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Journal Search - issue 1, 2009


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Jennifer Richmond
1 PhD, Editor-in-chief *


* Jennifer Richmond


1 Rural and Remote Health


31 March 2009 Volume 9 Issue 1


RECEIVED: 30 March 2009

ACCEPTED: 31 March 2009


Richmond J.  Journal Search - issue 1, 2009. Rural and Remote Health 2009; 9: 1210.


© Jennifer Richmond 2009 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: 2009; 25:(1)
Issue includes:

Do Children in Rural Areas Still Have Different Access to Health Care? Results from a Statewide Survey of Oregon's Food Stamp Population
Jennifer E. DeVoe, Lisa Krois, Rob Stenger

Purpose: To determine if rural residence is independently associated with different access to health care services for children eligible for public health insurance.
Methods: We conducted a mail-return survey of 10,175 families randomly selected from Oregon's food stamp population (46% rural and 54% urban). With a response rate of 31%, we used a raking ratio estimation process to weight results back to the overall food stamp population. We examined associations between rural residence and access to health care (adjusting for child's age, child's race/ethnicity, household income, parental employment, and parental and child's insurance type). A second logistic regression model controlled for child's special health care needs.
Findings: Compared with urban children (reference = 1.00), rural children were more likely to have unmet medical care needs (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.07-2.04), problems getting dental care (OR 1.36, 95% CI 1.03-1.79), and at least one emergency department visit in the past year (OR 1.42, 95% CI 1.10-1.81). After adjusting for special health care needs (more prevalent among rural children), there was no rural-urban difference in unmet medical needs, but physician visits were more likely among rural children. There were no statistically significant differences in unmet prescription needs, delayed urgent care, or having a usual source of care.
Conclusions: These findings suggest that access disparities between rural and urban low-income children persist, even after adjusting for health insurance. Coupled with continued expansions in children's health insurance coverage, targeted policy interventions are needed to ensure the availability of health care services for children in rural areas, especially those with special needs.

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties
George Rust, Peter Baltrus, Jiali Ye, Elvan Daniels, Alexander Quarshie, Paul Boumbulian, Harry Strothers

Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities.
Purpose: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence.
Methods: We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits.
Findings: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22).
Conclusions: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Sustaining the Rural Workforce: Nursing Perspectives on Worklife Challenges
Mabel Hunsberger, Andrea Baumann, Jennifer Blythe, Mary Crea

Context: Concerns have been raised about the sustainability of health care workforces in rural settings. According to the literature, rural nurses' work satisfaction varies with the resources and supports available to respond to specific challenges. Given the probable effects of stressors on retention, it is essential to understand the unique requirements of nurses in rural practice environments.
Purpose: To investigate whether nurses receive the resources and supports necessary to meet the challenges of rural practice.
Methods: Semi-structured interviews were conducted with 21 managers and 44 staff nurses in 19 selected rural hospitals in Ontario, Canada. The interviews were taped and transcripts interpreted through a thematic analysis. Major worklife themes were identified and analyzed within a healthy work environment model based on the work of Kristensen.
Findings: Three interrelated dimensions of the model were relevant to workforce sustainability: the balance between demands and the resources of the person, the level of social support, and the degree of influence. The availability of resources and supports affected whether the nurses perceived challenges as stimulating or overwhelming. Deficits interfered with practice and the well-being of the nurses and patients.
Conclusions: The nurses felt frustrated and powerless when they lacked resources, support, and influence to manage negative situations. Strategies to achieve workforce sustainability include resources to reduce stress in the workplace, education to meet the needs of new and experienced nurses, and offering of employment preferences to the workforce. Addressing resources, support, and influence of rural nurses is essential to alleviate workplace challenges and sustain the rural nursing workforce.

Trends in the Rehabilitation Therapist Workforce in Underserved Areas: 1980-2000
Richard D. Wilson, Steven A. Lewis, Patrick K. Murray

Context: There is little information about how increases in the rehabilitation therapist workforce have been distributed over the nation. There is evidence that rural areas continue to face a shortage of trained rehabilitation providers. There has also been little attention to therapist distribution in non-rural settings where health professionals are in short supply.
Purpose: To assess the change in the distribution of rehabilitation therapists in 1980, 1990, and 2000 across counties with different levels of health professional shortages and the difference between metropolitan and non-metropolitan counties.
Methods: A trend analysis of cross-sectional data of employment of physical therapists, occupational therapists, and speech-language pathologists from 1980 to 2000 by county, relative to population, was done. The groups were stratified by shortage area, partial shortage area, and non-shortage counties and metropolitan and non-metropolitan counties.
Findings: There is a maldistribution of rehabilitation therapists in the United States. Although the absolute differences have remained the same or, in most instances, have increased, the relative change was greatest in the shortage areas and non-metropolitan areas. If the trends in the relative changes continue, the absolute differences may begin to narrow.
Conclusions: This study provides evidence that there are maldistributions of rehabilitation therapists in traditionally underserved areas. It is unclear if these maldistributions represent a shortage of rehabilitation therapists. Continued monitoring of the rehabilitation therapist workforce and the determination of the optimal supply should be undertaken in the future.

