Journal Search

Journal Search - issue 2, 2009


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Jennifer Richmond
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* Jennifer Richmond


1 Rural and Remote Health


30 June 2009 Volume 9 Issue 2


RECEIVED: 29 June 2009

ACCEPTED: 30 June 2009


Richmond J.  Journal Search - issue 2, 2009 . Rural and Remote Health 2009; 9: 1261.


© 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 readers 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:(2)
Issue includes:

Are There Enough Doctors in My Rural Community? Perceptions of the Local Physician Supply
Holly Biola, Donald E. Pathman

Purpose: To assess whether people in the rural Southeast perceive that there is an adequate number of physicians in their communities, assess how these perceptions relate to county physician-to-population (PtP) ratios, and identify other factors associated with the perception that there are enough local physicians.
Methods: Adults (n = 4,879) from 150 rural counties in eight southeastern states responded through a telephone survey. Agreement or disagreement with the statement "I feel there are enough doctors in my community" constituted the principal outcome. Weighted chi-square analysis and a generalized estimating equation (GEE) assessed the strength of association between perceptions of an adequate physician workforce and county PtP ratios, individual characteristics, attitudes about and experiences with medical care, and other county characteristics.
Findings: Forty-nine percent of respondents agreed there were enough doctors in their communities, 46% did not agree, and 5% were undecided. Respondents of counties with higher PtP ratios were only somewhat more likely to agree that there were enough local doctors (Pearson's correlation coefficient = 0.09, P < .001). Multivariate analyses revealed that perceiving that there were enough local physicians was more common among men, those 65 and older, whites, and those with lower regard for physician care. Perceptions that the local physician supply was inadequate were more common for those who had longer travel distances, problems with affordability, and little confidence in their physicians. Perceptions of physician shortages were more common in counties with higher poverty rates.
Conclusions: County PtP ratios only partially account for rural perceptions that there are or are not enough local physicians. Perceptions of an adequate local physician workforce are also related to how much people value physicians' care and whether they face other barriers to care.

Do International Medical Graduates (IMGs) "Fill the Gap" in Rural Primary Care in the United States? A National Study
Matthew J. Thompson, Amy Hagopian, Meredith Fordyce, L. Gary Hart

Context: The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers.
Purpose: To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties.
Methods: We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state.
Findings: One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs.
Conclusions: IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs.

Perspectives on Rural Health Workforce Issues: Illinois-Arkansas Comparison
Martin MacDowell, Michael Glasser, Michael Fitts, Mel Fratzke, Karen Peters

Context: Past research has documented rural physician and health care professional shortages.
Purpose: Rural hospital chief executive officers' (CEOs') reported shortages of health professionals and perceptions about recruiting and retention are compared in Illinois and Arkansas.
Methods: A survey, previously developed and sent to 28 CEOs in Illinois, was mailed to 110 CEOs in Arkansas. Only responses from rural CEOs are presented (Arkansas n = 39 and Illinois n = 22).
Findings: Physician shortages were reported by 51 CEOs (83.6%). Most reported physician shortages in Arkansas were for family medicine, internal medicine, cardiology, obstetrics-gynecology, general surgery, and psychiatry. Most reported physician shortages in Illinois were for family medicine, obstetrics-gynecology, orthopedic surgery, internal medicine, cardiology, and general surgery. Additionally, registered nurses and pharmacists were the top 2 allied health professions shortages. Multivariate analysis (factor and discriminant analyses) examined community attributes associated with ease of recruiting physicians. Six factors were identified and assessed as to their importance in influencing ease of recruitment, with the state included in the model. Three factors were identified as discriminating whether or not physician recruitment was easy: community supportive for family, community cooperates and perceives a good future, and community attractiveness.
Conclusions: Similarities in shortages and attributes influencing recruitment in both states suggest that efforts and policies in health professions workforce development can be generalized between regions. This study further reinforces some important known issues concerning retention and recruitment, such as the importance of identifying providers whose preferences are matched to the characteristics and lifestyle of a given area.

Rurality and Birth Outcomes: Findings From Southern Appalachia and the Potential Role of Pregnancy Smoking
Beth A. Bailey, Laura K. Jones Cole

Context: Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region.
Purpose: This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations.
Methods: Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records.
Findings: Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking.
Conclusions: Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.

