Journal Search

Journal Search - issue 2, 2008


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


30 June 2008 Volume 8 Issue 2


RECEIVED: 30 June 2008

ACCEPTED: 30 June 2008


Richmond J.  Journal Search - issue 2, 2008. Rural and Remote Health 2008; 8: 1032.


© Jennifer Richmond 2008 A licence to publish this material has been given to ARHEN,

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Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in North American and Australian rural health journals.


Journal of Rural Health

Contents: 2008; 24: (2)
Issue includes:

Health Care Information Technology in Rural America: Electronic Medical Record Adoption Status in Meeting the National Agenda
James A. Bahensky, Mirou Jaana, Marcia M. Ward

ABSTRACT: Continuing is a national political drive for investments in health care information technology (HIT) that will allow the transformation of health care for quality improvement and cost reduction. Despite several initiatives by the federal government to spur this development, HIT implementation has been limited, particularly in the rural market. The status of technology use in the transformation effort is reviewed by examining electronic medical records (EMRs), analyzing the existing rural environment, identifying barriers and factors affecting their development and implementation, and recommending needed steps to make this transformation occur, particularly in rural communities. A review of the literature for HIT in rural settings indicates that very little progress has been made in the adoption and use of HIT in rural America. Financial barriers and a large number of HIT vendors offering different solutions present significant risks to rural health care providers wanting to invest in HIT. Although evidence in the literature has demonstrated benefits of adopting HIT such as EMRs, important technical, policy, organizational, and financial barriers still exist that prevent the implementation of these systems in rural settings. To expedite the spread of HIT in rural America, federal and state governments along with private payers, who are important beneficiaries of HIT, must make difficult decisions as to who pays for the investment in this technology, along with driving standards, simplifying approaches for reductions in risk, and creating a workable operational plan.

The Importance of Location for Tobacco Cessation: Rural-Urban Disparities in Quit Success in Underserved West Virginia Counties
Mary E. Northridge, Donna Vallone, Haijun Xiao, Molly Green, Julia Weikle Blackwood, Suzanne E. Kemper, Jennifer Duke, Kimberly A. Watson, Barri Burrus, Henrie M. Treadwell

Context: Adults who live in rural areas of the United States have among the highest smoking rates in the country. Rural populations, including Appalachian adults, have been historically underserved by tobacco control programs and policies and little is known about their effectiveness. Purpose: To examine the end-of-class quit success of participants in A Tobacco Cessation Project for Disadvantaged West Virginia Communities by place of residence (rural West Virginia and the urban area of Greater Charleston).
Methods: This collaborative program was implemented in 5 underserved rural counties in West Virginia and consisted of 4 intervention approaches: (1) a medical examination; (2) an 8-session educational and behavioral modification program; (3) an 8-week supply of pharmacotherapy; and (4) follow-up support group meetings.
Findings: Of the 725 program participants, 385 (53.1%) had successfully quit using tobacco at the last group cessation class they attended. Participants who lived in rural West Virginia counties had a lower end-of-class quit success rate than those who lived in the urban area of Greater Charleston (unadjusted odds ratio [OR] = 0.69, 95% confidence interval [CI] = 0.48, 0.99), even after taking into account other characteristics known to influence quit success (adjusted OR = 0.58, 95% CI = 0.35, 0.94).
Conclusions: Tobacco control programs in rural West Virginia would do well to build upon the positive aspects of rural life while addressing the infrastructure and economic needs of the region. End-of-class quit success may usefully be viewed as a stage on the continuum of change toward long-term quit success.

Understanding Smoking Cessation in Rural Communities
Tresza D. Hutcheson, K. Allen Greiner, Edward F. Ellerbeck, Shawn K. Jeffries, Laura M. Mussulman, Genevieve N. Casey

Context: Rural communities are adversely impacted by increased rates of tobacco use. Rural residents may be exposed to unique communal norms and other factors that influence smoking cessation. Purpose: This study explored facilitating factors and barriers to cessation and the role of rural health care systems in the smoking-cessation process.
Methods: Focus groups were conducted with smokers (N = 63) in 7 Midwestern rural communities. Qualitative analysis and thematic coding of transcripts was conducted.
Findings: Three levels of pertinent themes-intrinsic, health-system resource, and community/social factors-were identified. Intrinsic factors facilitating cessation included willingness to try various cessation methods, beliefs about consequences of continuing smoking (eg, smoking-related illnesses), and benefits of quitting (eg, saving money). Intrinsic barriers included skepticism about resources, low self-efficacy and motivation for smoking cessation, concern about negative consequences of quitting (eg, weight gain), and perceived benefits of continued smoking (eg, enjoyment). Key health-system resource facilitators were pharmacotherapy use and physician visits. Resource barriers included infrequent physician visits, lack of medical/financial resources, limited local smoking-cessation programs, and lack of knowledge of existing resources. In terms of community/social factors, participants acknowledged the negative social impact/image of smoking, but also cited a lack of alternative activities, few public restrictions, stressors, and exposure to other smokers as barriers to cessation.
Conclusions: Smokers in rural communities face significant challenges that must be addressed. A multilevel model centered on improving access to health care system resources while addressing intrinsic and community/social factors might enhance smoking-cessation interventions and programs in rural communities.

