Journal Search

Journal Search - issue 3, 2009


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond




29 September 2009 Volume 9 Issue 3


RECEIVED: 24 September 2009

ACCEPTED: 29 September 2009


Richmond J.  Journal Search - issue 3, 2009. Rural and Remote Health 2009; 9: 1323.


© 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:(3)
Issue includes:

Prevalence of Rural Intimate Partner Violence in 16 US States, 2005
Matthew J. Breiding, Jessica S. Ziembroski, Michele C. Black

Context: Intimate partner violence (IPV) is a public health problem that affects people across the entire social spectrum. However, no previous population-based public health studies have examined the prevalence of IPV in rural areas of the United States. Research on IPV in rural areas is especially important given that there are relatively fewer resources available in rural areas for the prevention of IPV.
Methods: In 2005, over 25,000 rural residents in 16 states completed the first-ever IPV module within the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a Centers for Disease Control and Prevention-sponsored annual random-digit-dialed telephone survey. The BRFSS provides surveillance of health behaviors and health risks among the non-institutionalized adult population of the United States and several US territories.
Findings: Overall, 26.7% of rural women and 15.5% of rural men reported some form of lifetime IPV victimization, similar to the prevalence found among men and women in non-rural areas. Within several states, those living in rural areas evidenced significantly higher lifetime IPV prevalence than those in non-rural areas.
Conclusion: IPV is a significant public health problem in rural areas, affecting a similar portion of the population as in non-rural areas. More research is needed to examine how the experience of IPV is different for rural and non-rural residents.

Rural Health Clinics and Diabetes-Related Primary Care for Medicaid Beneficiaries in Oregon
Kelly Kirkbride, Neal Wallace

Background: This study assessed whether Rural Health Clinics (RHCs) were associated with higher rates of recommended primary care services for adult beneficiaries diagnosed with diabetes in Oregon's Medicaid program, the Oregon Health Plan (OHP).
Methods: OHP claims data from 2002 to 2003 were used to assess quality of diabetic care for beneficiaries residing in urban areas or rural areas with or without at least 1 RHC. Study subjects included Temporary Assistance to Needy Families (TANF) or disabled beneficiaries, aged 18-64, who were enrolled in the OHP for 12 months per study year and had at least 1 claim with a diabetes diagnosis (n = 6,267). Diabetes-related primary care was measured by the proportion of patients receiving each of 3 recommended tests at least once during the calendar year: hemoglobin A1c (HbA1c), lipid profile, and eye exam. Logistic regression models were used to identify differences in testing rates across the geographic areas, after controlling for individual differences including age, race, sex, and health status.
Results: Rural areas with no RHC had significantly lower rates of HbA1c testing, lipid profiles, and eye exams than urban areas (P < .01). Rural areas with at least 1 RHC had significantly higher rates for lipid profiles and eye exams than other rural areas (P < .05). No significant differences were detected in testing rates between rural areas with an RHC present and urban areas.
Conclusions: RHCs in rural Oregon were associated with higher rates of recommended primary care for diabetes, consistent with the intent of the policy intervention.

Practical and Policy Implications of Using Different Rural-Urban Classification Systems: A Case Study of Inpatient Service Utilization Among Veterans Administration Users
Ethan M. Berke, Alan N. West, Amy E. Wallace, William B. Weeks

Context: Several classification systems exist for defining rural areas, which may lead to different interpretations of rural health services data.
Purpose: To compare rural classification systems on their implications for estimating Veterans Administration (VA) utilization.
Methods: Using 7 classification systems, we counted VA health care enrollees who lived in each category, and number admitted to VA hospitals or non-VA hospitals under Medicare. For dual VA-Medicare enrollees over age 65, we compared VA and private sector hospitalizations on numbers of admissions and bed-days of care. We compared VA enrollees' relative proportions across rural to urban categories for each classification system and evaluated discordance between systems at the veterans-integrated service networks (VISN) level.
Findings: Enrollment and inpatient utilization counts for rural veterans vary considerably from one classification system to another, though the systems generally agree that admission rates, length of stay, and reliance on the VA for care are lower for rural veterans. Among older dual VA and Medicare enrollees, rural residents rely on non-VA facilities more, though this effect also varies widely depending on the classification scheme. VISNs vary greatly in the proportions of patients who are rural residents, and in the degree to which classification systems are discordant in designating patients as rural.
Conclusions: Decisions about allocating VA health care resources to target "rural" patients may be affected greatly by the rural classification system chosen, and the impact of this choice will affect some hospital networks much more than others.