Does Rural Residence Affect Access to Prenatal Care in Oregon?
Beth Epstein, Therese Grant, Melissa Schiff, Laurin Kasehagen

Context: Identifying how maternal residential location affects late initiation of prenatal care is important for policy planning and allocation of resources for intervention.
Purpose: To determine how rural residence and other social and demographic characteristics affect late initiation of prenatal care, and how residence status is associated with self-reported barriers to accessing early prenatal care.
Methods: This observational study used data from the 2003 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) (N = 1,508), with late initiation of prenatal care (after the first trimester) as the primary outcome. We used Rural-Urban Commuting Area (RUCA) codes to categorize maternal residence as urban, large rural, or small/isolated rural. Multivariate logistic regression was used to evaluate whether category of residence was associated with late initiation of prenatal care after adjusting for other maternal factors. Association between categories of barriers to prenatal care and maternal category of residence were determined using the Cochran-Mantel-Haenszel test of association.
Findings: We found no significant association between residence category and late initiation of prenatal care, or residence category and barriers to prenatal care initiation. Urban women tended to be over age 34 or nonwhite. Women from large rural areas were more likely to be younger than 18 years, unmarried, and have an unintended pregnancy. Women from small rural areas were more likely to use tobacco during pregnancy.
Conclusions: Maternal residence category is not associated with late initiation of prenatal care or with barriers to initiation of prenatal care. Differences in maternal risk profiles by location suggest possible new foci for programs, such as tobacco education in small rural areas.

A Rural Perspective on Perinatal Depression: Prevalence, Correlates, and Implications for Help-Seeking Among Low-Income Women
Sarah Kye Price, Enola K. Proctor

Context/Purpose: To examine a low-income sample of women in the rural Midwest (N = 1,086) who were screened for perinatal depression through the outreach and education activities within a Healthy Start Initiative project. Specifically, we describe the frequency and severity of depressive symptoms, explore social and demographic correlates of depression, and examine help-seeking through patterns of self-referral to a Healthy Start perinatal depression project in a rural, medically underserved community.
Methods: Depression screening data using the Primary Care Evaluation of Mental Disorders (PRIME-MD) as well as intake records from the project were analyzed in a retrospective analysis to identify important demographic and psychosocial characteristics associated with elevated levels of depressive symptoms and help-seeking patterns.
Findings: Thirty-six percent of screened women met criteria for major, minor, or subthreshold depression, with 13% meeting diagnostic criteria for major depression alone. Less than 8% were currently receiving any type of mental health services or treatment at screening. The most significant correlate of self-referral to the Healthy Start project was meeting symptom criteria for major depression, although minor depression, subthreshold depression, and status as low-income/Temporary Aid to Needy Families (TANF)-eligible were all significantly associated with self-referral.
Conclusions: The findings from this study highlight the potential significance of identifying and addressing the unmet mental health needs of low-income rural women during and around pregnancy. In addition, the study illustrates that low income, in addition to depressive symptoms, impacts mental health service delivery in this rural community with a fragmented mental health service infrastructure.

Screening Mammography Utilization in Tennessee Women: The Association With Residence
Kathleen C. Brown, Eugene C. Fitzhugh, James J. Neutens, Diane A. Klein

Context: Approximately 70% of US women over age 40 report mammography screening within 2 years. However, rates are likely to vary by age, income, educational level, and residence.
Purpose: To describe the prevalence of screening mammography and associated factors in women living in rural and urban areas of Tennessee.
Methods: Using pooled data from the Tennessee Behavioral Risk Factor Surveillance System (BRFSS; 2001 and 2003), utilization of screening mammography within a 2-year period was examined for a sample of 1,922 women, 40 years and older. Demographic, behavior, and health-related variables were used to examine associations with utilization.
Findings: The prevalence of screening mammography utilization (71.3% 95% CI 67.4-75.2) in women living in rural areas of Tennessee was significantly lower than utilization among women living in urban areas (78.3% 95% CI 75.9-80.7). Higher utilization was associated with having attained at least a high school education, having health insurance, identifying a personal health care provider, being a nonsmoker, recent use of alcohol, having had a recent clinical breast exam or Papanicolau (Pap) test done, and meeting the Healthy People 2010 (HP 2010) recommendation for physical activity. After controlling for all other factors, rural residence was not associated with utilization. For rural women, identifying a personal health care provider was significantly associated with increased likelihood of utilization.
Conclusions: Lower income and lower education, each associated with lower screening utilization, were more common in rural Tennessee women. The significance of a personal health care provider for utilization in rural women is meaningful for service providers.