Kansas Primary Care Weighs In: A Pilot Randomized Trial of a Chronic Care Model Program for Obesity in 3 Rural Kansas Primary Care Practices
Andrea C. Ely, Angela Banitt, Christie Befort, Qing Hou, Paula C. Rhode, Chrysanne Grund, Allen Greiner, Shawn Jeffries, Edward Ellerbeck

Context: Obesity is a chronic disease of epidemic proportions in the United States. Primary care providers are critical to timely diagnosis and treatment of obesity, and need better tools to deliver effective obesity care. Purpose: To conduct a pilot randomized trial of a chronic care model (CCM) program for obesity care in rural Kansas primary care.
Methods: We enrolled 107 participants to a 6-month, 2-armed, randomized trial comparing a CCM for obesity with usual care. The primary outcome was weight change at 90 days. The usual care arm received educational weight loss materials and outcome assessments at day 0, 90, and 180. The active arm received the same elements as the usual care arm plus a multicomponent obesity CCM.
Findings: The Day 90 mean ± SD weight change for the active arm (n = 34) and control arm (n = 33), respectively, was −4.5 ± 7.7 pounds and −2.4 ± 8.1 pounds (P = .27 for difference). The Day 180 mean ± SD weight change for the active (n = 27) and control (n = 27) arms, respectively, was −9.4 ± 10.3 pounds and −2.1 ± 10.7 pounds (P = .01 for difference). There was no significant change in physical activity, or fruit and vegetable intake at day 90 or day 180.
Conclusions: Improving the recognition and treatment of obesity in primary care settings is a critical initiative. Rural populations suffer disproportionately with obesity, and better methods of delivering obesity care are needed for this population. Further research is needed to establish the effectiveness of a CCM approach for obesity care.

Vital Signs Screening for Alcohol Misuse in a Rural Primary Care Clinic: A Feasibility Study
J. Paul Seale, Monique R. Guyinn, Michael Matthews, Ike Okosun, M. Marie Dent

Context: Alcohol misuse is more common in rural areas, and rural problem drinkers are less likely to seek alcohol treatment services. Rural clinics face unique challenges to implementing routine alcohol screening and intervention. Purpose: To assess the feasibility of using the single alcohol screening question (SASQ) during routine nursing vital signs in a rural clinic, and to determine its effect on alcohol screening and intervention rates.
Methods: Patient exit interviews were used to identify alcohol misuse and to measure changes in screening and intervention rates. Chi-square tests were used to compare rates of screening across study phases, while odds ratios from logistic regression analyses were used to quantify association between nurse screening and clinician intervention.
Findings: Exit interviews were completed by 126 current drinkers (41 before vital signs screening implementation and 85 afterward). Screening rates for alcohol misuse rose from 14.6% at baseline to 20.0% (P = .027) after screening implementation. Clinician intervention rates among alcohol misusers rose from 6.3% to 11.8% (P = .039). Nurse screening increased the odds of clinician intervention (OR 1.47; 95% CI 1.10-1.95).
Conclusions: Vital signs screening proved to be feasible in this rural clinic and produced modest but significant increases in alcohol screening by nurses and brief interventions by clinicians. Additional studies are needed to define effective strategies for further increasing these rates.