Malpractice Burden, Rural Location, and Discontinuation of Obstetric Care: A Study of Obstetric Providers in Michigan
Xiao Xu, Kristine A. Siefert, Peter D. Jacobson, Jody R. Lori, Iana Gueorguieva, Scott B. Ransom

Context: It has long been a concern that professional liability problems disproportionately affect the delivery of obstetrical services to women living in rural areas. Michigan, a state with a large number of rural communities, is considered to be at risk for a medical liability crisis.
Purpose: This study examined whether higher malpractice burden on obstetric providers was associated with an increased likelihood of discontinuing obstetric care and whether there were rural-urban differences in the relationship.
Methods: Data on 500 obstetrician-gynecologists and family physicians who had provided obstetric care at some point in their career (either currently or previously) were obtained from a statewide survey in Michigan. Statistical tests and multivariate regression analyses were performed to examine the interrelationship among malpractice burden, rural location, and discontinuation of obstetric care.
Findings: After adjusting for other factors that might influence a physician's decision about whether to stop obstetric care, our results showed no significant impact of malpractice burden on physicians' likelihood to discontinue obstetric care. Rural-urban location of the practice did not modify the nature of this relationship. However, family physicians in rural Michigan had a nearly 4-fold higher likelihood of withdrawing obstetric care when compared with urban family physicians.
Conclusions: The higher likelihood of rural family physicians to discontinue obstetric care should be carefully weighed in future interventions to preserve obstetric care supply. More research is needed to better understand the practice environment of rural family physicians and the reasons for their withdrawal from obstetric care.

Exploring the Temperament and Character Traits of Rural and Urban Doctors
Diann Eley, Louise Young, Thomas R. Przybeck

Context: Australia shares many dilemmas with North America regarding shortages of doctors in rural and remote locations. This preliminary study contributes to the establishment of a psychobiological profile for rural doctors by comparing temperament and character traits with an urban cohort.
Purpose: The aim was to compare the individual levels and combinations of temperament (mildly heritable and stable) and character (developmental and modifiable) traits of rural and urban general practitioners (GPs).
Methods: Rural (n = 120) and urban (n = 94) GPs completed a demographic questionnaire and the TCI-R 140 to identify levels of the 7 basic dimensions of temperament and character. These are Novelty Seeking (NS), Harm Avoidance (HA), Reward Dependence (RD), Persistence (PS), Self-Directedness (SD), Cooperativeness (CO), and Self-Transcendence (ST).
Findings: Preliminary results show rural GPs were higher in the temperament traits of NS and lower in HA compared with the urban sample. All female GPs were higher in RD and CO compared with all males, and all older GPs (over 55 years) were lower in RD compared with all younger GPs.
Conclusions: This preliminary work may be the precursor to a new approach for the recruitment and retention of rural doctors through a greater awareness of personality traits conducive to the rural workforce. Further work may help inform appropriate policies to attract and retain this workforce and be a useful adjunct to the counseling of students interested in rural medicine by providing a better understanding of "what it takes" to be a rural doctor.

Childhood Conduct Problems and Other Early Risk Factors in Rural Adult Stimulant Users
Teresa L. Kramer, Xiaotong Han, Carl Leukefeld, Brenda M. Booth, Carrie Edlund

Context: Understanding childhood risk factors associated with adult substance use and legal problems is important for treatment and prevention.
Purpose: To examine the relationship of early substance use, conduct problems before age 15, and family history of substance abuse on adult outcomes in rural, stimulant users.
Methods: Adult cocaine and methamphetamine users (N = 544) in rural Arkansas and Kentucky were interviewed. Data were analyzed using both bivariate analyses and multiple logistic and log-linear regression models, with dependent variables being any substance abuse/dependence, stimulant abuse/dependence, total number of arrests since age 18 and days incarcerated since age 18.
Findings: One third reported 3 or more conduct disorder problems prior to age 15; half reported initiation of substances (excluding alcohol) before age 15; and 60% reported family history of substance problems. All 3 variables were associated with adult substance abuse/dependence but only the latter two were associated with stimulant abuse/dependence.
Conclusions: This study highlights early risk factors for adult substance abuse/dependence among rural stimulant users.

