindeke, Angela Jukkala, Mary Tanner

Context: Rural residents experience the same incidence of acute illness as urban populations and have higher levels of chronic illness. Overall, access to adequate rural health care is limited. Nurse practitioners (NPs) have been identified as safe, cost-effective providers in meeting these challenges in rural settings.
Purpose: This replication study was conducted to examine NP perceptions of barriers to rural practice in Minnesota. Findings were compared to earlier studies to examine issues that have persisted over time.
Methods: A Barriers to Practice checklist was mailed to NPs from the database of the Board of Nursing of a midwestern state. Rural NPs (n Π191) identified and described barriers to practice and rated the overall restrictiveness of their practice.
Findings: Barriers to practice were perceived to be prevalent. Persisting barriers continued to stand in the way of full utilization of NP roles. Lack of understanding of NP roles on the part of the public and other health professionals has been particularly problematic over time. Key issues in 2001 were low salaries, lack of adequate office space, and a limited peer network. Perceived restrictiveness of the practice climate, gauged as somewhat restrictive, remained unchanged between 1996 and 2001.
Conclusions: NPs have an excellent history of meeting rural primary health care needs. Enhancing the NP work environment could prove instrumental to retaining these professionals in the work force and thereby contribute to improved access and quality of care in underserved rural communities.

Herbal Remedies Used by Selected Migrant Farmworkers in El Paso, Texas
Jane Poss, Rebecca Pierce, Veronica Prieto

Context: Little is known about the use of complementary and alternative medicine among the approximately 1.6 million migrant farmworkers in the United States.
Purpose: To evaluate the use of medicinal plants and natural remedies among a convenience sample of 100 migrant farmworkers living temporarily in a migrant worker center in El Paso, Texas.
Methods: A structured interview instrument was designed to elicit information about reasons for medicinal herb use, form in which herbs were ingested, serious side effects experienced, location of purchase, effectiveness of treatment, and use of allopathic medications.
Findings: The majority of workers used herbal remedies or other natural products because they believed them to be more effective than pharmaceuticals and because of tradition. Most learned about herbal remedies from a relative, primarily from their mother, and the majority who used herbal remedies believed them to be very helpful in treating specific illnesses. No adverse reactions to any herbal remedy were reported. The majority of participants did not inform their physician about their use of herbal remedies. According to the literature, potential adverse interactions between herbal remedies used and allopathic medications included gastrointestinal irritation, renal toxicity, and hypoglycemia.
Conclusions: Health care providers must be knowledgeable about the use of herbal remedies among migrant farmworkers. By showing an understanding of and sensitivity to the use of these remedies, health care providers will be able to conduct more comprehensive health assessments of migrant workers and their families and provide them with more culturally competent care.

Are rural adolescents necessarily at risk of poorer obstetric and birth outcomes?
Mavis Gaff-Smith

Objective: The purpose of the present study were to describe the sociodemographic and clinical characteristics of adolescent women giving birth at Wagga Wagga Base Hospital, and compare these with those with all adolescents in New South Wales.
Design: An investigative approach.
Main outcome measures: Obstetric complications, delivery intervention and adverse infant outcomes.
Setting: Wagga Wagga Base Hospital.
Participants: One hundred and sixteen adolescents aged 15 19 years.
Results: In relation to obstetric complications and infants with complications, the study sample was found to be representative of New South Wales adolescents. However, for type of delivery there was a higher rate of forceps delivery (12.3% (15) vs 4.7% (415) P = 0.0001), forceps rotation (4.1% (5) vs 0.9% (80) P = 0.004) and fewer normal vaginal deliveries (67.2% (82) vs 80.8% (7108) P = 0.006) at Wagga Wagga Base Hospital.
Conclusion: These findings suggest that rural adolescents are at risk of delivery complications and are less likely to have a normal vaginal delivery. More research is required into obstetric and birth outcomes for the rural adolescent population.

New South Wales trends in mortality differentials between small rural and urban communities over a 25-year period, 1970-1994
Lillian J Hayes, Susan Quine, Richard Taylor

Objective: To identify trends in premature mortality differences between urban and small rural communities in NSW over a 25-years period.
Design: A longitudinal population-based study. ABS population and death data by local government area, sex and age for the period 1970 to 1994, were used to derive mortality measures for urban and small rural communities in NSW.
Setting: NSW local government areas categorised by the Rural and Remote Metropolitan Area Classification system as 'capital city' (the Sydney Statistical Division) and 'other rural area' and 'other remote area'.
Subjects: All persons aged 0 74 years resident in the aforementioned NSW local government areas between 1970 and 1994 inclusive.
Main outcome measure: Whether premature mortality differentials have widened, narrowed or remained the same over the study period and the magnitude of any identified changes.
Result: There was a decrease in premature mortality rates for men and women in both urban and small rural communities. However, the decline was less in small rural communities, with the differential between small rural and urban areas increasing 2 3% every 5 years.
Conclusions: Differences in age structure, proportion of indigenous and migrant populations between small rural communities and urban NSW can not fully account for the increasing differential. Other possible explanatory factors include socioeconomic status and different exposures and practices in rural areas.