Bypassing the Local Rural Hospital for Outpatient Procedures
Charles Saunders, Gail R. Bellamy, Nir Menachemi, Askar S. Chukmaitov, Robert G. Brooks

Purpose: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures.
Methods: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004.
Findings: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care.
Conclusions: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations.

A Population-Based Survival Assessment of Categorizing Level III and IV Rural Hospitals as Trauma Centers
Melanie Arthur, Craig D. Newgard, Richard J. Mullins, Brian S. Diggs, Judith V. Stone, Annette L. Adams, Jerris R. Hedges

Context: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse.
Purpose: To determine if there is improved survival among injured patients hospitalized in states that categorize rural hospitals as trauma centers.
Methods: We analyzed a retrospective cohort of injured patients included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 1997 to 1999. We used generalized estimating equations to compare survival among injured patients hospitalized in states that categorize rural hospitals as Level III and IV trauma centers versus those that do not. Multivariable models adjusted for important confounders, including patient demographics, co-morbid conditions, injury severity, and hospital-level factors.
Findings: There were 257,044 admitted patients from 7 states with a primary injury diagnosis, of whom 64,190 (25%) had a "serious" index injury, 32,763 (13%) were seriously injured (by ICD-9 codes), and 12,435 (5%) were very seriously injured (by ICD-9 codes). There was no survival benefit associated with rural hospital categorization among all patients with a primary injury diagnosis or for those with specific index injuries. However, seriously injured patients (by ICD-9 codes) had improved survival when hospitalized in a categorizing state (OR for mortality 0.72, 95% confidence interval [CI] 0.53-0.97; OR for very seriously injured 0.68, 95% CI 0.52-0.90).
Conclusions: There was no survival benefit to categorizing rural hospitals among a broad, heterogeneous group of hospitalized patients with a primary injury diagnosis; however the most seriously injured patients did have increased survival in such states.

Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training
Edward Lew, Lyle J. Fagnan, Nora Mattek, Jo Mahler, Robert A. Lowe

Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine.
Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training.
Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices.
Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority.
Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.

Teledermatology Consultations Provide Specialty Care for Farmworkers in Rural Clinics
Quirina M. Vallejos, Sara A. Quandt, Steven R. Feldman, Alan B. Fleischer, Jr, Thanh Brooks, Gonzalo Cabral, Judy Heck, Mark R. Schulz, Amit Verma, Lara E. Whalley, Thomas A. Arcury

Context: Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care.
Purpose: This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics.
Methods: Dermatologists provided 79 consultations, using store-and-forward teledermatology, to farmworkers who presented with a skin disease to rural North Carolina clinics. Clinic providers rated the value of the consultation.
Findings: Most requests for consultations (94%) came from family nurse practitioners or physician assistants. Twelve percent of consultations were rated somewhat helpful, and the remainder helpful or very helpful. After receiving the consultation, providers changed the diagnosis in 13% of cases. The consultation led providers to contact or attempt to contact 21% of patients to change treatment recommendations.
Conclusions: Access to expert dermatologic services is needed by rural health care providers. Teledermatology consultations may be a helpful tool to meet this need

Retail Food Availability, Obesity, and Cigarette Smoking in Rural Communities
Akiko S. Hosler

Context: Disparities in the availability of nutritionally important foods and their influence on health have been studied in US urban communities.
Purpose: To assess the availability of selected retail foods and cigarettes, and explore ecologic relationships of the availability with obesity and smoking in rural communities.
Methods: Inventories of all food stores (n = 182) in 2 rural New York counties were surveyed. The study area was divided into 4 regions through cluster analysis of 2000 Census and geographic information system data. Weight-adjusted per 10,000-population density of stores carrying selected foods was used as a standardized measure of availability. Prevalence of overweight/obesity (BMI ≥25.0 kg/m2) and smoking among adults was obtained from secondary data. Bivariate correlations among availability of foods and cigarettes, overweight/obesity, and smoking were analyzed at the regional level.
Findings: Nutritionally important foods, including fresh fruit, vegetables (dark green or orange colored), low-fat (≤1%) milk, high-fiber (≥2g per slice) bread, and fish were most available in the semiurbanized region, followed by the rural heartland, the remote mountains region, and the most urbanized inner-town. No significant difference was found in the availability of general food items and cigarettes. Overweight/obesity was inversely associated with the availability of fresh fruit, vegetables, and low-fat milk. Smoking was positively associated with the availability of cigarettes, white bread, whole milk, and eggs.
Conclusions: The observed disparities in food availability and their ecologic association with health risks in rural adults expanded the knowledge base of built environment and its association with health beyond the urban setting.