Rates of Physical Activity Among Appalachian Adolescents in Ohio
Brian Hortz, Emily Stevens, Becky Holden, R. Lingyak Petosa

Purpose: The purpose of this study was to describe the physical activity behavior of high school students living in the Appalachian region of Ohio.
Methods: A cross-sectional sample of 1,024 subjects from 11 schools in Appalachian Ohio was drawn. Previously validated instruments were used to measure physical activity behavior over 7 days.
Findings: Appalachian adolescents fell short of recommended levels of activity. They reported high rates of sedentary behavior by 9th grade. Appalachian adolescents may be acquiring sedentary behaviors earlier than adolescents living in other regions. Low rates of activity make this population particularly at risk for the health consequences associated with inactivity.

Do Older Rural and Urban Veterans Experience Different Rates of Unplanned Readmission to VA and Non-VA Hospitals?
William B. Weeks, Richard E. Lee, Amy E. Wallace, Alan N. West, James P. Bagian

Context: Unplanned readmission within 30 days of discharge is an indicator of hospital quality.
Purpose: We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts.
Methods: We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity.
Findings: Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital.
Conclusions: Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.

Factors Associated with Iowa Rural Hospitals' Decision to Convert to Critical Access Hospital Status
Pengxiang Li, Marcia M. Ward, John E. Schneider

Context: The Balanced Budget Act (BBA) of 1997 allowed some rural hospitals meeting certain requirements to convert to Critical Access Hospitals (CAHs) and changed their Medicare reimbursement from prospective to cost-based. Some subsequent CAH-related laws reduced restrictions and increased payments, and the number of CAHs grew rapidly.
Purpose: To examine factors related to hospitals' decisions to convert and time to CAH conversion.
Methods: Eighty-nine rural hospitals in Iowa were characterized and observed from 1998 to 2005. Cox proportional hazards models were used to identify the determinants of time to CAH conversion.
Findings: T-test and one-covariate Cox regression indicated that, in 1998, Iowa rural hospitals with more staffed beds, discharges, and acute inpatient days, higher operating margin, lower skilled swing bed days relative to acute days, and located in relatively high density counties were more likely to convert later or not convert before 2006. Multiple Cox regression with baseline covariates indicated that lower number of discharges and average length of stay (ALOS) were significant after controlling all other covariates.
Conclusion: Iowa rural hospitals' decisions regarding CAH conversion were influenced by hospital size, financial condition, skilled swing bed days relative to acute days, length of stay, proportion of Medicare acute days, and geographic factors. Although financial concerns are often cited in surveys as the main reason for conversion, lower number of discharges and ALOS are the most prominent factors affecting rural hospitals' decision on when to convert.

Electronic Patient Registries Improve Diabetes Care and Clinical Outcomes in Rural Community Health Centers
Cecil Pollard, Kelly A. Bailey, Trisha Petitte, Adam Baus, Mary Swim, Michael Hendryx

Context: Diabetes care is challenging in rural areas. Research has shown that the utilization of electronic patient registries improves care; however, improvements generally have been described in combination with other ongoing interventions. The level of basic registry utilization sufficient for positive change is unknown.
Purpose: The goal of the current study was to examine differential effects of basic registry utilization on diabetes care processes and clinical outcomes according to level of registry use in a rural setting.
Methods: Patients with diabetes (N = 661) from 6 Federally Qualified Health Centers in rural West Virginia were entered into an electronic patient registry. Data from pre- and post-registry were compared among 3 treatment and control groups that had different levels of registry utilization: low, medium, or high (for example, variations in the use of registry-generated progress notes examined at the point-of-care and in the accuracy of registry-generated summary reports to track patients' care). Data included care processes (annual exams, screens to promote wellness, education, and self-management goal-setting) and clinical outcomes (HbA1c, LDL, HDL, cholesterol, triglycerides, blood pressure).
Findings: The registry assisted in significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol) for patients exposed to at least medium levels of registry utilization, but not for the controls. For example, the percent of patients who had received an annual eye exam at follow-up was 11%, 34%, and 38% for the low, medium, and high utilization groups, respectively; only the latter groups improved.
Conclusions: As an initial step to achieving control of diabetes, basic registry utilization may be sufficient to drive improvements in provider-patient care processes and in patient outcomes in rural clinics with few resources.