Characteristics and Recruitment Paths of Certified Nursing Assistants in Rural and Urban Nursing Homes
Janice C. Probst, Jong-Deuk Baek, Sarah B. Laditka

Context: Most nursing home care is provided by certified nursing assistants (CNAs), but little is known about rural CNAs.
Purpose: To develop a representative geographic profile of the CNA workforce, focusing on paths leading to present job.
Methods: Cross-sectional analysis of data from the 2004 National Nursing Assistant Survey (NNAS), a nationally representative survey of 3,017 CNAs; analysis was restricted to 2,897 currently working CNAs. Location was categorized as metropolitan, micropolitan, or neither (other rural county). Demographics included age, sex, race, education, income, and years at present job. Analyses were weighted to reflect the complex sampling design.
Findings: CNAs in micropolitan and other rural nursing homes were more likely to be white and US citizens than were urban CNAs. Rural or micropolitan CNAs were more likely to note "job close to home" as a reason for becoming a CNA than were urban CNAs (70.8%, 66.3%, and 43.6%, respectively; P < .001). Over half of CNAs (52.2%) entered the field from a different job category. CNAs in micropolitan and small rural counties were more likely than urban CNAs to report being trained at a nursing facility (61.4%, 65.4%, 52.5%; P < .001) rather than community college or other site. Informal means (family and friends) were the most common recruitment path.
Conclusions: Career-changers (individuals entering the CNA role from another job) represent a major recruitment target. The prevalence of informal networks in CNA recruitment history suggests that nursing homes seeking to become "employers of choice" will be advantaged when recruiting.

Factors That Influence Physicians to Practice in Rural Locations: A Review and Commentary
Darra Ballance, Denise Kornegay, Paul Evans

Rural populations remain underserved by physicians, despite various efforts by medical schools and other institutions/organizations to correct this disparity. We examined the literature on factors that influence rural practice location decisions by physicians to determine what opportunities exist along the entire educational pipeline to entice physicians to, and retain them in, rural areas. Results reported in the literature favor a multidisciplinary or multi-faceted approach that results in more residents and physicians locating their practices in rural areas. The need to define proven strategies is not the pressing issue; rather, the needs are to define the commitments necessary to implement proven strategies, as well as the will to make physician distribution a priority issue in medical education.

Preparing Daughters: The Context of Rurality on Mothers' Role in Contraception
Joanne Noone, Heather M. Young

Context: The United States continues to have the highest rate of adolescent childbearing among developed countries. Lack of access and disadvantage contribute to this problem, which disproportionately impacts rural women. Given the increased difficulty rural young women face regarding contraceptive access, parental communication and support play an even more vital role in assisting them to navigate decisions about and access to contraception.
Purpose: To examine rural women's perspectives on how living in a rural area impacts issues surrounding pregnancy prevention for their daughters and parent-child communication regarding pregnancy prevention.
Methods: Open-ended interviews were conducted with 30 mothers of adolescent women in 3 rural counties in southern Oregon. Thematic analysis within and across interviews using constant comparative analysis was used to explore barriers, facilitators and strategies mothers identified in talking with their daughters about contraception.
Findings: Specific themes found that related to the rural environment included (1) conservatism, (2) isolation, (3) lack of privacy, (4) stigma, (5) the paradox of the rural environment, and (6) the uniqueness of rural life.
Conclusions: The context of living in a rural environment may present unique barriers to facilitate parent-child communication when discussing intimate topics. The design of interventions needs to take into consideration these issues, particularly when attempting to serve hard-to-reach populations.