Physical Activity, Metabolic Syndrome, and Overweight in Rural Youth
Justin B. Moore, Catherine L. Davis, Suzanne Domel Baxter, Richard D. Lewis, Zenong Yin

Background: Research suggests significant health differences between rural dwelling youth and their urban counterparts with relation to cardiovascular risk factors. This study was conducted to (1) determine relationships between physical activity and markers of metabolic syndrome, and (2) to explore factors relating to physical activity in a diverse sample of rural youth.
Methods: Data were collected from 4th, 6th, 8th, and 11th grade public school students in the rural Southeastern United States in the spring of 2002. Physiological data included anthropometrics, fasting glucose, lipids, hemodynamics, and skinfold measurements. Psychosocial data included parental support for physical activity, accessibility of physical activity facilities, and safety concerns for physical activity. Behavioral data included self-reported physical activity and sedentary behaviors.
Results: After adjusting for sex, race, and age, subjects with low level of physical activity were 3 times more likely to be positive for metabolic syndrome compared to those reporting a high level of physical activity. Subjects reporting a low level of physical activity were 2.4 times more likely to be overweight compared to subjects reporting a high level of physical activity. Students with high levels of physical activity were more likely to have parents who provided money for physical activity lessons and sports teams.
Conclusions: Rural youth with low levels of physical activity participation were at increased risks for metabolic syndrome and overweight. Effective physical activity promotions addressing supports for physical activity are urgently needed in rural America.

Alcohol Consumption and Injury Among Canadian Adolescents: Variations by Urban-Rural Geographic Status
Xuran Jiang, Dongguang Li, William Boyce, William Pickett

Context: The impact of alcohol consumption on risks for injury among rural adolescents is an important and understudied public health issue. Little is known about whether relationships between alcohol consumption and injury vary between rural and urban adolescents. Purpose: To examine associations between alcohol and medically attended injuries by urban-rural geographic status using a representative national sample of Canadian adolescents.
Methods: The study involved a secondary analysis of a national sample of Canadian adolescents aged 11-15 years (n = 7,031) from the 2001-2002 Health Behavior in School-Aged Children Survey. Respondents were classified into 5 geographic categories of rural-urban status. Multiple logistic regression was used to examine the magnitude and homogeneity of associations between drinking patterns and adolescent injuries across these 5 geographic groupings.
Findings: Higher rates of alcohol consumption and adolescent injuries were observed in more rural areas. Alcohol consumption was significantly associated with higher risks for injury occurrence with evidence of a dose-related pattern of risk. Associations between alcohol consumption and injury were consistent by urban-rural geographic status.
Conclusions: Misuse of alcohol is an important potential cause of injury. Adolescents whose lifestyle includes alcohol consumption experience higher risks for injury, and this association is observed consistently by urban-rural geographic status. Findings of this study emphasize a need to intervene with high-risk adolescents as a tertiary prevention strategy, irrespective of geographic background.

The Occupational Mix Adjustment to the Medicare Hospital Wage Index: Why the Rural Impact Is Less Than Expected
Kristin L. Reiter, Rebecca Slifkin, George M. Holmes

Context: Rural hospitals are heavily dependent on Medicare for their long-term financial solvency. A recent change to Medicare prospective payment system reimbursement-the occupational mix adjustment (OMA) to the wage index-has attracted a great deal of attention in rural policy circles. Purpose: This paper explores variation in the OMA across and within urban and rural markets. Reasons why the effect of the OMA has been less than some rural advocates anticipated are discussed.
Methods: Data were obtained from the fiscal year 2007 Final Occupational Mix Survey Data Public Use File and the fiscal year 2007 Final Rule Wage Data Public Use File. Descriptive statistics were generated to determine the need for the OMA and the potential impact of its application on hospitals located in rural markets.
Findings: The average OMA for nonmetropolitan markets is greater than 1, indicating that hospitals in these markets use a less-skilled mix of labor than the national average. However, almost one third of nonmetropolitan markets had an OMA that was less than 1 and experienced a net decrease in Medicare reimbursement due to the OMA.
Conclusions: There are several reasons why the impact of the OMA is smaller than many rural hospital administrators expected. The most important is that the adjustment happens at the market-level rather than for individual hospitals, so a small hospital's staffing mix may have almost no effect on the final payment adjustment. In rural markets, it appears that hospitals in micropolitan areas exert a large influence on the OMA.

Medicare Hospital Charges in the Last Year of Life: Distribution by Quarter for Rural and Urban Nursing Home Decedents With Cognitive Impairment
Charles E. Gessert, Irina V. Haller

Background: Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence.
Methods: We analyzed Medicare hospital charges in the last year of life for nursing home residents with severe cognitive impairment, focusing on rural-urban differences. The study population consisted of 3,703 nursing home residents (1,882 rural, 1,821 urban) in Minnesota and Texas who died in 2000-2001. Data on Medicare hospital charges were obtained from 1998-2001 Centers for Medicare and Medicaid Services MedPAR files.
Results: During the last year of life, unadjusted charges averaged $12,448 for rural subjects; $31,780 for urban. The charges were distributed across the last 4 quarters similarly for the 2 populations, with 15%-20% of charges incurred in each of the first 3 quarters, and 47% (rural) and 52% (urban) in the last quarter. At the individual level, a higher percentage of hospital charges were incurred in the last 90 days by urban than by rural residents (P < .001). A larger proportion of urban (43%) than rural (37%) residents were hospitalized in the final quarter. The charges for hospitalized residents (N = 1,994) were distributed similarly to those of the entire study population.
Discussion: Medicare hospital charges during the last year of life were lower for rural nursing home residents with cognitive impairment than for their urban counterparts. Charges tend to be more concentrated in the last 90 days of life for urban residents.