Predisposing and Enabling Factors Associated with Mammography Use Among Hispanic and Non-Hispanic White Women Living in a Rural Area
Silvia Tejeda, Beti Thompson, Gloria D. Coronado, Diane P. Martin, Patrick J. Heagerty

Context: Women who do not receive regular mammograms are more likely than others to have breast cancer diagnosed at an advanced stage.
Purpose: To examine predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic White women.
Methods: Baseline data were used from a larger study on cancer prevention in rural Washington state. In a sample of 20 communities, 537 women formed the sample for this study. The main outcomes were ever having had a mammogram and having had a mammogram within the past 2 years.
Findings: Reporting ever having had a mammogram was inversely associated with lack of health insurance (OR = 0.37, 95% CI: 0.16-0.84), ages under 50 years (OR = 0.23, 95% CI: 0.12-0.45), high cost of exams (OR = 0.48, 95% CI: 0.27-0.87), and lack of mammography knowledge (OR = 0.16, 95% CI: 0.07-0.37), while increasing education levels were positively associated (OR = 1.72, 95% CI: 1.09-2.70). Reporting mammography use within the past 2 years was inversely associated with ages under 50 years (OR = 0.49, 95% CI: 0.27-0.88) and over 70 years (OR = 0.47, 95% CI: 0.24-0.94), lack of health insurance (OR = 0.23, 95% CI: 0.10-0.50), and high cost of exams (OR = 0.55, 95% CI: 0.35-0.87).
Conclusions: Continued resources and programs for cancer screening are needed to improve mammography participation among women without health insurance or low levels of education.

Racial Differences in HPV Knowledge, HPV Vaccine Acceptability, and Related Beliefs Among Rural, Southern Women
Joan R. Cates, Noel T. Brewer, Karah I. Fazekas, Cicely E. Mitchell, Jennifer S. Smith

Context: Because cervical cancer mortality in the United States is twice as high among black women as white women and higher in rural areas, providing human papillomavirus (HPV) vaccine to rural black adolescents is a high priority.
Purpose: To identify racial differences in knowledge and attitudes about HPV, cervical cancer, and the HPV vaccine that may influence uptake of the vaccine.
Methods: We interviewed women (91 black and 47 white) living in a rural area of the Southern United States in 2006. Analyses controlled for socioeconomic status, age, and recruitment location.
Findings: More white respondents had heard of HPV than had black respondents (57% vs 24%, P < .001), and whites had higher HPV knowledge (42% vs 29% correct responses, P < .05). Blacks were less likely than whites to think that cervical cancer would be a serious threat to their daughters' health (75% vs 96%, P < .001). More blacks than whites thought the ideal age to receive the vaccine was 17 years or older (63% vs 40%, P < .05). Blacks reported lower intentions to vaccinate their daughters than whites (M = 4.14 vs 4.55, P < .05 in unadjusted analyses, but not statistically significant in adjusted analyses).
Conclusions: Black and white respondents had different awareness, knowledge, and beliefs related to the HPV vaccine. Communication-based interventions to maximize uptake of the HPV vaccine in the rural, Southern United States may need different messages for black parents of adolescent girls.

Health Care Utilization Among Migrant Latino Farmworkers: The Case of Skin Disease
Steven R. Feldman, Quirina M. Vallejos, Sara A. Quandt, Alan B. Fleischer Jr, Mark R. Schulz, Amit Verma, Thomas A. Arcury

Context: Skin diseases are common occupational illnesses for migrant farmworkers. Farmworkers face many barriers in accessing health care resources.
Purpose: Framed by the Health Behavior Model, the purpose of this study was to assess health care utilization for skin disease by migrant Latino farmworkers.
Methods: Three hundred and four migrant and seasonal Latino farmworkers in North Carolina were enrolled in a longitudinal study of skin disease and health care utilization over a single agricultural season. Self-reported and dermatologist-diagnosed skin condition data were collected at baseline and at up to 4 follow-up assessments. Medical visit rates were compared to national norms.
Findings: Self-reported skin problems and diagnosed skin disease were common among farmworkers. However, only 34 health care visits were reported across the entire agricultural season, and none of the visits were for skin diseases. Nevertheless, self-treatment for skin conditions was common, including use of non-prescription preparations (63%), prescription products (9%), and home remedies (6%). General medical office visits were reported in 3.2% of the assessments, corresponding to 1.6 office visits per person year.
Conclusions: The migrant farmworker population consists largely of young men who make little use of clinic services. Skin conditions are very common among these workers, but use of medical services for these conditions is not common. Instead, farmworkers rely primarily on self-treatment. Clinic-based studies of farmworker skin conditions will not account for most injury or disease in this population and have the potential for biased estimates.