Pharmacy Characteristics Associated With the Provision of Drug Therapy Services in Nonmetropolitan Community Pharmacies
Abhijit S. Gadkari, David A. Mott, David H. Kreling, Joseph K. Bonnarens

Context: Higher prevalence of chronic diseases and reduced access to other health professionals in rural areas suggest that rural Medicare enrollees will benefit from pharmacist-provided drug therapy services (DTS).
Purpose: The purpose of this study was to describe non-metropolitan community pharmacy sites in Wisconsin, the provision of DTS at these sites, and to identify factors associated with provision of DTS.
Methods: A cross-sectional, descriptive survey design was used to collect primary data in 2005. The manager/owner listed for each of the 279 non-metropolitan community pharmacy sites in Wisconsin was surveyed using an 8-page instrument. The 7 drug therapy services that key informants were asked to report on included 6 disease state management (DSM) programs and medication therapy management services (MTMS). Descriptive statistics were calculated for variables describing the pharmacy sites and how DTS were provided. Logistic regression was performed, with any drug therapy service provision as the dependent variable and 8 independent variables.
Findings: The response rate to the survey was 44%. Overall, 31% of the respondent pharmacies offered MTMS and 31% offered DSM programs. Higher service orientation, location in a more rural area, and lower workload per pharmacist were significantly positively related to provision of any DTS.
Conclusions: Conducted 4 months prior to the implementation of Medicare Part D, the results serve as a baseline against which the effects of Part D on MTMS provision may be evaluated. The negative association of pharmacist workload with pharmacy provision of DTS, coupled with the current pharmacist shortage, has important implications for patients' access to these services in rural areas.

Nurses' Comfort Level With Emergency Interventions in the Rural Hospital Setting
Erin L. Ross, Sue E. Bell

Context: One quarter of the persons living in the United States receive their emergency care in a rural hospital. Nurses employed in these hospitals see few emergencies but must be prepared to provide expert and efficient care when they do occur.
Purpose: The purpose of this study was to determine the influence of registered nurses' certifications and years of experience on comfort level in emergencies.
Methods: Data were collected using a survey design. The questionnaire gathered demographic data, number and type(s) of certifications held, and comfort level with 7 emergency interventions. The sample was recruited from registered nurses (RNs) working in 10 Critical Access Hospitals that represented different geographic locations and different distances to larger, more comprehensive hospitals in an upper Midwestern state.
Findings: Mean comfort level of all respondents with the 7 selected emergency interventions ranged from 2.3 for assisting with thoracentesis to 3.6 for assisting with precipitous vaginal delivery, indicating only a moderate comfort level with the selected emergency interventions. While 70% of the 86 respondents answered "yes" when asked if they felt comfortable in emergency situations, the percentage of respondents who reported being comfortable ranged from 33% to 83%.
Conclusions: Number and type(s) of certifications and years of experience as an RN were associated with higher comfort levels. Responses to open-ended questions provided insight into the realities of rural emergency nursing and strategies for improving comfort levels of rural nurses in emergency situations.

Knowledge, Attitudes, Beliefs, and Personal Practices Regarding Colorectal Cancer Screening Among Health Care Professionals in Rural Colorado: A Pilot Survey
Sun Hee Rim, Linda Zittleman, John M. Westfall, Linda Overholser, Desireé Froshaug, Steven S. Coughlin

Purpose: This study reports the baseline knowledge, attitudes, beliefs, and personal practices of health care professionals regarding colorectal cancer (CRC) screening in the High Plains Research Network (HPRN) of rural Colorado prior to a community-based educational intervention. It also examines the association between health care staff members' knowledge, attitudes, beliefs, and personal practices for CRC screening and patient screening levels by practice.
Methods: Surveys were mailed to health care professionals in the HPRN. Participating clinics (n = 21) distributed patient surveys on CRC screening to persons aged ≥50 for a 2-week period in 2006.
Results: The survey response rate was 81% for providers (n = 46) and 90% for nursing staff (n = 63). Only 54% of health care professionals knew CRC is a leading cause of cancer deaths. When surveyed on their attitudes toward colon cancer, 92%"strongly agreed" or "agreed" that colon cancer is preventable. About 99% (n = 107) of providers and nurses "strongly agreed" or "agreed" that testing could identify problems before colon cancer starts. Most health care professionals (61%) aged ≥50 years had previously been tested and were up-to-date (52%) with screening. Provider knowledge was significantly associated with higher patient screening (P = .02), but provider attitudes and beliefs were not. Moreover, personal screening practices of health care professionals did not correlate with more patients screened.
Conclusion: Background knowledge of CRC among HPRN health care professionals could be improved. The results of this pilot study may help focus effective approaches such as increasing provider knowledge to enhance CRC screening in the relevant population.

