Journal Search - Issue 3, 2004
Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in rural health/ primary healthcare journals, worldwide, including a link to the Contents page of a non-English language rural health journal from Norway. For the first time, Journal users may take a direct link to the latest issue of the journal Education for Health.
Volume 17, Number 1 / March 2004
Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Preserving the "team" in "teamwork"
John Wootton, Scientific Editor
Discharges against medical advice: a community hospital's experience
Heidi Seaborn Moyse, William E Osmun
Objectives: To understand the characteristics of patients who leave hospital against medical advice (known as "discharges against medical advice" [DAMA]) in a small community hospital and to study how these patients compare to current literature on the topic. To evaluate chart documentation pertaining to such discharges.
Methods: A retrospective chart audit was performed, covering a 2-year period, on patients who had discharged themselves against medical advice. The data were compared to the general patient population of the same period. Evaluation of DAMA documentation was also conducted by chart survey.
Results: The rate of DAMA in the study hospital was found to be 0.57%, and the average length of stay was 2.8 days. Patients who leave hospital against medical advice differ from the general patient population: they include a higher proportion of males (p = 0.007), demonstrate a different age distribution (p < 0.001), have shorter stays in hospital (p < 0.001), and have a considerably greater frequency of substance abuse (p < 0.001) and psychiatric conditions (p < 0.001) associated with their admissions. DAMA documentation was included in the charts of 81.6% of patients involved, but only 22.9% of these charts included documentation with respect to patient competency.
Conclusion: Patients who leave hospital against medical advice represent a high-risk population: they suffer a greater incidence of mental illness and substance abuse. Potential interventions are limited, but influence strategies may have a role. Early identification of patients at risk may facilitate this process, thereby decreasing the occurrence of DAMA and improving health outcomes. More consistent and comprehensive documentation is needed for these patients.
Rural community and health care interdependence: an historical, geographical study
Denise Grafton, Michael Troughton, James Rourke
The relationships between rural health care and community development were examined over time, for the case-study area of Huron and Perth counties in Southwestern Ontario. The underlying premises were that an historicalgeographic study could provide both a perspective on the development of rural health services and explore the interdependent relationship between rural community and health care. The research concentrated on examinations of the 2 key elements of rural health care, namely the rural practitioner and the community hospital. Detailed reconstruction revealed that, over time, both physicians and hospitals moved from a marginal to a central position and identity within the community, in parallel with the stages of community development in the 19th and 20th centuries, with hospitals emerging as major foci of rural sustainability. In the last 2 decades, the strength of the area's rural community health system was successfully marshalled to offset the potentially negative aspects of provincial health care restructuring. This reinforced both the perception and the reality of the interdependence of health services and communities in the predominantly rural area.
Having a regular doctor: rural, semi-urban and urban differences in Newfoundland
Maria Mathews, Alison C Edwards
Introduction: Recent studies suggest that 23% of adult Newfoundlanders do not have a regular doctor. Using data from the 1995 Newfoundland Panel on Health and Medical Care study, we examined the urban, semi-urban and rural differences in the characteristics of adult (age 20 and over) Newfoundlanders who did and did not have a regular doctor.
Methods: We used *2 tests and logistic regression to analyze data from 11 789 respondents from randomly selected households in Newfoundland. The dependent variable was "Have a regular doctor" (Yes / No). The independent variable was "Place of residence" (Urban / Semi-urban / Rural) and covariates included socio-demographic and health-related variables.
Results: Fifteen percent (1771) of Newfoundlanders did not have a regular doctor. Of these, the largest proportion of respondents without a regular doctor lived in rural communities (74.4%); were male (62.6%); were 2029 years old (28.7%); married (68.8%); of high socio-economic status (44.7%); working full-time (35.3%); had excellent or good health (83.0%); had no chronic illness (40.3%), disability (93.3%) or impairments to activities of daily living (98.0%); and were in excellent or good emotional health (90.7%). Compared to their urban counterparts, residents of semi-urban communities were as likely (odds ratio 1.03; 95% confidence interval [CI] 0.841.26) not to have a regular doctor and residents of rural communities were 4.03 (95% CI 3.504.65) times more likely than their urban counterparts not to have a regular doctor.
Conclusion: In 1995, fewer adult Newfoundlanders than previously estimated did not have a regular doctor. Rural residents were more likely not to have a regular doctor than residents of either urban or semi-urban communities.
Contents: 2004; 20 (3): Summer
Rural Minority and Multicultural Preventive Care, Primary Care, and Mental Health Issues: Challenges and Opportunities
Rosemary McKenzie, Angeline Bushy
Disparities in Access to Care Among Rural Working-age Adults
Saundra Glover, Charity G. Moore, Janice C Probst, Michael E Samuels
Context: Nationally, minority population disparities in health and in the receipt of health services are well documented but are infrequently examined within rural populations.
Purpose: The purpose of this study is to provide a national picture of health insurance coverage and access to care among rural minorities.
