Journal Search

Journal Search - issue 4, 2008


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


23 December 2008 Volume 8 Issue 4


RECEIVED: 22 December 2008

ACCEPTED: 23 December 2008


Richmond J.  Journal Search - issue 4, 2008 . Rural and Remote Health 2008; 8: 1148.


© 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:(4)
Issue includes:

Research on Rural Veterans: An Analysis of the Literature
William B. Weeks, Amy E. Wallace, Alan N. West, Hilda R. Heady, Kara Hawthorne

Context: The Veterans Health Administration (VA) provides comprehensive health care services to veterans across the United States. Recently, the VA established an Office of Rural Health to address the health care needs of rural veterans. Purpose: To review the literature on rural veterans' health care needs in order to identify areas for future research.
Methods: We conducted a literature review of articles listed in the Medline, CINAHL, and BIOSIS datasets since 1950. We reviewed and summarized the findings of 50 articles that specifically examined rural veterans.
Findings: The literature on rural veterans included 4 articles examining access to care, 7 evaluating distance technology, 4 examining new models of care delivery, 11 studying rural veterans' patient characteristics, 10 evaluating programs provided in a rural setting, 6 examining rural health care settings, and 8 exploring rural veterans' health services utilization patterns. Most studies were small, based on data obtained before 2000, and consisted of uncontrolled, retrospective, descriptive studies of health care provided in rural VA settings. Definitions of rural were inconsistent, and in 20% of the articles examined the rural aspect of the setting was incidental to the study.
Conclusions: The literature on rural veterans' health care needs warrants expansion and investment so that policy makers can make informed decisions in an environment of limited resources and competing interests.

Recruitment and Retention of Rural Physicians: Outcomes From the Rural Physician Associate Program of Minnesota
Gwen Wagstrom Halaas, Therese Zink, Deborah Finstad, Keli Bolin, Bruce Center

Context: Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. Purpose: To examine RPAP outcomes in recruiting and retaining rural primary care physicians.
Methods: The RPAP database, including moves and current practice settings, was examined using descriptive statistics.
Findings: On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice.
Conclusion: RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.

The Rural Physician Associate Program: The Value of Immersion Learning for Third-Year Medical Students
Therese Zink, Gwen W. Halaas, Deborah Finstad, Kathleen D. Brooks

Context: Changes in health care and new theories of learning have prompted significant changes in medical education. Some US medical schools employ immersion learning in rural communities to increase the number of physicians who choose to practice in these areas. Founded in 1971, the rural physician associate program (RPAP) is a longitudinal immersion learning experience for students during their third year of medical school. Students are assigned to a primary care preceptor(s) in a rural community ranging in population from 1,000 to 30,000 for 36 weeks. Purpose: To describe students' perceived value of this immersion learning experience.
Methods: Data from 3 classes (2004, 2005, 2006) of students (n = 95) were analyzed, including final essays that reflect on their experiences and logs of their patient encounters and procedures. Themes from students' essays related to the hands-on learning experience are presented. Frequencies of ambulatory encounters and procedures were calculated and compared with those of metropolitan area colleagues where possible.
Findings: The continuity experience allows for one-to-one mentoring and long-term relationships. Students see physicians, clinic/hospital staff, and patients as their teachers. The environment is nurturing, but nudges them outside their comfort zone. Students gain increasing competence with their skills and do best if they are independent and seek out learning opportunities. They report more hands-on experience, more confidence and autonomy than their peers in the metropolitan area.
Conclusions: The RPAP experience provides a nurturing, longitudinal, immersion learning experience that facilitates the gradual but steady development of clinical skills alongside a personal and professional mentor.