Multifaceted Inpatient Psychiatry Approach to Reducing Readmissions: A Pilot Study
Timothy P. Lang, James E. Rohrer, Pierre A. Rioux br>

Context: Access to psychiatric services, particularly inpatient psychiatric care, is limited and lacks comprehensiveness in rural areas.
Purpose: The purpose of this study was to evaluate the impact on readmission rates of a multifaceted inpatient psychiatry approach (MIPA) offered in a rural hospital.
Methods: Readmissions within 30 days of patients who were admitted to an inpatient psychiatric unit using a MIPA model of care (N = 147) were compared to readmissions of a comparison group of patients who were admitted prior to the adoption of the MIPA (N = 37). Case mix differences were adjusted using multiple logistic regression analysis (N = 184).
Findings: Patients treated in the MIPA model of care had lower odds of readmission within 30 days (odds ratio 0.14, 95% CI 0.02-0.87, P < .03).
Conclusions: Effective inpatient psychiatric care can be provided in rural hospitals.

Exceptional Brain Aging in a Rural Population-Based Cohort
Jeffrey Kaye, Yvonne Michael, James Calvert, Marjorie Leahy, Debbie Crawford, Patricia Kramer

Context: The 2000 US Census identified 50,454 Americans over the age of 100. Increased longevity is only of benefit if accompanied by maintenance of independence and quality of life. Little is known about the prevalence of dementia and other disabling conditions among rural centenarians although this information is important to clinicians caring for them. Purpose: To determine the prevalence of disabling conditions, including cognitive impairment, among the very elderly in a rural setting to guide clinicians in their care. Methods: We performed a population-based cohort study of all residents 97 years and older in the Klamath Basin, a rural region in southern Oregon. The prevalence of disabling conditions was determined by in-person examination. Findings: About 100% of the target sample was identified. Of the eligible 67 individuals ≥97 years old, 31 were evaluated in-person. The prevalence of dementia (probable or possible Alzheimer's disease or vascular dementia) was 61.3% (95% CI: 43.8, 76.2), mild cognitive impairment was 29.0% (95% CI: 16.1, 46.6), and no dementia was 9.7% (95% CI: 3.4, 25.0). Parkinsonism and the APOEe4 allele were rare. Systemic vascular disease was almost universally present. Conclusions: While cognitive impairment was nearly universal in this rural population of very elderly persons, almost 40% had not progressed to full dementia. Determining risk factors for dementia in this population can identify strategies to prevent progression to dementia among younger elderly populations.

Comparison of Program Costs for Parent-Only and Family-Based Interventions for Pediatric Obesity in Medically Underserved Rural Settings
David M. Janicke, Bethany J. Sallinen, Michael G. Perri, Lesley D. Lutes, Janet H. Silverstein, Babette Brumback

Purpose: To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities.
Methods: Ninety-three overweight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions.
Findings: Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were $13,546 and $20,928, respectively. Total cost per child for the parent-only and family interventions were $521 and $872, respectively.
Conclusions: Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.


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

[in French and English]

Contents: 2009; 14:(3)
Issue includes:

Teaching children's mental health to family physicians in rural and under serviced areas
Neal Stretch, Margaret Steele, Brenda DavidsonRichard Andreychuk, Heather Sylvester, James Rourke, Gordon Dickie

Objective: To evaluate a curriculum for teaching family physicians (FPs) in rural and underserviced areas about children's mental health, and to evaluate a collaborative model of teaching using child psychiatrists and FPs.
Methods: A child psychiatrist and a rural FP provided training to rural FPs in attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs). Training consisted of a half-day workshop in 11 communities located in southwestern Ontario. Workshops included didactic teaching, observation of standardized videos demonstrating interviewing skills, and interactive discussion. Participants completed pre- and posttraining questionnaires about their confidence in managing these conditions, and completed standardized questionnaires on the effectiveness of the workshop and videos. One month after the training, participants were randomly assigned to receive individual interviews. Three months later 2 questionnaires were mailed to participants for evaluation of their confidence after their training and for evaluation of the impact on their practice.
Results: Fifty-six FPs attended the workshops and, of these, 80% completed the study. Family physicians reported improved confidence in their abilities to diagnose and treat ADHD and DBDs after the training.
Conclusion: Didactic presentations by child psychiatrists and FPs, followed by video examples of interviewing skills, and informal discussions with small groups, was found to be an effective curriculum for teaching rural FPs about children's mental health.