Methods: A cross-sectional analysis using the 1999–2000 National Health Interview Surveys examined insurance status and receipt of ambulatory care during the past year. Multiple logistic regression was used to measure factors influencing the odds of insurance coverage and a provider visit.
Findings: Among rural minority adults, 32% of blacks, 35% of "other" race persons, and 45% of Hispanics were uninsured compared to 18% of whites. Differences in insurance status were not significant for rural blacks and Hispanics after resources such as education, income, and employment were held constant. Examining use, 37% of rural Hispanics and 27% of blacks, versus 20% of whites and 19% of persons of other race, had not made a health care visit in the past year. When resources were held constant, blacks and persons of other race/ethnicity no longer differed from whites, but differences among Hispanics persisted.
Conclusions: A comprehensive approach to the health needs of rural working age adults must consider the unique characteristics of rural communities and populations, requiring cultural as well as financial creativity in the design of health delivery systems. The importance of resources such as education and employment points to the need to link health problems to area-specific rural economic development.
Factors Influencing the Retention and Attrition of Community Health Aides/Practitioners in Alaska
Beth Landon, Jenny Loudon, Mariko Selle, Sanna Doucette
Context: The Community Health Aide Program (CHAP) is a unique program employing local, indigenous peoples as primary care nonphysician providers in extremely remote frontier, tribal Alaskan communities. With attrition rates up to 20%, recommendations for improving retention are necessary to maintain access to health services for Alaska Natives in these communities.
Purpose: The purpose of this study was to identify factors contributing to retention in Alaska’s CHAP program.
Methods: Key informant interviews were conducted with 41 community health aides/practitioners (CHA/Ps) in 15 villages statewide. Efforts were made to ensure the sample included a mix of villages with high retention of health aides and villages with lower retention. Geographic and ethnic diversity were also considered. Transcripts were coded using NUD*IST software, and data were analyzed for differences between high retention and low retention villages and between more experienced and less experienced CHA/Ps.
Findings: Five fundamental needs of health aides were identified as crucial for retention of personnel. These needs include strong co-worker support, access to basic training, a fully staffed clinic, good community support, and supportive families.
Conclusions: For 35 years, the CHAP program has worked to diminish health disparities for Alaska Natives. Though unique challenges associated with the job have factored into low retention of CHA/Ps, improved retention is possible with easier access to basic training, increased support from colleagues and community, enhanced team-building skills, and better on-call schedules.
Cost Analysis in Telemedicine: Empirical Evidence From Sites in Arizona
Adela de la Torre, Clemente Hernandez-Rodriguez, Lorena Garcia
Context: Support of telemedicine for largely rural and ethnically diverse populations is premised on expectations that it increases opportunities for appropriate and timely medical services, and that it improves costeffective service delivery.
Purpose: To understand the cost-effectiveness of telemedicine in 8 small and/or rural sites in Arizona.
Methods: A cost analysis framework was used to measure the efficacy of telemedicine in the selected sites from May 1, 2000, to April 30, 2001.
Findings: The costs for telemedicine services in half the study sites were more than the costs for conventional face-to-face diagnosis when the volume of telemedicine services used at a site was relatively low. This result persisted even when the opportunity cost for the patients in accessing more traditional types of care was included in the cost estimates.
Conclusions: These preliminary findings suggest that telemedicine in some instances may not be cost-effective for providing medical specialists for underserved communities, particularly if these networks are underutilized by the patient population. Further analyses are needed to assess factors influencing utilization patterns of telemedicine services by underserved and ethnic communities before implementing these programs at clinical sites.
Rural Mexican-American Adolescent Sexual Risk Behavior
Jane Dimmitt Champion, Pat Kelly, Rochelle N. Shain, Jeanna M. Piper
Context: There is a need for community based, culturally sensitive, cognitive-behavioral interventions to reduce sexual risk behavior among minority adolescents. Studies of adolescent risk and protective behaviors have focused on identifying modifiable psychosocial variables that predict differential outcomes for subsequent intervention efforts. Research has been scarce in studies of rural minority adolescent women.
Purpose: To examine the protective and risk behaviors of these rural Mexican-American adolescent women and their relationship to physical or sexual abuse.
Methods: Mexican-American adolescent women aged 14–19 years were recruited through a rural health clinic and administered a self-report assessment for protective and risk behavior and sexual, physical, and psychological abuse.
Findings: Rural minority adolescent women endured high levels of psychological distress and many risk behaviors yet experienced few protective behaviors. Barriers to health care included access and confidentiality. Physically or sexually abused adolescents endured relatively greater risk and fewer protective behaviors than nonabused.
Conclusions: Rural Mexican-American adolescent women may benefit from confidential identification and assessment of abuse history and risk and protective behaviors so that appropriate psychological treatment can accompany accessible medical treatment. The prevalence of risk behaviors and abuse among these women presents a need for development of behavioral interventions for risk reduction and promotion of health protective behaviors.