A Contract-Based Training System for Rural Physicians: Follow-Up of Jichi Medical University Graduates (1978-2006)
Masatoshi Matsumoto, Kazuo Inoue, Eiji Kajii

Context: The number of studies on long-term effects of rural medical education programs is limited. Personal factors that are associated with long-term retention of physicians in rural areas are scarcely known. Purpose: The authors studied the outcomes of Jichi Medical University (JMU), whose mission is to produce rural doctors, and analyzed the characteristics of its graduates who engaged in rural practice even after their 9-year obligation of rural practice.
Method: A retrospective cohort study was conducted including 2,988 JMU students who graduated between 1978 and 2006. Baseline data were collected at matriculation and graduation. Workplace addresses were surveyed in 2000, 2004, and 2006. Follow-up rates were 98.7%, 98.2%, and 98.0% respectively.
Findings: After their obligation period, JMU graduates were 4 times more likely than non-JMU graduates to work in rural areas. The higher proportion of JMU graduates in rural areas did not change significantly between 1994 and 2004. The rural recruitment rate of post-obligation JMU graduates was somewhat lower than rates reported for top rural medical education programs in the United States. In multivariate analyses, rural upbringing and primary care specialty were positively associated with having a rural address in at least one post-obligation study year (OR 1.89 [95% CI 1.27-2.81]; and 7.63 [4.37-13.34], respectively) and settlement (ie, having a rural address over multiple years) after the contract (1.90 [1.04-3.48]; and 32.07 [4.43-232.24], respectively). Graduation from a private high school had a negative association with recruitment (0.56 [0.33-0.96]).
Conclusions: JMU was successful in increasing the number and retention of rural physicians. Rural origin and primary care specialty have a positive impact on both recruitment and retention after the rural obligation.

Addressing Agricultural Issues in Health Care Education: An Occupational Therapy Curriculum Program Description
Stacy Smallfield, Angela J. Anderson

Context: Medical and allied health professionals who work in agricultural states frequently address the needs of clients who live and work in rural and frontier environments. The primary occupations of those living in rural areas include farming, ranching, or other agriculture-related work. Farming is consistently ranked as one of the most high-risk occupations for work-related injuries and accidents; therefore, it is critical that health education programs include content to prepare future medical and health professionals to work with this population.
Purpose and Description: This paper describes the rural issues component of the occupational therapy curriculum at The University of South Dakota. This rural issues module is designed to provide occupational therapists with training about the physical, temporal, and sociocultural aspects of production agriculture and the impact these have on the health and well-being of the agricultural population. It also addresses the occupational therapy implications for farmers and ranchers who have disabilities. Student assessments of the course content have been above average.
Conclusion: Training in agricultural health enables our occupational therapy students to be well prepared for work in the rural and frontier areas of South Dakota and other rural locations.

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural, Small Town America
Joseph Stenger, Suzanne B. Cashman, Judith A. Savageau

Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns.
Methods: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed.
Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere.
Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

The Physician Pipeline to Rural and Underserved Areas in Pennsylvania
Myron R. Schwartz

Context: An implicit objective of a state's investments in medical education is to promote in-state practice of state educated physicians.
Purpose: To present a tool for evaluating this objective by analyzing the "pipeline" from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania.
Methods: AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data.
Results: About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty-four percent of physicians who received both undergraduate and graduate medical education in-state are retained.
Conclusions: These retention rates have developed within the context of a middle-of-the-road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.

Access to Cancer Services for Rural Colorectal Cancer Patients
Laura-Mae Baldwin, Yong Cai, Eric H. Larson, Sharon A. Dobie, George E. Wright, David C. Goodman, Barbara Matthews, L. Gary Hart

Context: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. Purpose: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services-surgery, medical oncology consultation, and radiation oncology consultation.
Methods: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996.
Findings: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles.
Conclusions: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Impact of Critical Access Hospital Conversion on Beneficiary Liability
Boyd H. Gilman

Context: While the Medicare Critical Access Hospital (CAH) program has improved the financial viability of small rural hospitals and enhanced access to care in rural communities, the program puts beneficiaries at risk for paying a larger share of the cost of services covered under the Medicare part B benefit. Purpose: This paper examines the impact of hospital conversion to CAH status on beneficiary out-of-pocket coinsurance payments for hospital outpatient services.
Methods: The study is based on a retrospective observational design using administrative data from Medicare hospital cost reports and fee-for-service beneficiary claims from 1999 to 2003. The study compares changes in beneficiary co-payments before versus after CAH conversion with payment trends among small rural non-converting hospitals over the same period.
Findings: Conversion to CAH status is associated with an increase in beneficiary coinsurance payments per outpatient visit of $17.19, equivalent to 34% of the sample average. However, CAH designation had no significant effect on the share of outpatient costs paid by the beneficiary. Most of the increase in beneficiary liability associated with conversion is attributable to the provision of more services per outpatient visit.
Conclusions: While this and other studies show that conversion to CAH status results in more intensive outpatient care, CAH conversion does not appear to inadvertently create financial barriers to accessing ambulatory services in remote rural communities by forcing beneficiaries to pay a higher share of their Medicare part B costs.