Rural-Urban Differences in Primary Care Physicians' Practice Patterns, Characteristics, and Incomes
William B. Weeks, Amy E. Wallace

Context: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. Purpose: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians.
Methods: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics.
Findings: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: −$14,569, −$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts.
Conclusions: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.

Expanding the Role of Nurse Practitioners: Effects on Rural Access to Care for Injured Workers
Jeanne M. Sears, Thomas M. Wickizer, Gary M. Franklin, Allen D. Cheadle, Bobbie Berkowitz

Context: A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician. Purpose: The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing.
Methods: Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group.
Findings: NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas.
Conclusions: Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.

Mental Health Professional Shortage Areas in Rural Appalachia
Michael Hendryx

Context: Research on health disparities in Appalachia has rarely compared Appalachia to other geographic areas in such a way as to isolate possible Appalachian effects. Purpose: This study tests hypotheses that nonmetropolitan Appalachia will have higher levels of mental health professional shortage areas than other nonmetropolitan areas of the same states, but that these disparities will dissipate when accounting for social and economic differences.
Methods: The study analyzed secondary data for nonmetropolitan counties (N = 618) in the 13 Appalachian states. Appalachian counties were identified from the Appalachian Regional Commission designations. Mental health professional shortages were identified from Health Resources and Services Administration data. Area Resource File data were used to measure county-level income, education, uninsurance, unemployment, race/ethnicity percentages, and urban influence codes. Logistic regression models tested whether Appalachia was significantly associated with shortage areas, and whether the Appalachian effect persisted after accounting for social and economic covariates.
Findings: Seventy percent of Appalachian nonmetropolitan counties were mental health professional shortage areas, significantly higher than non-Appalachian, nonmetropolitan counties in the same states. The Appalachian effect did not persist after controlling for the full set of other variables; education and race/ethnicity emerged as significant predictors.
Conclusions: Appalachia location is associated with mental health professional shortages, but this effect is driven by underlying social differences, in particular by lower education. This method of identifying Appalachia for comparative purposes may be applied to many other health services research questions and to other defined geographic regions.

Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments
Lars E. Peterson, Martey Dodoo, Kevin J. Bennett, Andrew Bazemore, Robert L. Phillips

Context: Rural areas have fewer physicians compared to urban areas, and rural emergency departments often rely on community or contracted providers for staffing. The emergency department workforce is composed of a variety of physician specialties and clinicians. Purpose: To determine the distribution of emergency department clinicians and the proportion of care they provide across the rural-urban continuum.
Methods: Cross-sectional analysis of secondary data. The distribution of clinicians who provide emergency department care by county was determined using the 2003 Area Resource File. The percentage of emergency department care provided by clinician type was determined using 2003 Medicare claims data. Logistic regression analyses assessed the odds of being seen by different clinicians with a patient's rurality when presenting to the emergency department.
Findings: Board-certified emergency physicians provide 75% of all emergency department care, but only 48% for Medicare beneficiaries of the most rural of counties. The bulk of the remainder of emergency department care is largely provided by family physicians and general internists, with the percentage increasing with rurality. The likelihood of being seen by an emergency physician in the emergency department decreases 5-fold as rurality increases, while being seen by a family physician increases 7-fold.
Conclusion: Nonemergency physicians provide a significant portion of emergency department care, particularly in rural areas. Medical specialties must cooperate to ensure the availability of high-quality emergency department care to all Americans regardless of physician specialty.

Stroke Knowledge Among Urban and Frontier First Responders and Emergency Medical Technicians in Montana
Michael J. McNamara, Carrie Oser, Dorothy Gohdes, Crystelle C. Fogle, Dennis W. Dietrich, Anne Burnett, Nicholas Okon, Joseph A. Russell, James DeTienne, Todd S. Harwell, Steven D. Helgerson.