Heart rate variability analysis: a useful assessment tool for diabetes associated cardiac dysfunction in rural and remote areas
Allyson C Flynn, Herbert F Jelinek, Megan Smith

Objective: Cardiovascular complications are the main cause of death in people with diabetes. Early, asymptomatic changes are due to autonomic nervous system dysfunction, which if identified can lead to improved health. This study used detrended fluctuation analysis to identify changes in heart rate variability (HRV) associated with short-time electrocardiograph (ECG) recordings. The aim of the study was to determine whether heart rate variability analysis on short ECG recordings has the potential to be a useful adjunct to clinical practice.
Design: Comparative design with three independent simple random samples.
Setting: University-based research project.
Participants: Forty-eight people with no diabetes or cardiovascular complications had a 20 min ECG recorded, which was subsequently analysed using mathematical procedures. All participants also had a lying-to-standing autonomic nervous system test. Data was analysed using a Student t-test.
Results: Heart rate variability expressed as a numeric value ( 1), is reduced in disease states. We found a significant difference in 1(P = 0.03) between the ECG recordings of the diabetes and control groups. In addition lower 1values were obtained from people identified with autonomic dysfunction within the diabetes group.
Conclusion: The importance of our findings is that abnormal HRV identifies people with cardiovascular disease, irrespective of diabetes status, that may have autonomic neuropathy. HRV analysis is easily implemented by primary health care providers and has the potential to lead to improved health care by reducing inequity in rural areas and specifically addressing cardiovascular complications associated with diabetes.

Hospital to home: An integrated approach to discharge planning in a rural South Australian town
Denise Bolch, Julie B Johnston, Lynne C Giles, Craig Whitehead, Paddy Phillips, Maria Crotty

Objective: To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings.
Design: Plan Do Study Act framework using case-note audit and focus groups.
Setting: Central Yorke Peninsula Hospital in South Australia.
Subjects: All patients aged 65 years or older admitted between October 2001 and June 2002.
Interventions: Range of communication strategies designed to improve discharge planning practices.
Main outcome measures: Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge.
Results: There was a significant increase in the proportion of patients with a documented discharge plan for both non-Aboriginal (23%) and Aboriginal patients (52%). There was also a significant increase in the proportion of patients who received timely and informative risk screening (41% for non-Aboriginal and 58% for Aboriginal patients). Referrals to community health service providers also increased significantly from baseline to the intervention period (14% for non-Aboriginal and 33% for Aboriginal patients). The project also resulted in improved communication processes between hospital staff and community health service providers.
Conclusions: This National Demonstration Hospitals Program project has impacted on both hospital discharge planning and the hospital community interface. Flow-on effects to other initiatives within the region are likely.

Home management of childhood febrile illnesses in a rural community in Nigeria
Adenike AE Olaogun, Olufemi Ayandiran, Olayinka A Olasode, Abayomi Adebayo, Folasade Omokhodion

Objective: To assess the care given to febrile children under 5 years old at home prior to attending health facility.
Design: Cross sectional design.
Setting: Outpatient clinic of a government health facility.
Subjects: Two hundred mothers who brought their sick children to the outpatient department were interviewed.
Results: The ages of mothers ranged from 15 to 50 years (mean of 26.2 years). Most of them had formal education although below grade 12. Only 12.5% of them were full-time housewives. Others were engaged in self-employed occupations. Fifty-one percent of the children were females. Their ages ranged between 6 months and 5 years with a mean of 2.6 years. Over 60% of the children were suffering from symptoms of acute respiratory infections while 28% had symptoms of malaria. There was no significant difference between mothers' diagnosis and researchers' diagnosis ( 2 = 0.199, P < 0.05). The duration of children's illnesses spanned from 1 to 60 days (mean of 4.8 days). Only one mother reported at the clinic within 24 h of the onset of the child's illness. Eighty-one percent had taken action before coming to clinic. They had used combinations of drugs namely antipyretics, antimalarials and antibiotics. The average amount spent on drugs was US$0.57. These drugs were purchased at local medicine stores.
Conclusion: The findings indicate home use of drugs that were not prescribed by health professionals. There is therefore a strong need to give appropriate education and counselling to mothers/care givers and medicine vendors on early detection and proper home management of febrile illnesses.

South African Red Cross Flying Doctors Service quality and safety in the rural and remote South African environment
Aristomenis K Exadaktylos, Farhaad Haffejee, Darryl Wood Philip Erasmus

Context: The South African Red Cross Air Mercy Service and its Flying Doctors Service provides health care to far flung and disadvantaged communities in South Africa.
Purpose: The purpose of this article is to highlight the importance and effectiveness of the service in providing health care to a range of people who have poor or no access to certain health services in South Africa.
Methods: Data and information was collected from records and statistical data of our service. Data was evaluated and compiled into a report highlighting the achievements of this organisation from its infancy to the present day.
Findings: The Flying Doctor and Health Outreach Programme has made a difference in improving health care by providing specialist services, transport of patients and training of medical personnel in outlying areas of South Africa that have poor access to health care. Emergency Air Ambulance and Rescue Services have proven to be supportive in providing rapid advanced life support and rescue services to patients in emergency situations. Many lives have been saved through this service.
Conclusion: The South African Red Cross Air Mercy Service plays a crucial role in delivering specialised health care to disadvantaged communities in South Africa.

The family and nurse in partnership: Providing day-to-day care for rural cancer patients
Lesley M Wilkes, Kate White

Objective: To explore demands made on family members in managing symptoms and providing for the day-to-day care of relatives with cancer in rural New South Wales and how specialist palliative care nurses support these family members.
Design: Cross sectional qualitative study.
Setting: Seven health centres across rural New South Wales that cover a broad geographical area and reflect the diversity in economic conditions, population density and distance from three major urban centres in New South Wales.
Subjects: The study involved two groups of participants. The first group consisted of one or more members of families of oncology patients who were accessed through health workers at the seven centres. Nineteen family members from 17 families were interviewed. The second group comprised 10 nursing staff working as specialist palliative care nurses across the same geographical area as the families.
Main outcome measures: Physical care and symptom management were the two main areas of interest.
Results: The rural experience of caring for palliative care patients was challenging, with support nurses needing to take into consideration all aspects of the patients' and families' living environments.
Conclusion: There is a need for equipment and basic resources to be readily available to practitioners, funding for ongoing education and 24-h care.