Urban-Rural Differences in Overweight Status and Physical Inactivity Among US Children Aged 10-17 Years
Jihong Liu, Kevin J. Bennett, Nusrat Harun, Janice C. Probst

Context: Few studies have examined the prevalence of overweight status and physical inactivity among children and adolescents living in rural America. Purpose: We examined urban and rural differences in the prevalence of overweight status and physical inactivity among US children.
Methods: Data were drawn from the 2003 National Survey of Children's Health, restricted to children aged 10-17 (unweighted N = 47,757). Overweight status was defined as the gender- and age-specific body mass index (BMI) values at or above the 95th percentile. Physical inactivity was defined using parentally reported moderate-to-vigorous intensity leisure-time physical activity lasting for at least 20 minutes/d on less than three days in the past week. The 2003 Urban Influence Codes were used to define rurality. Multiple logistic regression models were used to examine urban/rural differences in overweight status and physical inactivity after adjusting for potential confounders.
Findings: Overweight status was more prevalent among rural (16.5%) than urban children (14.3%). After adjusting for covariates including physical activity, rural children had higher odds of being overweight than urban children (OR: 1.13; 95% CI: 1.01-1.25). Minorities, children from families with lower socioeconomic status, and children living in the South experienced higher odds of being overweight. More urban children (29.1%) were physically inactive than rural children (25.2%) and this pattern remained after adjusting for covariates (OR: 0.79; 95% CI: 0.73-0.86).
Conclusions: The higher prevalence of overweight among rural children, despite modestly higher physical activity levels, calls for further research into effective intervention programs specifically tailored for rural children.

Trends in Rural and Urban Deliveries and Vaginal Births: California 1998-2002
Susan Hughes, John A. Zweifler, Alvaro Garza, Matthew A. Stanich

Context: Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. Purpose: Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings.
Methods: Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers.
Findings: Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different.
Conclusions: Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Rural Hospital Preparedness for Neonatal Resuscitation
Angela Jukkala, Susan J. Henly, Linda Lindeke

Context: Neonatal resuscitation is a critical component of perinatal services in all settings. Purpose: To systematically describe preparedness of rural hospitals for neonatal resuscitation, and to determine whether delivery volume and level of perinatal care were associated with overall preparedness or its indicators.
Methods: We developed the 15-point Hospital Neonatal Resuscitation Survey to examine institutional preparedness for neonatal resuscitation in 4 areas: policy and procedure, resuscitation team membership, continuing education, and connections with a wider system of perinatal care. All 58 rural hospitals with perinatal services in 2 upper Midwestern states (North Dakota and Minnesota) were asked to provide information describing preparedness for neonatal resuscitation. Nursing administrators responded to the survey.
Findings: A total of 26 hospitals took part. Annual delivery volume ranged from 4 to 958. Preparedness scores ranged from 4 to 12. Hospitals with more than 125 deliveries each year reported significantly higher levels of preparedness than lower volume hospitals (9.50 vs 5.83, P < .001). Overall preparedness was not associated with level of perinatal care. Most rural hospitals did not identify a formal collaborative relationship with a regional level III perinatal center.
Conclusions: Substantial variation in hospital preparedness for neonatal resuscitation was identified. Preparedness was associated with delivery volume. Lack of collaborative agreements between rural hospitals and level III perinatal centers was pervasive. Additional research into the measurement of hospital preparedness for neonatal resuscitation as a component of quality rural perinatal care is needed to optimize outcomes for rural-born neonates.