Body Mass Index and Cancer Screening in Older American Indian and Alaska Native Men
Kyle J. Muus, Twyla Baker-Demaray, Leander R. McDonald, Richard L. Ludtke, Alan J. Allery, T. Andy Bogart, Jack Goldberg, Scott D. Ramsey, Dedra S. Buchwald

Context: Regular screenings are important for reducing cancer morbidity and mortality. There are several barriers to receiving timely cancer screening, including overweight/obesity. No study has examined the relationship between overweight/obesity and cancer screening among American Indian/Alaska Natives (AI/ANs).
Purpose: To describe the prevalence of fecal occult blood testing (FOBT) and prostate-specific antigen (PSA) testing among AI/AN men within the past year by age and rurality, and determine if body mass index (BMI) is associated with screening.
Methods: A national cross-sectional survey was administered face-to-face to 2,447 AI/AN men at least 55 years of age in 2004-2005. Participants were asked when they last had FOBT and PSA testing. BMI was derived from self-reported height and weight, and rurality of residence was defined by rural-urban commuting area codes. We assessed the association of cancer screening and BMI with logistic regression models, adjusting for demographic and health factors.
Findings: Prevalence of up-to-date FOBT and PSA testing were 23% and 40%, respectively. Older men were more likely than younger men to have FOBT and PSA testing. BMI was not associated with receipt of FOBT or PSA testing.
Conclusions: This is the first study to examine obesity and health care in AI/ANs. As in other populations, FOBT and PSA testing were suboptimal. Screening was not associated with BMI. Studies of AI/AN men are needed to understand the barriers to receiving timely screenings for prostate and colorectal cancer.

An Exploration of the Relationship Between Depressive Symptoms and Cortisol Rhythms in Colorado Ranchers
Emily Schulze, Mark Laudenslager, Mary Coussons-Read

Context: Although the effects of stress on health have been studied in numerous urban-dwelling populations, fewer studies have addressed these effects in rural populations, such as farmers and ranchers.
Purpose: The present study focuses on seasonal levels of depressed affect and perceived stress in Western Colorado ranchers, and how those phenomena related to their levels of cortisol.
Methods: Twenty-one (21) ranchers, who were permittees on the Colorado Grand Mesa, completed the study. Participants identified 2-week time periods during the year representing relative high, medium, and low stress. During each period, participants took saliva samples, rated stress levels, and completed a daily health diary. In addition, the Beck Depression Inventory (BDI-II), the perceived stress scale (PSS), and a life events scale (LES) were administered.
Results: Results showed a strong relationship between BDI-II and PSS scores (r = 0.748, P < .01). The decreased daytime cortisol decline supports the notion that the hypothalamic-pituitary-adrenal (HPA) axis negative feedback loop is disrupted in chronic stress and depression, thus resulting in chronically elevated cortisol levels.
Conclusion: This study supports the relationship between stress, depression, and HPA dysregulation in ranchers.


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

Contents: 2009; 14:(1)
Issue includes:

Use of palliative care services in a semirural program in British Columbia
Diane E. Allan; Shelly Waskiewich; Kelli I. Stajduhar; Darcee Bidgood

Introduction: Although specialized palliative care services in rural areas are scarce, many people who are dying, and their families, want to remain in their homes or within their own community. As such, semirural communities across Canada have developed a variety of initiatives to address this need. The purpose of our paper is to describe a semirural palliative care program located in British Columbia.
Methods: We used univariate and bivariate analyses to examine all patients for whom a palliative care bed was requested in the Saanich Peninsula Hospital Palliative Care Unit (PCU) between Jan. 1, 2005, and Dec. 31, 2006.
Results: Data suggest that there is provision of care for local residents in this semirural community. Throughout 2005 and 2006, SPH received a total of 411 requests for a palliative care bed with about three-quarters of admissions coming from other units within the hospital and from local residents.
Conclusion: Use of services data collected from hospital charts can provide valuable information to help inform program and policy decision-makers. Yet such information is limited in relation to answering the question of whether the end-of-life needs of local residents are being met. Future studies should consider input from families and patients to enhance our understanding of the role of a PCU in a semirural environment.

Use of a "secure room" and a security guard in the management of the violent, aggressive or suicidal patient in a rural hospital: a 3-year audit
Gordon Brock; Vydas Gurekas; Anne-Fredrique Gelinas; Karina Rollin

Introduction: Little has been published on the management of psychiatric crises in rural areas, and little is known of the security needs or use of "secure rooms" in rural hospitals.
Method: We conducted a 3-year retrospective chart audit on the use of our secure room/security guard system at a rural hospital in a town of 3500, located 220 km from our psychiatric referral centre.
Results: Use of our secure room/security guard system occurred at the rate of 1.1 uses/1000 emergency department visits, with the most common indication being physician perception of risk of patient suicide or self-harm. Concern for staff safety was a factor in 10% of uses. Eighty percent of patients were treated locally, with most being released from the secure room after 2 days or less. Fourteen percent of patients required ultimate transfer to our psychiatric referral centre and 6% to a detoxification centre. The average annual cost of security was $16 259.61.
Discussion: A secure room can provide the opportunity for close observation of a potentially self-harming patient, additional security for staff and early warning if a patient flees the hospital. Most admissions were handled locally, obviating the need for transfer to distant psychiatric referral centres. Most patients who were admitted were already known as having a psychiatric illness and 80% of the patients required the use of the secure room/security guard system for less than a 2-night stay, suggesting that most rural mental health crises pass quickly.
Conclusion: Most patients admitted to a rural hospital with a mental health crisis can be managed locally if an adequate secure room/security guard system is available.