Extra-Individual Correlates of Physical Activity Attainment in Rural Older Adults
Kindal A. Shores, Stephanie T. West, Daniel S. Theriault, Elizabeth A. Davison

Context: Challenged with a higher incidence of disease, reduced social support, and less access to physical activity facilities and services, rural older adults may find healthy active living a challenge. Despite these challenges, some rural older adults manage to achieve active lifestyles.
Purpose: This study investigates the relative importance of 4 extra-individual correlates of physical activity to physical activity achievement in rural seniors.
Methods: Data were drawn from mail questionnaires completed by 454 adults age 65 and over in 7 rural North Carolina counties.
Findings: Results from an analysis of covariance indicate that respondents who approached CDC/ACSM recommended levels of physical activity were significantly more likely to report that they lived within walking distance to parks, perceived they had transportation to physical activity areas, had a partner with whom to be active, and felt activity facilities were safe. Next, 7 extra-individual correlates of physical activity were entered into a backward logistic regression. The resultant model predicting physical activity achievement among rural older adults included social support for physical activity, a safe environment for physical activity, and reported ability to walk to a local park.
Conclusions: Interventions designed to provide social support, heighten safety at activity areas and improve park infrastructure may provide opportunities to increase physical activity among seniors.

Perspectives on Safety and Health Among Migrant and Seasonal Farmworkers in the United States and México: A Qualitative Field Study
Lorann Stallones, Martha S. Vela Acosta, Pat Sample, Philip Bigelow, Monica Rosales

Context: A large number of hired farmworkers in the United States come from México. Understanding safety and health concerns among the workers is essential to improving prevention programs.
Purpose: The purpose of this pilot study was to obtain detailed information about safety and health concerns of hired farmworkers in Colorado and in México.
Methods: A total of 10 migrant farmworkers from northern Colorado and 5 seasonal farmworkers from Guanajuato, México, were interviewed using a semi-structured interview process. The social cognitive theory (SCT) served as a framework to gain understanding of safety and health among workers.
Findings: Topics of concern identified included causes of farm, home and motor vehicle injuries, and treatment preferences for injuries and illnesses. Four main themes emerged: safety and health concerns, personal control and prevention strategies, factors affecting control and prevention strategies, and the importance of family.
Conclusions: Further study of the themes using a revised semi-structured interview will be done in a larger study among hired farmworkers. The results add to the current work to understand specific health and safety concerns among these workers.

High Self-Reported Prevalence of Diabetes Mellitus, Heart Disease, and Stroke in 11 Counties of Rural Appalachian Ohio
Frank Schwartz, Anirundth Ruhil, Sharon Denham, Jay Shubrook, Chris Simpson, Sara L. Boyd

Context/Purpose: There is an epidemic of obesity and diabetes in the United States, especially in economically at-risk populations such as rural Appalachia. This survey determined the self-reported prevalence of obesity, diabetes mellitus, and associated macrovascular complications in 11 rural counties of Appalachian Ohio. The impacts of lifestyle, cardiovascular risk factors, income, and access to medical care were also determined.
Methods: A telephone survey identical to the 2004 Behavioral Risk Factor Surveillance System (BRFSS) survey was conducted. Surveys were collected from 3,927 randomly selected residents 18 years of age and older in 11 counties of Appalachian Ohio and compared to published aggregate Ohio and national 2004 BRFSS data.
Findings: The self-reported prevalence of diabetes (11.3%) was markedly higher in Appalachian Ohio counties surveyed compared to aggregate Ohio (7.8%) or national (7.2%) 2004 BRFSS data (P < .044). The prevalence of heart disease (7.6%) and stroke (4.1%) in these counties was slightly higher than aggregate Ohio or national 2004 BRFSS data. In persons with diabetes, the prevalence of heart disease was 2-fold higher (20.0%) and stroke 3-fold higher (11.4%) than among nondiabetics (P < .042) in the region and higher than aggregate Ohio and National 2004 BRFSS data. Lower-income levels and decreased access to medications and glucose monitoring supplies correlated with the increased risk for cardiovascular complications in this rural population (P < .042).
Conclusion: The self-reported prevalence of diabetes mellitus and its associated macrovascular complications are much higher in rural Appalachian Ohio compared to aggregate Ohio and National 2004 BRFSS data.