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

Contents: 2008; 13:(2)
Issue includes:

Oligoanalgesia in a rural emergency department
Dean Vlahaki, William Kenneth Milne

Objective: Multiple studies conducted over many years have demonstrated that pain is poorly managed in the emergency department (ED). This phenomenon has been referred to in the medical literature as "oligoanalgesia." However, little is known about whether oligoanalgesia occurs in a rural ED. National Ambulatory Care Reporting System data from 2003 for a small rural hospital in Ontario showed patients were satisfied with the amount of pain medicine they received in the ED. We designed a study to replicate a published urban study that investigated the use of analgesia in isolated lower limb injuries. Our objective was to see if oligoanalgesia was also a problem in a rural ED.
Methods: In 2003 we conducted a retrospective chart review of patients who presented to the South Huron Hospital ED with isolated lower extremity injuries for which radiographs of the foot, ankle or both were obtained. Demographics of the ED patients with lower extremity injuries were quantified. Other parametres included whether or not patients received analgesia in the ED; how long it took to get assessed, treated and discharged; whether patients received any analgesia upon discharge; what type of analgesia they received; and whether it required a prescription.
Results: A total of 189 patients met inclusion criteria, with 35 fractures identified (18.5%). Sixty-three percent of patients were male. The average age was 32.6 years. The mean Canadian Emergency Department Triage and Acuity Scale level was 4.4. The mean time to physician assessment was 31.6 minutes. The mean length of time spent in the ED was 74 minutes. Over one-half of the patients received analgesia upon discharge from the ED whether or not they had a fracture. In addition, 73% of the people in the fracture group received analgesia requiring a prescription, versus only 46% in the nonfracture group. Narcotics were used more often in the fracture group than in the nonfracture group (26% v. 6%).
Conclusion: The phenomenon of oligoanalgesia was not observed as often in our rural ED for isolated lower limb injuries, when compared with the published urban study.

An analysis of appendectomies performed in a Labrador general surgery practice
Colin Clarkson, Narsing Pradhan

Introduction: The main objective of our study was to determine the rates of negative appendectomies and perforated appendices at the Labrador Health Centre, and make a comparison with the rates published in the literature.
Methods: The study population consisted of all patients who underwent appendectomies during the 5-year period ending Apr. 3, 2006. The number and rates of negative appendectomies and perforated appendices were determined for each age and sex category.
Results: Of the 64 patients who were included in the study, 11% were found to have undergone negative appendectomies and 27% had perforated appendices. There was a clear trend toward decreasing perforation rates with increasing age as well as a trend toward increasing negative appendectomy rates with increasing age.
Conclusion: The rates of negative appendectomies and perforated appendices at the Labrador Health Centre are comparable with those published in the literature. Trends found in the data will help to guide future improvements in patient management.

The difference between medical students interested in rural family medicine versus urban family or specialty medicine
Kymm Feldman, Wayne Woloschuk, Margot Gowans, Dianne Delva, Fraser Brenneis, Bruce Wright,; Ian Scott

Objective: To determine how first-year medical students interested in rural family medicine in Canada differ from their peers.
Method: From 2002 to 2004, first-year students (n = 2189) from 16 classes in 8 Canadian medical schools ranked intended career choices and indicated influences on their choices using Likert scales. We used t tests and χ2 tests to determine demographic influences and factor analysis, and we used analysis of variance to examine associated attitudes.
Results: Of the 1978 surveys returned (90.3%), 1905 were used in the analysis. Rural family medicine was ranked first by 11.1%, varying from 4.7% to 20.2% among schools. Students interested in rural family medicine were more likely to have grown up rurally, graduated from a rural high school and have family in a rural location than others (p < 0.001). They were more likely to be older, in a relationship, to have volunteered in a developing nation and less likely to have university-educated parents than those interested in a specialty (p < 0.008). Attitudes of students choosing family medicine, rural or urban, include social orientation, preference for a varied scope of practice and less of a hospital orientation or interest in prestige, compared with students interested in specialties (p < 0.001).
Conclusion: Medical schools may address the rural physician shortages by considering student demographic factors and attitudes at admission.