Where did the doctors go? A study of retention and migration of provisionally licensed international medical graduates practising in Newfoundland and Labrador between 1995 and 2006

Rick Audas; Ann Ryan; David Vardy

Introduction: More than any other Canadian province, Newfoundland and Labrador (NL) relies on provisionally licensed international medical graduates (PLIMGs) to provide primary health care, particularly in rural communities. However, turnover among PLIMGs is high, and this is expensive and disruptive to the populations they serve.
Methods: We developed and analyzed a database that allowed us to quantify the turnover among PLIMGs and also to determine the Canadian destinations of PLIMGs who cease practising in NL.
Results: We found that about 1 in 5 PLIMGs remain in province for a period of 5 years and that those who emigrate within Canada are most likely to go to Ontario. Many PLIMGs cannot be tracked after they leave the province.
Conclusion: We speculate that many PLIMGs are moving on to the more lucrative US market.


Australian Journal of Rural Health

2008; 16:(6)
issue includes:

Suicides on farms in South Australia, 1997-2001
Keith Miller, Catherine Burns

Objective: Despite much having been written, both nationally and internationally, about rural suicides, no one in Australia knows either the number of residents on farms or the suicide rate for this group of people. This paper seeks to determine the number of residents on farms in South Australia, along with the suicide rate.
Design, setting and participants: A retrospective audit review of the files of suicides completed between the 1 January 1997 and 31 December 2001 was undertaken in the South Australian Coroner's Office. There were 1033 cases examined for sociodemographic details and 380 files were explored in detail.
Results: Estimating both the number of agricultural establishments in South Australia and the resident population on farms for 2001, and determining the number of suicides on farms between 1997 and 2001, the farm suicide rate was found to be 33.8 for men, 6.7 for women and 21.6 per 100 000 for persons, much higher than the rural suicide rate for South Australia in 2001 (23.8 for men, 5.6 for women and 14.5 per 100 000 for persons) according to the Australian Bureau of Statistics.
Conclusions: This study provides an estimate of the number of farm residents in South Australia in 2001, the number and rate of suicides on farms in South Australia in 2001, and shows that this rate is significantly higher than the overall rate of suicide in South Australia in 2001.

Young driver restrictions: Does the evidence support them?
Ross Blackman, Tracy Cheffins, Craig Veitch, Teresa O'Connor

Objective: To assess the suitability of Queensland's graduated licensing system in the context of rural and remote Queensland.
Design: Age-based comparison of crash data collected by the Rural and Remote Road Safety Study (RRRSS).
Setting: Rural and remote North Queensland.
Participants: A total of 367 vehicle controllers aged 16 years or over hospitalised at Townsville, Cairns or Mount Isa for at least 24 hours, or killed, as a result of a vehicle crash.
Measurements: Specific RRRSS variables are assessed in relation to Queensland's graduated licensing program, including rates of unlicensed driving/riding, late night crashes, crashes with multiple passengers, contributing factors in crashes and vehicle types involved.
Results: While people between 16 and 24 years of age comprise 16% of the target population, 25% of crashes meeting RRRSS criteria involved a vehicle controller in that age group. 12.8% of all cases involved an unlicensed driver/rider, within which 66% were below 25 years of age. Young drivers/riders were represented in 50% of crashes occurring between 11:00 p.m. and 5:00 a.m., and 33% of crashes in vehicles with multiple passengers. Motorcyclists represented about 40% of cases in both age groups. There were no significant differences between age groups in vehicle types used, or circumstances that contributed to crashes.
Conclusions: The general overrepresentation of young drivers/riders in rural and remote North Queensland supports tailored interventions, such as graduated licensing. However, while some measures in the legislation are well supported, problems surrounding unlicensed driving/riding might be exacerbated.