Purpose: To assess stroke knowledge and practice among frontier and urban emergency medical services (EMS) providers and to evaluate the need for additional prehospital stroke training opportunities in Montana.
Methods: In 2006, a telephone survey of a representative sample of EMS providers was conducted in Montana. Respondents were stratified into 2 groups: those working in urban and frontier counties.
Findings: Compared to EMS providers from urban counties, those from frontier counties were significantly more likely to be older (mean age 44.7 vs 40.1 years), have fewer personnel working in their service (mean 17.7 vs 28.6), to be located farther away from a computed tomography scan (CT scan) (mean 41.3 vs 17.6 miles), and to be volunteers (84% vs 49%). They were also less likely to have a stroke protocol (58% vs 66%) and use a stroke screening tool (36% vs 47%) than their urban counterparts. There were no significant differences between frontier and urban EMS respondents' ability to correctly identify 4 or more stroke warning signs (58% vs 61%), 4 or more stroke risk factors (46% vs 43%), or the 3-hour recombinant tissue plasminogen activator (rt-PA) treatment window (56% vs 57%). Approximately two thirds of respondents from urban and frontier counties believed they had adequate stroke knowledge, but 90% indicated they were interested in additional stroke-related training.
Conclusions: Although stroke knowledge did not differ between urban and frontier groups, stroke screens and stroke protocols were less likely to be used in the frontier areas. Training opportunities and the implementation of stroke protocols and screening tools are needed for EMS providers, particularly in frontier counties.

Uninsured Hospitalizations: Rural and Urban Differences
Wanqing Zhang, Keith J. Mueller, Li-Wu Chen

Context: Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences. Purpose: To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations.
Methods: We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Project's National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations.
Findings: Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than $35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals.
Conclusions: The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.

Rural Residence and Prescription Medication Use by Community-Dwelling Older Adults: A Review of the Literature
Ruby E. Grymonpre, Pamela G. Hawranik

Context: Due to various barriers to health care access in the rural setting, there is concern that rural older adults might have lower access to prescribed medications than their urban counterparts. Purpose: To review published research reports to determine prevalence and mean medication use in rural, noninstitutionalized older adults and assess whether rural-urban differences exist.
Methods: PubMed, Ageline, Cinahl, PsycInfo, International Pharmaceutical Abstracts, Agricola, and Institute for Scientific Information Web of Science - Social Science Index were searched. English-language articles through May 2005 involving a sample of rural, noninstitutionalized older adults and analyses of overall medication prevalence and/or intensity were included. Review articles, conference abstracts, dissertations, books, and articles targeting nonprescription or specific therapeutic categories were excluded. A total of 206 citations were identified and 26 met the inclusion criteria.
Findings: Reported prevalence of prescription medication use by rural older adults varied between 62% and 96%, with 2-6 prescriptions per person. Multivariate analyses results were equally inconsistent. Controlling for insurance, most US studies suggest there is no rural-urban difference in access to prescribed medications. However, this finding may not be generalizable across all regions in the United States or other countries.
Conclusions: Geographic location may not be as important a variable for medication usage as for other health services utilization.

Determinants of Rural Women's Health: A Qualitative Study in Southwest Ontario
Beverly D. Leipert, Julie A. George

Context: The influences of gender and geography are increasingly being acknowledged as central to a comprehensive understanding of health. Since little research on rural women's health has been conducted, an in-depth qualitative approach is necessary to gain a better initial understanding of this population. Purpose: To explore the determinants of health and their influence on rural women's health.
Methods: From November 2004 to September 2005, 9 focus groups and 3 individual interviews were conducted in 7 rural southwestern Ontario communities. Sixty-five rural residents aged 26 years and older participated in the study. Semi-structured interview questions were used to elicit participants' perceptions regarding determinants of rural women's health.
Findings: Four Health Canada determinants (employment, gender, health services, and social environments) and 3 new determinants (rural change, rural culture, and rural pride) emerged as key to rural women's health.
Conclusions: Although health determinants affect both urban and rural people, this qualitative study revealed that rural women experience health determinants in unique ways and that rural residents may indeed have determinants of their health that are particular to them. More research is needed to explore the nature and effects of determinants of health for rural residents in general, and rural women in particular.

Reason for Visit: Is Migrant Health Care That Different?
George F. Henning, Marie Graybill, John George

Purpose: The purpose of this pilot study was to determine the reasons for which migrant agricultural workers in Pennsylvania seek health care.
Methods: Participants were individuals 14 years of age and over, actively involved in agricultural labor and presenting for medical care at 6 migrant health care centers. Bilingual health care providers randomly selected and interviewed the participants.
Findings: The most commonly reported reason for visiting the health care provider was for physical examination. The most frequent acute problems were related to the musculoskeletal and integumentary systems. Frequently cited problems in the medical history were hypertension, musculoskeletal/back pain, and gastrointestinal conditions. Most medications being taken were for cardiovascular or pain-related problems.
Conclusions: These results suggest that migrant workers present with medical problems that are similar to those of the general primary care population. Many problems were recurrent and represented common chronic medical conditions.