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine

[in French and English]

Contents: 2009; 14:(2)
Issue includes:

Brief smoking cessation interventions by family physicians in northwestern Ontario rural hospitals
Patricia M. Smith; Scott M. Sellick; Peter Brink; Alan D. Edwardson

Introduction: We report on physicians' beliefs, confidence and clinical practice relative to the provision of smoking cessation interventions in northwestern (NW) Ontario, where tobacco use and tobacco-related disease prevalence are high and smoking cessation services are scarce.
Methods: Physicians working at the 12 rural hospitals in NW Ontario were eligible for inclusion in the study. Survey items included clinical practices based on the "5 A's" protocol for tobacco intervention, and beliefs about, confidence in, and barriers and facilitators to intervention.
Results: Physicians from 8 of the 12 hospitals responded. Almost all (> 91%) reported positive beliefs about providing smoking cessation interventions and were confident intervening. Relative to the 5 A's protocol for tobacco intervention, 100% of respondents ask, advise, assess and assist patients to quit smoking, and 89% arrange follow-up. The most frequent methods of assistance included pharmacotherapy, suggestions of specific actions to make it easier to quit and recommendations for alternatives to tobacco use. The most frequent barrier to intervenion was lack of time.
Discussion: Based on respondents' positive beliefs, confidence and current clinical practice relative to tobacco interventions, physicians in NW Ontario seem well positioned to play a key role in helping to reduce the high rates of tobacco use and tobacco-related diseases by providing smoking cessation interventions to patients who have been admitted to hospital.

How important are out-of-pocket costs to rural patients' cancer care decisions?
Maria Mathews; Roy West; Sharon Buehler

Objective: We examined the importance of 5 items (stage of illness, personal feelings, travel costs, drug costs and child care costs) in the cancer treatment decisions of urban and rural residents after they had started treatment for their cancer.
Methods: We surveyed 484 adults who presented for care at cancer clinics in Newfoundland and Labrador from September 2002 to June 2003. Respondents rated the importance of each of the 5 items in their cancer care decisions on a 5-point Likert scale, which was later collapsed into 2 categories, "important" and "not important." We used ?2 tests and multiple logistic regression to compare the responses of urban and rural residents.
Results: In our sample of 484 respondents, there were 258 (53.3%) urban and 226 (46.7%) rural residents. After controlling for other significant predictors, we found that rural residents were more likely to report that travel costs (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.21-2.63), drug costs (OR 1.69, 95% CI 1.13-2.23) and child care costs (OR 2.33, 95% CI 1.09-4.96) were "important" in cancer treatment decisions compared with urban residents. Stage of disease and personal feelings were equally important to urban and rural residents.
Conclusion: Financial impediments disproportionately affect rural residents' decisions about cancer care and highlight the need to ensure that centralized specialist care, such as cancer treatment, is accessible.

Prevalence of impaired glucose tolerance and the components of metabolic syndrome in Canadian Tsimshian Nation youth
Alexandra Zorzi; Gita Wahi; Andrew J. Macnab; Constadina Panagiotopoulos