The occasional intraosseous infusion
N. John Bosomworth

Long bones in infants are filled with marrow that contains vascularized sinusoids. These sinusoids eventually drain into the systemic venous circulation. The marrow cavity acts as a rigid vein and so will not collapse, even in the face of severe volume loss. No matter how dehydrated or volume-depleted the child is, there is always a rigid tube that can be punctured to replace the required fluids.

Australian Journal of Rural Health

2008; 16:(5)
issue includes:

Profile of occupational therapy practice in rural and remote South Australia
Kobie Boshoff, Sue Hartshorne

Objective: The aim of this report is to discuss the results of a questionnaire conducted with occupational therapists providing services in rural and remote South Australia. It is envisaged that the results will be of interest to health professionals working in country areas of Australia. The questionnaire aimed at capturing descriptive information from these therapists in regards to the type of services they deliver and the strategies they employ to deliver services, including information on human resources and staff retention.
Design and methods: A questionnaire sent to occupational therapy managers and yielded a 44% response rate.
Results: Results provide descriptive information on the services provided, for example, the vast geographical areas covered. Respondents described the challenges they face in service delivery and these include the wide range of services to diverse client groups, high client-therapist ratio and limited human resources. Examples of strategies used are less labour-intensive service delivery models, multi-skilling of staff, networking and use of problem-solving techniques. Most perceived their services to be addressing client needs and they felt supported in their roles by other occupational therapists and their organisations.
Conclusions: Occupational therapists working in rural and remote South Australia are overcoming the challenges identified in this questionnaire by implementing innovative strategies.

Influences on medical students' decisions to study at a rural clinical school
Ryan J. Spencer, Anthony J. Cardin, Geetha Ranmuthugala, George T. Somers and Barbara Solarsh

Objective: To identify factors that influenced medical students at Monash University to undertake their first year of clinical training (third year of the medical course) at a rural clinical school (RCS).
Design: Third-year Monash University medical students undertaking clinical placements at a RCS were surveyed in 2005. A semistructured questionnaire was used to ask students to rate the influence of a list of factors on their decision to undertake their year-long placement at a RCS.
Results: Under half (48%) of students studying at an RCS reported that they were of rural background. All surveyed items were identified as having had a positive influence. Greater clinical experience, learning opportunities and patient access were identified as having the greatest positive influence followed closely by free accommodation and other financial and supportive incentives. Future rural career intention was eight times more likely to be a positive influence in rural compared with urban background students.
Conclusion: The most important positive influence on Monash third-year medical students' decision to study at an RCS is the perception of high-quality clinical experiences and education. This perception arises from rural exposure during pre-clinical years.

Geographical variation of incidence of cutaneous melanoma in Queensland
Petra Gertraud Buettner, Robert MacLennan

Objective: The study investigated geographical differences and time trends of incidence rate and body site distribution of cutaneous melanoma in Queensland.
Design: Analysis of data recorded by Queensland Cancer Registry.
Patients: Analysis included 34 021 patients with invasive and 10 710 patients with in situ melanoma diagnosed between 1982 and 2002.
Main outcome measures: Age-standardised incidence rates (world standard population) per 100 000 inhabitants of cutaneous melanoma and annual percentage change (APC).
Results: Yearly age-standardised incidence rates of invasive melanoma averaged over the 21 years of observation were highest in the south-eastern part of the state, notably in the statistical division Moreton for men (54.2) and in Fitzroy for women (51.4). Inland divisions had on average lower rates than coastal areas. For both men and women, age-standardised incidence rates of invasive and of in situ melanoma increased between 1982 and 2002 for Queensland as a whole and for almost all its statistical divisions. For invasive cancer, the increase was strongest for Moreton (APC men: 5.4%; women: 4.5%; P < 0.001, respectively). APCs were higher for in situ melanoma compared with invasive melanoma for all statistical divisions and both genders. In both genders, the increase in invasive rates was most pronounced for the trunk (APC men: 3.2%, P = 0.040; women: 2.3%; P = 0.306).
Conclusions: The south-eastern corner of Queensland endured the main burden of melanoma. Behavioural and lifestyle choices might create the observed differences between statistical divisions. The increase in trunk melanomas is discussed with respect to aetiology.