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English

To browse back issues of CJRM, take this link]


Australian Journal of Rural Health

2008; 16: (3)
issue includes:

Extended scope practitioners and clinical specialists: A place in rural health?
Sally A. Ruston

This review identifies two models of allied health advanced practitioner practice that are currently in place in the National Health Service in the United Kingdom (UK). A review of the background to advanced practitioner status is given for UK allied health professionals and comments made on the outcomes of the UK roles. Description of the work of Clinical Specialist and Extended Scope Practitioner is given. Alignment with senior physiotherapy staff roles in Australia is commented upon. Some barriers or impediments to implementation of such a system in Australia are discussed with respect to registration, funding and support. The feasibility of such advanced practice roles for physiotherapy is discussed while benefits and cautions are identified. The potential for such a model of health service to be used in Australia, particularly in rural and remote areas, is identified for debate.

Aboriginal and Torres Strait Islander women's experience when interacting with the Edinburgh Postnatal Depression Scale: A brief note
Alistair Campbell, Barbara Hayes, Beryl Buckby

Background: The Edinburgh Postnatal Depression Scale (EPDS) is one of the most widely used screening instruments for maternal perinatal anxiety and depression. It has maintained its robust performance when translated into multiple languages, when used prenatally and when used with perinatal fathers; thus the tool is also known as the Edinburgh Depression Scale (EDS). However, there have been no published psychometric data on versions of the EPDS adapted for screening Australian Aboriginal and Torres Strait Islander women. We describe the development of 'translations' of the EPDS and report their basic psychometric properties.
Method: During the Queensland arm of the beyondblue National Postnatal Depression Program (2001-2005), partnerships with Aboriginal and Torres Strait Islander women were forged. At TAIHS' stand alone "Mums and Babies" unit 181 women of Aboriginal or Torres Strait Islander descent were recruited into the study through their antenatal and postnatal visits and 25 were recruited at Mt Isa. Participants completed either the translation or the standard version of the EPDS both antenatally and postnatally.
Results: The 'translations' of the EPDS demonstrated a high level of reliability. The was a strong correlation between the 'translations' and the EPDS. The 'translations' and the standard EPDS both identified high rates of women at risk of depression although the 'translations' identified higher rates.
Conclusion: We argue that the 'translation' may have been a more accurate predictor of perinatal women at risk for depression, but acknowledge that a lack of validity evidence weakens this conclusion.

Effects of a 12-month exercise program on cardiorespiratory health indicators of Vietnam War veterans resident in the tropics
Rebecca M. Kerr, Anthony S. Leicht, Warwick L. Spinks

Objective: To measure the effect of a combined aerobic and resistance exercise program on key cardiovascular disease risk factors (i.e. body composition or anthropometry and cardiorespiratory function) of Australian male, Vietnam War veterans living in the tropics.
Design: Twelve-month exercise program with assessments at commencement, 3, 6 and 12 months.
Setting: North Queensland regional centre.
Participants: Australian male, Vietnam War veterans (n = 164) resident in north Queensland.
Main outcome measures: Measurement of heart rate, blood pressure, skinfold and girth measurements, exercise heart rate response and estimated aerobic capacity to determine whether the implementation of a simple aerobic and resistance exercise program could positively change selected cardiovascular disease risk factors in Vietnam Veterans.
Results: Significant improvements were reported for systolic blood pressure (131.1 (SD 15.7) reduced to 122.7 (12.4) mmHg), diastolic blood pressure (82.7 (9.1) reduced to 76.3 (10.3) mmHg), resting heart rate (73 (11) reduced to 69 (11) bpm), sum of skinfolds (127.5 (40.3) reduced to 99.5 (32.1) mm), waist girth (103.2 (12.0) reduced to 100.5 (12.1) cm), hip girth (105.3 (9.6) reduced to 103.7 (10.4) cm) and aerobic capacity (2.17 (0.39) increased to 2.36 (0.34) L min−1).
Conclusion: Participation in a combined aerobic and resistance training program elicited significant anthropometric and cardiorespiratory benefits that might lead to a decreased risk of developing cardiovascular disease for male Vietnam War veterans resident in rural and regional areas.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs
Carla De Angelis, Steve Bunker, Adrian Schoo