Introduction: Canadian Aboriginal people have been disproportionately affected by obesity and type 2 diabetes (T2D). Our objective was to determine the prevalence of obesity, glucose intolerance and the components of metabolic syndrome (MetS) in Tsimshian Nation youth living in 3 remote coastal communities.
Methods: A medical history, anthropometric measurements and an oral glucose tolerance test were performed in youth aged 6-18 years. We defined "overweight" by a body mass index (BMI) at the 85th percentile or higher and "obese" by a BMI at the 95th percentile or higher, by age and sex. We used the International Diabetes Federation criteria for MetS.
Results: Of the 224 eligible youth, 192 (85%) participated in the study. Nineteen percent were overweight, 26% were obese and 36% had central obesity (waist circumference ≥ 90th percentile for age and sex). No new cases of T2D were identified. The prevalence of impaired fasting glucose (IFG 5.6-6.9 mmol/L) and impaired glucose tolerance (IGT 2-hr glucose 7.8-11.0 mmol/L) were 19.3% and 5.2%, respectively. Five of the 10 youth with IGT had a fasting glucose less than 5.6 mmol/L. The prevalence of MetS was 4.7% and increased to 8.3% when pediatric hypertension norms were applied.
Conclusion: Tsimshian Nation youth have a high prevalence of central obesity, impaired glucose homeostasis and other components of MetS. The oral glucose tolerance test may be a more appropriate screening test to identify IGT in Aboriginal youth.

Rural and remote obstetric care close to home: program description, evaluation and discussion of Sioux Lookout Meno Ya Win Health Centre obstetrics
J. Dooley; Len Kelly; N. St Pierre-Hansen; I. Antone; J. Guilfoyle; T. O'Driscoll

Problem being addressed: Aboriginal and non-Aboriginal women in rural and remote settings struggle to access obstetric care close to home.
Objective of the program: To deliver a full range of modern and safe obstetric care to 28 remote Aboriginal communities served by rural-based health care.
Program description: Rural family physicians provide intrapartum, cesarean delivery and anesthesia services to 350 rural, primarily Aboriginal women in a collegial, supportive environment.
Conclusion: Rural and remote obstetric services need support before they fail. Patient volume, remote location and organizational culture are key elements. Evidence teaches us that outcomes are best when women deliver closer to home.


Australian Journal of Rural Health

2008; 17:(2)
Issue includes:

Four years after graduation: Occupational therapists' work destinations and perceptions of preparedness for practice
Dione Brockwell, Trish Wielandt, Michele Clark

Objective: The present study sought to identify the work destinations of graduates and ascertain their perceived preparedness for practice from a regional occupational therapy program, which had been specifically developed to support the health requirements of northern Australians by having an emphasis on rural practice.
Design: Self-report questionnaires and semistructured in-depth telephone interviews.
Participants: Graduates (n = 15) from the first cohort of occupational therapists from James Cook University, Queensland.
Main outcome measure: The study enabled comparisons to be made between rural and urban based occupational therapists, while the semistructured interviews provided a deeper understanding of participants' experiences regarding their preparation for practice.
Results: Demographic differences were noted between occupational therapists working in rural and urban settings. Rural therapists were predominantly younger and had worked in slightly more positions than their urban counterparts. The study also offered some insights into the value that therapists placed on the subjects taught during their undergraduate occupational therapy training, and had highlighted the differences in perceptions between therapists with rural experience and those with urban experience regarding the subjects that best prepared them for practice. Generally, rural therapists reported that all subjects included in the curriculum had equipped them well for practice.
Conclusions: Findings suggest the need to undertake further research to determine the actual nature of rural practice, the personal characteristics of rural graduates and the experiences of students while on rural clinical placements.

Workers compensation and occupational health and safety in the Australian agricultural industry
Robert Guthrie, Jennifer Westaway, Lisa Goldacre

Objectives: The objective of this paper is to review the available workers compensation and occupational health and safety data and the legal framework in relation to the agricultural industry to explore whether any factors highlight the need to pay special attention to the particular circumstances of those engaged in the industry.
Design: This paper explores some of the special features of the agricultural industry, looking first at agricultural worker fatalities and injuries as a matter of ongoing concern for all participants in this industry, government, as well as occupational health and workers compensation authorities. The paper analyses how occupational health and workers compensation laws may have special application to this industry. Finally, the paper considers some workers compensation provisions that have particular application to the agricultural industry.
Conclusions: Our survey of the available data and literature leads to the conclusion that the dangerous nature of agricultural work and the special legal and economic framework in which that work is undertaken identify the agricultural industry as presenting Australian Governments and specialist authorities with particular challenges in relation to improving workplace safety and reducing workplace injury.