Meeting Canadian Emergency Department Triage and Acuity Scale benchmarks in a rural emergency department
Dean Vlahaki, W. Ken Milne

Introduction: The Canadian Emergency Department Triage and Acuity Scale(CTAS) was implemented in 1999. The CTAS aims to more accurately define patients'needs for timely care and provide operating objectives to standardize this care. Theseobjectives are not being met across Ontario. The purpose of this study was to deter-mine if the CTAS benchmarks were being met at a rural emergency department (ED).
Methods: All ED visits to South Huron Hospital from Apr. 1, 2003, to Mar. 31, 2004,were reviewed. The percentage of visits receiving each CTAS category (I-V) was cal-culated. The median and 90th percentile time to physician initial assessment (PIA)were quantified by CTAS level.
Results: There was a total of 10 286 ED visits with 113 (1.1%) excluded because ofmissing triage codes. The percentage of visits assigned to CTAS categories I to V was0.3, 2.4, 16.0, 42.7 and 38.5, respectively. Time to PIA in minutes was 1, 12, 24, 28 and27 for CTAS I to V, respectively.
Conclusion: The CTAS guidelines for PIA were met at this rural ED.

Issues related to medical students' engagement in integrated rural placements: an exploratory factor analysis
Tyrone Donnon, Wayne Woloschuk, Doug Myhre

Objective: The purpose of this study was to identify and investigate the factors derived from the rural integrated community clerkship (RICC) questionnaire that influenced the decision of medical students to pursue a 36-week rural community placement option.
Methods: A total of 162 first-year (n = 92) and second-year (n = 70) medical students completed the 35-item RICC questionnaire. We used qualitative interviews to develop questionnaire items, and we used subsequent descriptive statistics and exploratory factor analyses to analyze the data.
Results: Students with origins in rural communities were not significantly more likely to consider a RICC than their urban counterparts. However, students who identified family medicine as their discipline of choice were 3 times more likely to consider a RICC. Exploratory factor analysis, based on correlation of questionnaire items, determined 7 factors (themes) for the questionnaire. The questionnaire had strong internal reliability (Cronbach α = 0.94).
Conclusion: Although generally supportive of the rural clerkship option, students are less concerned about the clinical experience than they are about the practical implications of moving to a rural community. The RICC questionnaire was shown to have strong reliability and construct validity in measuring students' perceptions of a long-term clerkship placement in a rural community.

Abridged version of the Society of Rural Physicians of Canada's discussion paper on rural hospital service closures
Peter Hutten-Czapski

Although Canada's beleaguered health care system still produces outcomes among the best in the world, there are growing signs that this is not the reality for Canadians living in smaller or more isolated communities across the country. Despite manifest rural-urban health inequity, regional management repeatedly finds it an easy decision to close, or hobble, a small peripheral hospital and transfer a portion of the funding for those services to the centre of power. This paper is an abridged form of the Society of Rural Physicians of Canada's discussion paper on rural service closures1 developed to examine the arguments and evidence for and against hospital and service closures.

Australian Journal of Rural Health

2009; 17:(3)
Issue includes:

Sixteen years on: Has quality of care for rural and non-compensable traumatic brain injury clients improved?

Anna M. O'Callaghan, Lindy McAllister, Linda Wilson

This review focuses on two factors that influence client access to care following head injury. These factors, namely the degree of rurality of a client's home town and the funding model to which they are allocated, are discussed in light of the results of the 'Head Injury Impact Project'. National and international publications, anecdotal reports and clinical experience illustrating current practices in care provision both nationally and internationally are then described. Finally, future research is proposed investigating perceived variations in access to services according to location, funding and other factors.

