Journal Search

Journal Search - issue 4, 2009


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Jennifer Richmond1
PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


23 December 2009 Volume 9 Issue 4


RECEIVED: 22 December 2009

ACCEPTED: 23 December 2009


Richmond J.  Journal Search - issue 4, 2009 . Rural and Remote Health 2009; 9: 1415.


© 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 recent rural health publications. This issue includes recent publications in North American and Australian rural health journals.


Journal of Rural Health

Contents: 2009; 25:(4)
Issue includes:

Differential Neonatal and Postneonatal Infant Mortality Rates Across US Counties: The Role of Socioeconomic Conditions and Rurality
P. Johnelle Sparks, Diane K. McLaughlin, C. Shannon Stokes

Purpose: To examine differences in correlates of neonatal and postneonatal infant mortality rates, across counties, by degree of rurality. Methods: Neonatal and postneonatal mortality rates were calculated from the 1998 to 2002 Compressed Mortality Files from the National Center for Health Statistics. Bivariate analyses assessed the relationship between neonatal and postneonatal mortality by Urban Influence (UI) codes. Multivariable, weighted least-squares regression models included measures of county socioeconomic conditions, health services and environmental risks. Findings: The bivariate analysis indicated neonatal and postneonatal mortality was significantly higher in the most nonmetropolitan counties compared to the most metropolitan counties. However the relationship was not linear across the Urban Influence codes. In the multivariable models, a nonmetropolitan advantage was observed for counties not adjacent to metropolitan areas for neonatal mortality. However, postneonatal mortality rates were higher in the most rural nonmetropolitan counties. Conclusions: Certain characteristics of nonmetropolitan counties not adjacent to metropolitan counties and with an urban area of 2,500 population or more are protective against neonatal mortality (UI = 7, UI = 8). This may indicate that just having access to health services is more important to creating a protective effect for these nonmetropolitan counties than having a high concentration of medical facilities. The nonmetropolitan, not adjacent (UI = 9) disadvantage observed for postneonatal mortality supports the idea that the isolation of these areas combined with the combination of risk factors across the most nonmetropolitan counties leads to poorer postneonatal health outcomes in these areas.

The Association Between Rural-Urban Continuum, Maternal Education and Adverse Birth Outcomes in Québec, Canada
Nathalie Auger, Marie-Andrée Authier, Jérôme Martinez, Mark Daniel

Context: Rural relative to urban area and low socioeconomic status (SES) are associated with adverse birth outcomes. Whether a graded association of increasing magnitude is present across the urban-rural continuum, accounting for SES, is unclear. We examined the association between rural-urban continuum, SES and adverse birth outcomes. Methods: Singleton births from 1999 to 2003 (n = 356,147) were linked to Québec municipalities ranked on a continuum of 3 urban and 4 rural areas based on population and economic base. Maternal education was used to represent SES. Odds ratios (OR) were calculated for preterm birth (PTB), low birth weight (LBW), and small-for-gestational-age (SGA) birth, accounting for municipality and individual-level covariates. We used stratified analyses to examine interaction between SES and rural-urban continuum. Findings: Relative to metropolitan area residence, living in small urban or rural areas was associated with adverse birth outcomes. Living in rural areas was associated with SGA birth (OR 1.11, 95% CI 1.05-1.17) and LBW (OR 1.15, 95% CI 1.05-1.26), and living in small urban areas was associated with PTB (OR 1.14, 95% CI 1.08-1.20). Upon stratification by education, living in remote rural relative to metropolitan areas was associated with adverse birth outcomes among university educated mothers only, and living in small urban areas was associated with adverse birth outcomes among mothers with lesser but not higher education. An SES gradient was present in all rural-urban areas, particularly for SGA birth. Conclusion: Differences in perinatal health exist across the rural-urban continuum, and maternal education has a modifying influence.

Implementing Patient Safety Initiatives in Rural Hospitals
Jill Klingner, Ira Moscovice, Judith Tupper, Andrew Coburn, Mary Wakefield

Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for patient safety initiatives in 8 small Tennessee rural hospitals using a multi-organizational collaborative model. The demonstration identified and facilitated implementation of 3 patient safety interventions: the Agency for Healthcare Research and Quality (AHRQ) patient safety culture survey, use of personal digital assistants (PDAs), and sharing of emergency room protocols. The experience suggested that a collaborative model between rural hospitals, a payer, a hospital association, a quality improvement organization, and academic institutions can effectively support patient safety activities in rural hospitals. Successful implementation of the 3 patient safety interventions depended on leadership provided by nursing and patient safety/quality managers and open, trusting communications within the hospitals.

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003
Jayashri Sankaranarayanan, Shinobu Watanabe-Galloway, Junfeng Sun, Fang Qiu, Eugene Boilesen, Alan G. Thorson

Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.