Health behaviours of young, rural residents: A case study
Lisa Bourke, John Humphreys, Fiona Lukaitis

Objective: To analyse self-reported health behaviours of young people from a rural community and the factors influencing their behaviours.
Methods: Interviews were conducted with 19 young people, 11 parents and 10 key informants from a small rural Victorian community, asking about teenage health behaviours and the factors influencing these behaviours.
Results: Young people ate both healthy and unhealthy foods, most participated in physical activity, few smoked and most drank alcohol. The study found that community level factors, including community norms, peers, access issues and geographic isolation, were particularly powerful in shaping health behaviours, especially alcohol consumption. Smoking was influenced by social participation in the community and national media health campaigns. Diet and exercise behaviour were influenced by access and availability, convenience, family, peers and local and non-local cultural influences.
Conclusion and implications: The rural context, including less access to and choice of facilities and services, lower incomes, lack of transport and local social patterns (including community norms and acceptance), impact significantly on young people's health behaviours. Although national health promotion campaigns are useful aspects of behaviour modification, much greater focus on the role and importance of the local contexts in shaping health decisions of young rural people is required.

Gender, socioeconomic status, need or access? Differences in statin prescribing across urban, rural and remote Australia
Nigel Stocks, Phil Ryan, James Allan, Susan Williams, Kristyn Willson

Objectives: To assess differences in statin prescribing across Australia by geographic area.
Design, setting and participants: A cross-sectional study using Pharmaceutical Benefits Scheme data on statin prescribing by rurality, gender and patient postcode for the period May to December 2002. Participants were the Australian population, stratified by gender, quintile of index of relative socioeconomic disadvantage and rural, remote and metropolitan areas classification.
Results: Statin prescribing (scripts per 1000 population per month) was higher in urban areas (women, 51.915; men, 51.892) than in rural (women, 48.311; men, 48.098) or remote (women, 39.679; men, 34.145) areas. In urban areas, weighted least squares regression analysis showed a significant negative linear association between statin prescribing and socioeconomic status for both women (weighted least squares slope, −3.358; standard error (SE) 0.057; P < 0.0001) and men (slope, −0.507; SE 0.056; P < 0.0001). A similar association occurred in rural areas: women (slope, −4.075; SE 0.122; P < 0.0001) and men (slope, −3.455; SE 0.117; P < 0.0001), but not in remote areas where there was a positive linear association (slope, 3.120; SE 0.451; P < 0.0001) and men (slope, 3.098; SE 0.346; P < 0.0001).
Conclusion: Our results suggest differences in statin prescribing in Australia across geographic location, adjusting for age, gender and socioeconomic status.
Implications: These findings suggest that health inequalities due to geography should be addressed.

Generational attitudes of rural mental health nurses
Andrew Crowther, Michael Kemp

Objective: To determine how attitudes of rural mental health nurses differ across generations.
Design: Survey.
Setting: Mental health services in rural New South Wales.
Participants: Practising mental health nurses.
Main outcome measures: Survey responses.
Results: Survey response rate 44%. A total of 89 mental health nurses, clustered in inpatient units and community health centres, responded. Of these nurses, 4 were veterans, 52 baby boomers, 17 Generation X and 5 Generation Y.
Conclusions: There are significant differences in how mental health nurses from different generations view their work, and in what is expected from managers. Managers need to modify traditional working styles, allowing greater flexibility of employment. They must also accept lower staff retention rates, and facilitate the development of younger staff.

Need for syphilis screening and counselling in HIV counselling and testing centres: A curtain raiser study from north India
Vijaya Lakshmi Nag, Nihar Ranjan Dash, Ashutosh Pathak, Surendra Kumar Agarwal

Background: Voluntary counselling and testing centres (VCTC) are important HIV screening points for the population with suspicion or apprehension for HIV, because of high-risk exposures. Theoretically, these are also at the risk of having co-infections, commonest being syphilis. The present short-term study was aimed at knowing the sero-reactivity of syphilis among a study cohort attending the VCTC in King George's Medical University, Lucknow, India.
Method: During a 2.5-month period, 49 HIV-positive and 171 HIV-negative sera were tested for venereal disease research laboratory (VDRL). The positive sera were further tested for treponema pallidum haemagglutination (TPHA).
Result: Eleven (22.4%) HIV-positive sera and 104 (60.8%) HIV-negative sera were VDRL-reactive (≥1:8 dilutions). Of these, TPHA was reactive in three (27.3%) and four (3.9%), respectively.
Conclusion: The result might suggest the need for routine screening and counselling for syphilis at VCTC. Studies from other centres on larger population are required.

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