Funding for rural health research from the Australian Research Council: A missed opportunity?
John McDonald

Objective: To determine the number of projects, and level of funding, for rural health research from the Australian Research Council (ARC).
Design: Analyses of ARC searchable datasets of completed, and new and ongoing projects from 2001 to 2008.
Main outcome measures: Number of rural health research projects as a proportion of total funding; level of funding for rural health research projects as a proportion of total funding.
Results: Only 46 of 6498 ARC completed projects were classified as rural health research projects. This represents 0.7% of the total number of projects, and 0.39% of the total funding allocated. Only 25 of 4659 ARC new and ongoing projects were classified as rural health research projects. This represents 0.54% of the total number of projects, and 0.27% of the total funding allocated. None of the 832 completed fellowships were classified as rural health. Only five (0.52%) of the 953 new and ongoing fellowships were classified as rural health.
Conclusions: The level of under-funding for rural health research could be partially addressed by directing applications towards the ARC, in addition to the National Health and Medical Research Council. With a few exceptions, rural health researchers are not yet competitive in the national funding arena.

The frontline and the ivory tower: A case study of service and professional-driven curriculum
Sue Lenthall, John Wakerman, Sabina Knight

Objective: To describe the development of a postgraduate, multidisciplinary program designed to meet the needs of remote health professionals, present formative evaluation findings and to offer an analysis of the difficulties and lessons learnt.
Design: Case study.
Setting: University Department of Rural Health in a remote region.
Participants: University staff, students and stakeholders involved in the development of the remote health practice program.
Results: Formative evaluation suggests that a curriculum driven by service and professional groups, such as the Flinders University Remote Health Practice program, is able to better prepare remote health practitioners and improve their effectiveness. Difficulties in development included a lack of recognition by some university academics of the value of practitioner knowledge and a reluctance to accept a clinical component in a masters program. Lessons learnt included the importance of: (i) respect for practitioner knowledge; (ii) explicit and appropriate values; (iii) high-quality academics with strong service links; (iv) appropriate length of lead time; (v) institutional links between university and both relevant professional organisations and health services; (vi) a receptive university; (vii) location; and (viii) ongoing engagement with services and professional responsive development.
Conclusion: The success of the program was due in large part to the relationship with professional bodies and close links with remote health services. We have described a number of lessons learnt from this experience that can be useful to other educational groups developing or revising their educational programs.

Loss of income and levels of scholarship support for students on rural clinical
Deborah Schofield, Sheila Keane, Susan Fletcher, Rupendra Shrestha, Richard Percival

Objective: To quantify the financial impact of rural clinical placements on medical, nursing and allied health students in rural Australia.
Design: The Careers in Health Tracking Survey provided data on whether students were employed, usual weekly hours of employment and a range of covariates, such as age, sex, course of study, marital status, dependants and rural or urban origin.
Participants: A total of 121 students from a range of health professions completed the Careers in Health Tracking Survey while on rural placement at the Northern Rivers University Department of Rural Health.
Outcome measures: Survey data.
Results: Forty-one per cent of respondents were working immediately before their clinical placements. Nursing students worked the longest hours by far and were significantly more financially disadvantaged than both medical and allied health students (P < 0.01). Scholarship support was unevenly distributed, with nursing and allied health students being relatively under-supported in relation to lost earnings.
Conclusion: Recruitment of students can be an effective strategy to address the rural health workforce shortage throughout Australia. However, there are a number of financial disincentives for students to undertake rural clinical placements. Additional support for some disciplines is needed to provide equitable distribution of scholarship support to offset this financial burden. Establishing an employment scheme for students on rural clinical placements and a scholarship for income replacement where employment is not available would also alleviate income loss.

Relationships between body fatness, small-screen sedentary activity and regionality among schoolchildren in Victoria, Australia
Helen M. Aucote, Andrew Cooper