Cervical cancer risk factors and predictors of cervical dysplasia among women in south-west Nigeria
Tosin Ogunbowale, Taiwo O. Lawoyin

Aim: This study identified predictors of cervical dysplasia and assessed the prevalence of risk factors for cervical cancer among women of different socioeconomic classes in Ogun State, Nigeria.
Method: In a two-phase study, self-reported information on cervical cancer awareness, risk factors and cervical cancer screening practices was obtained from 278 randomly selected working women. A random subset was screened for dysplasia using visual inspection with acetic acid (VIA).
Results: Of the 278 women, 126 (45.3%) were semi-skilled while 152 (54.7%) were skilled and professional workers. Median age at first sexual intercourse was 19 years (range 13-29) and lower than the median age at first marriage (25 years). Gonorrhoea and genital warts were the commonest reported sexually transmitted infections. Only 12.2% of the women used male condoms as their primary method of birth control and 4.7% of the women had ever had a Papanicolaou smear, a practice that was significantly higher among the professional/skilled compared with semi-skilled workers (P = 0.031). Of the 125 screened, 20 (16%) had positive VIA. Young age at first sex (≤17 years) (OR = 3.7 (95% CI, 1.07-12.8)) and early first marriage (<25 years) (3.3 (1.00-10.9)) were associated with a positive VIA. Women with lower parity (0-3) had borderline significantly increased risk of having a positive VIA (3.1 (0.9-10.6)). Women currently over 34 years and those without a history of sexually transmitted infections had lower risk of positive VIA (P > 0.05).
Conclusions: Acceptable screening services and cervical cancer awareness campaigns that address modifiable risk factors are urgently needed in this community.

Mental health of farmers in Southern Queensland: Issues and support
Delwar Hossain, Rob Eley, Jeff Coutts, Don Gorman

Objective: To inform the development of an initiative designed to support the mental well-being of farmers in Queensland.
Design: Interactive focus groups.
Setting: Rural and remote Queensland.
Participants: Health professionals, farmers and representatives of organisations and agencies working with farmers.
Main outcome measures: Determination of factors contributing to the declining mental health of rural landholders. Content material for inclusion into mental health first aid programs held for field officers.
Results: Key areas identified to contribute to the decline in mental health of farmers were: increasing isolation in its varying forms, the ongoing drought, increased government regulations and widening of the schism between urban and rural Australians. The issues that affect farmers are recognised to have a 'knock-on' effect on the people who interact with them. In particular, rural support organisations are concerned for the well-being of their staff, prompting some to begin to put protocols in place to address their staff need for mental health support. Additional mental health training of field officers that involves awareness, recognition, communication skills, understanding and empathy was recognised by participants to be beneficial.
Conclusion: Training of field officers was considered to be of benefit to the support of farmers. An understanding of the various and diverse issues that rural landholders face should be a fundamental component of that training.

Critical health infrastructure for refugee resettlement in rural Australia: Case study of four rural towns
Scott Sypek, Gregory Clugston, Christine Phillips

Objective: To explore the reported impact of regional resettlement of refugees on rural health services, and identify critical health infrastructure for refugee resettlement.
Design: Comparative case study, using interviews and situational analysis.
Setting: Four rural communities in New South Wales, which had been the focus of regional resettlement of refugees since 1999.
Participants: Refugees, general practitioners, practice managers and volunteer support workers in each town (n = 24).
Results: The capacity of health care workers to provide comprehensive care is threatened by low numbers of practitioners, and high levels of turnover of health care staff, which results in attrition of specialised knowledge among health care workers treating refugees. Critical health infrastructure includes general practices with interest and surge capacity, subsidised dental services, mental health support services; clinical support services for rural practitioners; care coordination in the early settlement period; and a supported volunteer network. The need for intensive medical support is greatest in the early resettlement period for 'catch-up' primary health care.
Conclusion: The difficulties experienced by rural Australia in securing equitable access to health services are amplified for refugees. While there are economic arguments about resettlement of refugees in regional Australia, the fragility of health services in regional Australia should also be factored into considerations about which towns are best suited to regional resettlement.

Lung cancer: An exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia
Sonja E. Hall, C D'Arcy J. Holman, Timothy Threlfall, Harry Sheiner, Martin Phillips, Paul Katriss, Suzanne Forbes

Objective: This study investigates if the pattern of diagnostic testing for suspected lung cancer, stage at diagnosis, patterns of specialist referral and treatment options offered to people in rural Western Australia are similar to those in the metropolitan area. It then explores the barriers to quality care in rural areas as perceived by GPs and patients.
Methods: There was a review of GP records to obtain clinical and referral information and an in-depth interview with patients and GPs concerning their perspectives of the quality of care.
Results/Discussion: We selected age and sex-matched samples of 22 rural and 21 metropolitan patients. Rural patients had more symptoms and took longer to consult their GPs, leading to later diagnosis and fewer treatment options. They experienced longer waits for specialist consultation and underwent less diagnostic testing. The GPs always referred lung cancer patients to a specialist, usually a respiratory physician. Teaching hospitals were preferred because of their comprehensive facilities and multidisciplinary teams. Rural GPs reported distance, time and availability of appointments as barriers; they also raised concerns about late confirmation of diagnosis. Rural and metropolitan patients were equally satisfied with their quality of care, but rural patients desired more information and better communication between hospital and GPs. Facilities for rural patients at some metropolitan hospitals were criticised. In conclusion, rural patients received a different care pattern from metropolitan patients and they and their GPs raised concerns about the equity and quality of lung cancer care.