Physical activity of young people in the Torres Strait and Northern Peninsula Region: An exploratory study
Rebecca Abbott, David Jenkins, Melissa Haswell-Elkins, Karla Fell, Doune MacDonald, Ester Cerin

Objective: The present study explored the practices of, and perceived barriers to, physical activity of young people living in remote communities in the Torres Strait and Northern Peninsula Area of Far North Queensland.
Design and setting: A cross-sectional survey exploring physical activity practices of children attending primary and secondary schools in two communities in the Torres Strait, Far North Queensland.
Participants: A total of 367 primary and secondary school-aged children (aged 9-16 years).
Main outcome measures: Only 50% of the children reported being active for more than 30 min a day and approximately 25% of both primary and high school children surveyed were 'pretty much active only at week-ends'. The major barriers cited to being active were related to the climate, lack of equipment and child-specific activities and low self-perception of ability.
Conclusions: A large proportion of school students in the Torres Strait and Northern Peninsula Area reported low levels of physical activity. The main barriers cited to being active suggest that structural and family-based strategies are required to help young people, especially girls, to engage in more physical activity. There is also a need for skills and confidence-building activities delivered in a non-competitive environment for those who feel that they lack the necessary skills to participate fully.

The oral health status and treatment needs of Indigenous adults in the Kimberley region of Western Australia
Estie Kruger, Kirrilee Smith, David Atkinson, Marc Tennant

Objective: The oral health of Indigenous Australians, whether urban or rural, is significantly poorer than their non-Indigenous counterparts, and it would be expected that the oral health of rural and remote Indigenous Australians would be particularly poor, although the extent of this extra disadvantage has not been thoroughly documented. The aim of this study was to assess the oral health status and oral health needs in a sample of adult residents of selected towns and remote communities in the Kimberley region of North-west Australia.
Design: A cross-sectional survey (dental examinations and oral health questionnaires) was carried out.
Setting: Rural and remote communities in the Kimberley region of Western Australia.
Participants: Adults in four selected communities.
Results: The mean Decayed, Missing and Filled Teeth (DMFT) score for all participants was 9.8 (SD 8.3). The mean DMFT increased with increasing age. Only 7.3% of people were caries-free. A total of 13% of participants had periodontal pockets of 6 mm or more, and only 3% had no periodontal disease. More than a third (37%) of all participants had advanced periodontal disease. Only 21% of participants did not need any dental treatment.
Conclusions: The oral health of Aboriginal and Torres Strait Islander people are listed as one of the priority areas of Australia's National Oral Health Plan. Based on the above results, oral health is clearly an important priority in the Kimberley.

Subjective well-being, sociodemographic factors, mental and physical health of rural residents
Adeline Lee, Mark Oakley Browne

Objective: To ascertain the relationship between subjective well-being and sociodemographic factors, mental and physical health of a sample of rural residents.
Design: Cross-sectional survey with stratified random sampling of persons based on the 2000 State Electoral Role. Questionnaire was forwarded to 23 000 residents throughout a rural area.
Setting: Households within Gippsland.
Participants: Five thousand three hundred and ninety-one adults aged 18 years and above.
Main outcome measures: Residents completed a self-reported questionnaire assessing life satisfaction/subjective well-being, psychological distress, sociodemographic factors, physical and mental health problems.
Results: Completed survey indicated that participants with lower levels of psychological distress, physical disability and mental disability had higher odds of being satisfied with their life. Participants with severe mental disability had the lowest odds of being satisfied with life. On average, participants were satisfied with their life (mean score of 21, SD = 5.9), are within the normal range of the Kessler-10 (mean score = 16.31, SD = 5.85), had no mental disability (mean score = 51.8, SD = 7.36) on the mental component of the Short Form-12 Health Survey, but are mildly physically disabled (mean score = 48.9, SD = 7.74).
Conclusions: The results of this study indicate that sociodemographic factors, psychological distress, physical health and mental health contribute to subjective well-being. Compared with other age groups, those aged 66 years and above had the highest level of life satisfaction. Those living with partner/spouse without children, with no mental or physical disability and no psychological distress had highest level of life satisfaction. Women also had higher levels of life satisfaction compared with men.