Objective: To examine the difference in body fatness and engagement in small-screen activities across children living in different degrees of regionality, and to examine the relationship between child body fatness and small-screen activities.
Design: Cross-sectional study design.
Participants: Grade 5-6 schoolchildren (n = 393) from central and metropolitan Victoria, and a parent/guardian of each child (n = 393).
Main outcome measures: Parents completed a questionnaire on their child's engagement in television (TV) viewing and video game playing (VGP). Children's weight and height were measured by a researcher. Body mass index (BMI) (kg/m2) was calculated and adjusted for age and sex. Regionality (metropolitan, population > 100 000; regional, 100 000 > population < 20 000; and rural, population < 10 000) and socioeconomic status (socioeconomic indexes for areas: index of disadvantage) were assigned according to school attended.
Results: BMI did not differ across regionality or sex. Boys engaged in more VGP than girls, and metropolitan children engaged in more VGP than rural and regional children. TV viewing did not differ across sex or regionality. VGP did not predict BMI, and TV viewing did not predict girls' BMI. Three to four per cent of the variance in boys' BMI was predicted by TV viewing.
Conclusions: Boys and metropolitan children engage in more VGP. Boys', but not girls', BMI is related to TV viewing. Interventions designed to decrease engagement in TV viewing should be targeting boys.

Stress and help-seeking for drought-stricken citrus growers in the Riverland of South Australia
Alice K. Staniford, Maureen F. Dollard, Bernard Guerin

Objective: To explore the psychological impact of a problematic industrial climate for citrus growers, their help-seeking behaviour and perspectives on ways to encourage better use of rural mental health services.
Design: Thematic analysis of in-depth interviews.
Setting: The Riverland of South Australia.
Participants: Sixteen citrus growers (12 male, 4 female) from eight Riverland towns.
Main outcome measures: Citrus growers' perceived factors relating to psychological stress, coping behaviours, impact of stress on well-being, help-seeking behaviours, barriers to help-seeking and ways to encourage better use of rural mental health services.
Results: Work-related stresses grouped under broad themes, including 'Uncontrollable events', 'Financial hardship' and 'Pressure', had negative effects on participants' well-being. Furthermore, it was found that significant difficulties arise because many of the stresses which growers endure are not controllable, and that the alleviation of strain with the help of mental health professionals is uncommon because of barriers preventing help-seeking. Five broad themes of barriers to help-seeking were extracted from the data: 'Self-reliance', 'Social image', 'Lack of knowledge', 'Negative perceptions of health professionals' efficacy' and 'Restrictive lifestyle factors'. A specialised model of occupational health for citrus growers was proposed.
Conclusions: These results highlight the practical need to address the identified issues in delivery and promotion of health services when facilitating help-seeking within this group. The findings also add to our knowledge of occupational health psychology broadly.

Promoting mental health care in a rural paediatric unit through participatory action research
Brenda Happell, Lorna Moxham, Kerry Reid-Searl, Trudy Dwyer, Julie Kahl, Jodie Morris, Narelle Wheatland

Objective: To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research.
Design: A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research.
Setting: A 16-bed paediatric unit of a rural general hospital.
Participants: A purposive convenience sample of all paediatric nursing staff (n = 20; of 24 nurses).
Outcome measures: In the first phase of this study, focus groups were conducted to explore the experiences of nurses.
Results: Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment.
Conclusions: There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority.

Adults with intellectual disability in regional Australia: Incidence of disability and provision of accommodation support to their ageing carers
Diann Eley, Joanne Boyes, Louise Young, Desley Hegney

Objective: This project aimed to identify a population of adults with intellectual disability and their carers in a defined regional area of Australia to determine their prevalence in this setting, their current accommodation situation and their future accommodation needs.
Design: Mixed method cross-sectional design employed a survey to collect data from both quantitative (Likert type) and qualitative (free response) questions.
Setting: Regional town and its contiguous shires in Queensland.
Participants: Adults (over 18 years) with an intellectual disability and their primary carers.
Main outcome measure: Identification of adults with intellectual disability and a description of their accommodation situation and perceived needs.
Results: Adults with intellectual disability (n = 156) were male (60%), mean age of 37.2 years (range 18-79). Carers (n = 146) were female (78%), mean age of 61.5 years (range 40-91). The majority of adults with intellectual disability (56%) are cared for at home (mean age = 35 years). Mean age of those who live away from home was 39.8 years. The levels of support required by those living at home and those living away from home were not different, nor were the age ranges of their carers.
Conclusions: Findings show that the majority of primary carers are over the age of 50 years and continue to provide medium-high levels of support within the family home. The advancing age of both carers and the people they support, combined with the location of that support, is a major issue in the provision of adequate services for this population.

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