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR.
Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team.
Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs.
Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs.
Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery.
Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook.
Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Risk behaviours and blood borne virus exposure for transient workers in rural Victoria
Alisa Pedrana, Campbell Aitken, Peter Higgs, Margaret Hellard

Objective: To investigate risk behaviours associated with the transmission of blood borne viruses (BBVs) and sexually transmitted infections (STIs) among transient rural workers in Victoria.
Design: Cross-sectional study using a convenience sampling frame.
Setting: Between June and August 2006, 89 participants were recruited from sites located in three rural centres in Victoria's Loddon and Mallee regions. Data were collected using a short questionnaire that asked about history of transient work, sexual history, condom use, alcohol and illicit drug use, and BBV history and testing. Finger-prick blood samples were collected in order to determine prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) exposure.
Results: Eighty-nine individuals completed a questionnaire, and 85 (96%) provided a finger-prick blood sample for antibody testing. Twenty-seven participants (30%) were consuming alcohol at levels risky to health. Thirty per cent of participants with new partners reported infrequent condom use. Illicit drug use (mainly marijuana) was widespread with more than 46% of the sample reporting recent use of illicit drugs. An HCV exposure prevalence of 2.4% was measured; no samples tested reactive for HIV antibodies.
Conclusions: Compared with nationally representative data, our study sample reported high rates of alcohol consumption at levels risky to health, illicit drug use and infrequent use of condoms. These results suggest that transient workers and their contacts would benefit from the targeted provision of harm-reduction services, with a particular focus on sexual behaviour and alcohol and drug use.

Rural pharmacy in New Zealand: Effects of a compulsory externship on student perspectives and implications for workforce shortage
Stuart Capstick, Rosemary Beresford, Andrew Gray

Objective: To explore student perceptions of rural pharmacy practice, factors affecting interest in rural work and effects of an educational intervention designed to raise awareness of rural practice.
Design: Qualitative and quantitative survey questionnaire administered before and after a week-long rural externship.
Setting: Undergraduate - rural pharmacy externship.
Participants: Third-year Bachelor of Pharmacy undergraduate cohort (n = 123).
Intervention: Week-long exposure to rural pharmacy practice
Main outcome measures: Rural/urban origin of students, interest in working in rural practice, views held of rural practice and towards externship.
Results: Rural-origin students were significantly more likely to report they would consider working in rural practice prior to the intervention than urban-origin students (77% rural origin versus 40% urban origin). The intervention significantly increased the overall proportion (48% pre-versus 73% post-externship), proportion of female students (48% pre versus 79% post-externship) and proportion of urban-origin students (38% pre-versus 67% post-externship) prepared to consider rural practice. Despite apprehension towards the externship, students reported overwhelmingly positive experiences of it. Negative aspects related mainly to travel and accommodation costs incurred.
Conclusions: This targeted, experiential intervention affected perceptions of rural practice in a positive direction among urban-origin students by raising awareness and challenging their preconceptions of rural pharmacy practice. Further research is required to see whether this will affect recruitment and to investigate what appears to be a particular effect on female students.

Profile of the rural allied health workforce in Northern New South Wales and comparison with previous studies
Tony Smith, Rod Cooper, Leanne Brown, Rebecca Hemmings, Julia Greaves

Objective: To survey allied health professionals in one region of New South Wales.
Design: A questionnaire designed to give a profile of the allied health workforce was mailed to 451 practitioners from 12 health professions between July and September 2005.
Setting: The region included the upper Hunter Valley, Liverpool Plains, New England Tablelands and North-west Slopes and Plains of New South Wales.
Main outcome measures: The overall response was 49.8%, although the response rates varied between disciplines. Data were collected for a wide range of dependent variables.
Results: Pharmacists were the most numerous respondents (21.8%), followed by physiotherapists (17.3%), psychologists (12.4%), radiographers (11.1%) and occupational therapists (10.6%). These five professions made up 73.3% of respondents. Approximately 75% of the sample worked in Rural, Remote and Metropolitan Areas (RRMA) 3 and 4 sized towns. The female to male ratio was 3:1. The mean age was 43 years, the average time since qualification was 20 years and the mean time in the current position was 10 years. Half of the respondents said they intended leaving within 5 years. Some 65% were of rural origin. The ratio of private to public sector employment was 0.75:1, with 64.0% working full-time.
Conclusions: Comparison is made between this and previous studies. The results highlight the need for further regional allied health workforce profiling and for a recruitment and retention strategy that targets new graduates of rural origin and encourages them to stay.