Increasing community participation in an Aboriginal health service
Sonia Champion, Christine Franks, Judy Taylor

Objective: To increase Aboriginal participation with mainstream health professionals in an Aboriginal health and well-being centre.
Design: Participatory Action Research using Aboriginal traditional symbolism to depict aspects of the research process, interview surveys and a document review.
Setting: A regional town with 629 Aboriginal and Torres Strait Islander residents and a newly established Aboriginal health and well-being centre (Nunyara).
Participants: Thirty Aboriginal community members were interviewed about their involvement with Nunyara and their health issues. Participants were selected through purposive 'pass-me-around' sampling to ensure that all family groups were included.
Results: The results are presented in two areas: the structure of the Aboriginal community that affects participation and community views about health issues. Aboriginal people living in the town come from 10 or more different language groups and relate almost exclusively within their own groups. Activities at Nunyara were seen as individual family group events and not for everyone. Aboriginal community participants had a broad view of health as they reported problems that included smoking and alcohol use. Almost all would like more involvement in health issues through Nunyara.
Conclusion: Aboriginal community members are willing to get involved in health issues in collaboration with Nunyara. However, fundamental to increasing participation is to bring people together from different family groups and increase social cohesion. This can be done through developing relationships with groups enabling different points of view to be heard and valued.

Health knowledge acquisition by rural women with chronic health conditions: A tale of two Web approaches
Clarann Weinert, Shirley Cudney, Wade Hill

Objectives: To determine the differences in health knowledge acquisition and the perceived impact on self-management of chronic illness provided by two approaches to providing Web-based information.
Design: Repeated-measure questionnaire administered at four time points: baseline, 11, 23 and 53 weeks; a post-computer intervention survey.
Setting and participants: One hundred and seventy-six chronically ill women (aged 32-68 years) living in rural areas.
Main outcome measures: Scores on knowledge questions within repeated measures; participant ratings on perceptions of abilities to self-manage.
Intervention: The 22-week computer-based intervention provided online support and health information. Women were randomly assigned to an intense intervention (n = 54), less-intense intervention (n = 58) or control group (n = 64).
Results: Both computer intervention groups gained significantly in health knowledge with little differential effect at intervention conclusion or after 6 months, when there was a drop-off in health knowledge retention of about one-third (intense - baseline mean = 0.54, week 23 = 0.69, week 53 = 0.65; less intense - 0.58, 0.68, 0.65). Control remained about the same (0.51, 0.51, 0.53). Using an ANOVA analysis, there was no appreciable difference between intervention groups in perceptions of ability to self-manage illness (intense - mean = 4.02 (on a scale of 1-6), standard deviation = 0.99); less intense - (mean = 3.85, standard deviation = 1.00), t(107) = 0.90, P = 0.37).
Conclusions: A less-intense intervention can be as effective as a more complex, labour-intensive and costly intervention in assisting chronically ill rural women to acquire health knowledge they consider to be moderately helpful in managing their chronic conditions.

Royal Flying Doctor Service 'field days': A move towards more comprehensive primary health care
Kristy Hill, Neil Harris

Objective: To examine the Royal Flying Doctor Service (RFDS) field day program as a means of strengthening community capacity within a primary health care context in remote communities of north Queensland.
Design: Qualitative explanatory study using in-depth face-to-face and phone interviews with field day participants, field day coordinators and RFDS staff and a focus group with RFDS staff.
Setting: Rural and remote communities of north Queensland that participate in RFDS field days.
Results: Field days were found to be contributing to building capacity for health in the remote communities that have been involved in field days. Participants reported increased linkages and partnerships; increased participation; improved problem-solving capacity and increased knowledge transfer associated with the conduct of RFDS field days.
Conclusion: RFDS field days represent a viable framework for building community capacity for health in remote communities within a primary health care context.

Improving mental health capacity in rural communities: Mental health first aid delivery in drought-affected rural New South Wales
Gina-Maree Sartore, Brian Kelly, Helen J. Stain, Jeffrey Fuller, Lyn Fragar, Anne Tonna

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought-affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems.
Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front-line workers from agricultural-related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families.
Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence-based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help.
Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.

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