Australian Journal of Rural Health
2003; 12 (3)
Evaluation of an after hours telephone support service for rural palliative care patients and their families: A pilot study
Lesley Wilkes, Shantala Mohan, Kate White, Helen Smith
Objective: To report on the introduction and evaluation of an after hours telephone support service for palliative care patients and their families at home.
Design: Descriptive evaluation using an audit of telephone logbook, text analysis of reflective journals, questionnaire and interviews.
Setting: Palliative care call service in Grafton, New South Wales, Australia.
Subjects: The participants were health professionals using the Palliative Care Service in Grafton (48 in total) and nurses providing the palliative care service (21 in total).
Results: Twelve calls were taken by the nurses during the pilot study. Three major themes emerged from the analysis: preparation involving publishing the after hours telephone support service (AHTSS) and nurse workshop; benefits such as support to families and health service resourcing; and nurses' experiences regarding personal impact and building support for each other.
Conclusion: It appears from the evaluation responses of health professionals and nurses that knowing the service was there was a great security and reduced the sense of isolation predominant in the experience of rural families caring for a palliative care patient at home. Based on the positive evaluation, the area health service provided ongoing funding for the service and is exploring avenues to extend the program into other areas. The service now requires a re-evaluation at 18 months and will form the second phase of the study that is currently being organised.
Anangu oral health: The status of the Indigenous population of the Anangu Pitjantjatjara lands
Colin Endean, Kaye Roberts-Thomson, Simon Wooley
Objective: To describe oral health in the Anangu Pitjantjatjaraku lands in South Australia and to compare with earlier surveys and national data.
Setting: Data were collected at the time of dental care service provision, according to World Health Organization protocols, at the request of the Nganampa Health Council on optical mark reader forms.
Participants: There were 356 Anangu adults and 317 children surveyed.
Results: The mean number of teeth affected by dental caries in the deciduous dentition in young children, aged 5-6 years, was double (mean 3.20) that of the overall Australian child population aged 5-6 years (mean 1.44). In contrast to the decline in deciduous caries in Australian children generally, Anangu children aged 5-9 years had a 42% increase in the mean number of teeth affected since 1987. Adults experienced low levels of dental caries, but severe periodontal disease was more prevalent among diabetics (79%) compared with-non-diabetics (13.8%). Tooth loss was found more frequently among adults with diabetes (mean 5.51) than non-diabetics (mean 1.53).
Conclusions: Oral health promotion strategies, in association with general health strategies, need to be developed to improve oral health in this remote Aboriginal population.
Experiences of Organization for Economic Cooperation and Development countries with recruiting and retaining physicians in rural areas
Objective: This present study discusses the potential pitfalls in measuring physician shortages in rural areas and presents existing evidence of the effectiveness of policy interventions designed to influence the geographical distribution of physicians.
Design: Information on the geographical distribution of physicians was derived from a survey of Organization for Economic Cooperation and Development (OECD) countries and a desk review of the academic literature and policy documents of OECD governments.
Main outcome measure: Whether policies have been effective in recruiting and retaining physicians in rural areas.
Results: Existing measures of physician shortages in rural areas may be misleading as they do not account for a number of supply side factors (e.g. physician productivity, mobility of physicians across areas) and demand-side factors (e.g. patient needs for physician services). Increases in the national number of physicians have narrowed, but not eliminated, shortages in rural areas. Some success in increasing physician supply to rural areas has been reported with educational, regulatory and financial policies; whereas countries' experiences with education-related funding policies are mixed. There is some evidence suggesting that the effectiveness of these policies can be enhanced by supporting occupational opportunities for the spouse/partner, education of children and accommodation.
Conclusions: Although there has been little evaluation of policy interventions, physician shortages in rural areas may be reduced by supply side policies that focus on the physician in combination with measures to sustain the economic and social viability of rural communities.
General practice in Greece: A student's and supervisor's perspective
Georgios Liangas, Christos Lionis
Objective: The present study reports the observations of an Australian medical student, his reflections on these observations and commentary from the Greek supervisor.
Setting: One urban General Practice at the University Hospital in Heraklion, Crete and three community health centres in rural Crete.
Main outcome measures: Points of comparison were formed during the patient's consultations and clinical investigations.
Results: Although the level of knowledge and GP's competence in Crete and New South Wales appear to be similar and there is an impression that the patient satisfaction in Greece is comparable to that in Australia, a striking feature in Greek primary care is the communication between practitioner and patient, as well as the poor level of note keeping. In contrast, Primary Care in Greece seems to be far more involved in research.
Conclusion: To attain a higher quality in primary care, leading to a better outcome for the people of Greece, the primary care physicians need more effective vocational training and the appropriate support from health authorities.
[Norwegian medical journal for general practice and public health] [in Norwegian]
© Paul Worley 2004 A licence to publish this material has been given to ARHEN, http://www.rrh.org.au