General practitioners' management of patients with mental health conditions: The views of general practitioners working in rural north-western New South Wales
Christian Alexander, John Fraser

Objective: To identify the needs of the region's general practitioners concerning diagnosing, treating and referring patients with mental health disorders and major barriers to the general practitioners' management of these patients.
Design: Cross-sectional survey.
Subjects: All general practitioners working in rural north-western New South Wales.
Measurements: Self-assessed levels of confidence (5-point Likert scale) in diagnosing and treating patients with a mental health condition. Practice data relating to presentation of such patients as well as issues affecting treatment and referral.
Results: The three most commonly diagnosed and treated mental health conditions are depression, anxiety and dementia. General practitioners assessed themselves as being confident in diagnosing and treating these three mental health conditions and in diagnosing and treating adults and the elderly. The only form of treatment intervention that the general practitioners self-assessed as being confident in relates to medication. Referrals to mental health specialists were due mostly to patients needing mental health counselling, the general practitioners seeking clarification of diagnosis as well as having insufficient skills to provide the best possible care. Barriers to being able to refer relate mainly to specialist services not being available and/or accessible as well as patients being reluctant to accept such a referral.
Conclusion: Our results indicate that other than for depression, anxiety and dementia, efforts to improve the general practitioners' diagnostic and treatment skills and to diagnose and treat adolescents and children are warranted. Up-skilling the general practitioners' ability to confidently use treatment options other than medication are worth considering.

Expanding the role of paramedics in northern Queensland: An evaluation of population health training
Carole Reeve, Dennis Pashen, Heather Mumme, Stephanie De La Rue, Tracy Cheffins

Objective: To describe the experience of the paramedics doing the population health component of the Graduate Certificate in Rural and Remote Paramedic Practice.
Design: Analysis of paramedics' reported opinions about the course and its impact.
Setting: Primary care.
Participants: Data were obtained from de-identified surveys submitted by the paramedics at the beginning and the end of the population health component of the course.
Results: All paramedics felt that after the course they were more committed to undertaking population health activities in their work and were better prepared to do so. As a result of undertaking the course, 73% of students have already changed their practice. Seventy-five per cent agreed that doing the course would increase the likelihood of staying in rural and remote areas and all agreed that doing the course resulted in increased job satisfaction. The majority (87%) of the students rated the course as excellent or very good and all of them said that they would recommend the course to others.
Conclusions: These results suggest that rural and remote paramedics have the opportunity and desire to incorporate more health promotion and prevention into their practice and that this course has provided them with the skills and knowledge to do so. The curriculum is based on National Health Priority Areas focusing in particular on lifestyle change to prevent and manage chronic disease. This means that in rural and remote areas, all health professionals can use a common framework to work together to enhance primary health care and chronic disease management as a multidisciplinary team.

A rural/urban comparison of the roles of the general practitioner in colorectal cancer management
Heather Hanks, P Craig Veitch, Mark F. Harris

Objective: To identify and compare the roles of urban, rural and remote general practitioners (GPs) in colorectal cancer (CRC) management.
Design: Semistructured interviews exploring GP views of their role in CRC management.
Setting: Urban, rural and remote general practices in north Queensland.
Participants: Fifteen GPs in urban, rural and remote practice.
Main outcome measures: Self-reported roles in the management of CRC patients and factors influencing these roles.
Results: All GPs, regardless of location of practice, played a role in diagnosis, referral, postoperative care, psychosocial counselling, follow up and palliative care. Involvement in treatment of CRC patients was only performed by remote GPs. In general, rural and remote GPs played greater roles in care coordination, clinical and psychosocial care. Rural and remote GPs were more heavily involved throughout the entire illness progression when compared with their urban counterparts.
Conclusions: The results of this study indicate that rural and remote GPs in north Queensland play a greater role than urban GPs in the management of CRC. In order to maintain and enhance the roles of rural and remote GPs in CRC care, appropriate guidelines and remuneration should be provided. Palliative care support might also be useful to rural and remote GPs.

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