Using overseas registered nurses to fill employment gaps in rural health services: Quick fix or sustainable strategy?
Karen Francis, Ysanne Chapman, Glenn Doolan, Ken Sellick, Tony Barnett

Objective: This study sought to identify and evaluate approaches used to attract internationally trained nurses from traditional and non-traditional countries and incentives employed to retain them in small rural hospitals in Gippsland, Victoria.
Design: An exploratory descriptive design.
Setting: Small rural hospitals in Gippsland, Victoria.
Participants: Hospital staff responsible for recruitment of nurses and overseas trained nurses from traditional and non-traditional sources (e.g. England, Scotland, India, Zimbabwe, Holland, Singapore, Malaysia).
Results and Conclusion: Recruitment of married overseas trained nurses is more sustainable than that of single registered nurses, however, the process of recruitment for the hospital and potential employees is costly. Rural hospitality diffuses some of these expenses by the employing hospitals providing emergency accommodation and necessary furnishings. Cultural differences and dissonance regarding practice create barriers for some of the overseas trained nurses to move towards a more sanguine position. On the positive side, single overseas registered nurses use the opportunity to work in rural Australian hospitals as an effective working holiday that promotes employment in larger, more specialized hospitals. Overall both the registered nurses and the employees believe the experience to be beneficial rather than detrimental.

Partnerships to promote mental health of NSW farmers: The New South Wales Farmers Blueprint for Mental Health
Lyn Fragar, Brian Kelly, Mal Peters, Amanda Henderson, Anne Tonna

Objective: To describe the process and outcome of development of a framework for planning and implementation of a range of interventions aimed at improving the mental health and wellbeing of farmers and farm families in New South Wales (NSW).
Design: In response to a major drought in New South Wales (NSW), key agencies were invited to participate in a longer-term collaborative program aimed at improving the mental health and well-being of the people on NSW farms. These agencies became the NSW Farmers Mental Health Network.
Setting: The Australian National Action Plan for Promotion, Prevention & Early Intervention for Mental Health 2000 proposed a population health approach base encompassing the range of risk and protective factors that determine mental health at the individual, family and community and society levels. It incorporated three traditional areas of health activity into programs aimed at achieving improved mental health for the Australian population - mental health promotion, prevention activities and early intervention. Although the farming population was not identified as a priority population, research has identified this population to be at high risk of suicide, and of having difficulty in coping with the range of pressures associated with life and work in this industry.
Participants: Participants were agencies providing services across rural NSW in the fields of farmer and country women's organisations, financial counselling services, government departments of primary industries and health, mental health advisory and support services, charitable organisations and others.
Results: The NSW Farmers Blueprint for Mental Health ( was developed to be 'a simplified summary of key issues that need to be addressed, and the major actions that we can be confident will be effective in achieving our purpose'. It has identified 'steps' along 'pathways to breakdown' from the range of known mental health and suicide risk factors that are relevant to the NSW farming population, and 23 areas of current and potential action that would contribute to improving mental health, as key steps along 'pathways to health'. For each of the areas of action there is described the rationale and basis for action, and the lead agency or individual who has accepted responsibility for coordinating and reporting further activity to the Network.
Conclusion: It is suggested that the NSW Farm Blueprint and the activities being implemented by the NSW Farmers Mental Health Network partners represent a model for implementation of a mental health promotion in identified at-risk Australian populations.

Community perception of childhood drowning and its prevention measures in rural Bangladesh: A qualitative study
Aminur Rahman, Shumona Shafinaz, Michael Linnan, Fazlur Rahman

Objectives: To gain an in-depth understanding of people's perception of causes and their concepts of prevention of childhood drowning in rural Bangladesh.
Design: A qualitative study and focus group discussion (FGD) was adopted.
Setting: A rural community in Bangladesh.
Participants: FGDs were conducted with mothers of children aged under 5 years, adolescent male and female students, fathers and local leaders. One FGD was conducted for each group. Out of 53 participants 25 were women.
Results: The respondents considered that children of 5-10 years are at risk of drowning. Ponds, ditches and canals were frequently mentioned locations of drowning. Most of the drownings were reported to occur around noon. For prevention of childhood drowning the participants suggested that the children should be constantly supervised, unwanted ditches should be filled in, ponds should be fenced and drowning prevention awareness in the community be increased by community leaders. They suggested that government should organise campaigns for preventing childhood drowning, promoting swimming instruction activities for children and motivating communities to fence ponds.
Conclusions: People interviewed in general know the causes of childhood drowning and its preventive measures, but they do not put their knowledge into preventative actions as they fail to recognise this as a major child survival issue and they are never reached with definite actions points to change the behaviours.

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