Does Distance Matter? Distance to Mammography Facilities and Stage at Diagnosis of Breast Cancer in Kentucky
Bin Huang, Mark Dignan, Daikwon Han, Owen Johnson

Background: National and regional data indicate that breast cancer early detection is low in Kentucky, especially rural regions, perhaps because access to mammography services can be problematic. Objective: This study examined the distance between residences of women diagnosed with breast cancer and the nearest mammography facility, as a risk factor for advanced stage diagnosis in rural populations. Methods: 1999-2003 Kentucky Cancer Registry data were used for this study. A total of 12,322 women, aged 40 and older at diagnosis, with no previous history of cancer, and with known cancer stage were included. Travel distance was obtained using a geographic information system (GIS). Hierarchical logistic regression models were used to analyze the relationship between travel distance and advanced stage diagnosis. Results: Advanced diagnoses had longer average travel distances than early stage diagnoses (P < 0.01). After adjusting for age, race, insurance, and education at census tract level, the odds of advanced diagnosis were significantly greater for women residing over 15 miles from a facility, compared to those living within 5 miles (adjusted OR = 1.50, 95% CI = 1.25-1.80). Conclusion: Although socioeconomic status, race, and age may help explain advanced diagnoses, longer travel distance also adversely affects early detection for rural populations. Accurate measurement of spatial accessibility indicators, such as travel distance, facilitates identification of at-risk groups so that interventions can be developed to reduce this disease.

Cancer Risk Assessment by Rural and Appalachian Family Medicine Physicians
Kimberly M. Kelly, Margaret M. Love, Kevin A. Pearce, Kyle Porter, Mary A. Barron, Michael Andrykowski

Context: Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region. Purpose: To examine primary care physicians' identification of hereditary cancers. Methods: A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (n = 176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed. Findings: Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario. Conclusions: Though rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services

Changes in Cancer Incidence Patterns Among a Northeastern American Indian Population: 1955-1969 Versus 1990-2004
Martin C. Mahoney, Puthiery Va, Adrian Stevens, Amy R. Kahn, Arthur M. Michalek

Purpose: This manuscript examines shifts in patterns of cancer incidence among the Seneca Nation of Indians (SNI) for the interval 1955-1969 compared to 1990-2004. Methods: A retrospective cohort design was used to examine cancer incidence among the SNI during 2 time intervals: 1955-1969 and 1990-2004. Person-years at risk were multiplied by cancer incidence rates for New York State, exclusive of New York City, over 5-year intervals. A computer-aided match with the New York State Cancer Registry was used to identify incident cancers. Overall and site-specific standardized incidence ratios (SIRs = observed/expected × 100), and 95% confidence intervals (CIs), were calculated for both time periods. Results: During the earlier interval, deficits in overall cancer incidence were noted among males (SIR = 56, CI 36-82) and females (SIR = 71, CI 50-98), and for female breast cancers (SIR = 21, CI 4-62). During the more recent intervals, deficits in overall cancer incidence persisted among both genders (males SIR = 63, CI 52-77; females SIR = 67, CI 55-80). Deficits were also noted among males for cancers of the lung (SIR = 60, CI 33-98), prostate (SIR = 51, CI = 33-76) and bladder (SIR = 17, CI = 2-61) and among females for breast (SIR = 33, CI = 20-53) and uterus (SIR = 36, CI = 10-92). No cancer sites demonstrated increased incidence. Persons ages 60-69 years, 70-79 years, and ages 80+ years tended to exhibit deficits in overall incidence. Conclusions: Despite marked changes over time, deficits in overall cancer incidence have persisted between the time intervals studied. Tribal-specific cancer data are important for the development and implementation of comprehensive cancer control plans which align with local needs.

Adaptation of Consultation Planning for Native American and Latina Women With Breast Cancer
Jeffrey Belkora, Lauren Franklin, Sara O'Donnell, Julie Ohnemus, Dawn Stacey

Context: Resource centers in rural, underserved areas are implementing Consultation Planning (CP) to help women with breast cancer create a question list before a doctor visit. Purpose: To identify changes needed for acceptable delivery of CP to rural Native Americans and Latinas. Methods: We interviewed and surveyed 27 Native American and Latino key informants. We coded interviews thematically, and calculated summary statistics for the survey data. Findings: Native American and Latino respondents endorsed CP as culturally acceptable to their communities, while suggesting changes. Respondents also raised the topic of how to further support patients once they have successfully prepared a question list using CP. Conclusions: The resource centers implemented the requested changes.

Exercise Preference Patterns, Resources, and Environment Among Rural Breast Cancer Survivors
Laura Q. Rogers, Stephen J. Markwell, Kerry S. Courneya, Edward McAuley, Steven Verhulst

Context: Rural breast cancer survivors may be at increased risk for inadequate exercise participation. Purpose: To determine for rural breast cancer survivors: (1) exercise preference "patterns," (2) exercise resources and associated factors, and (3) exercise environment. Methods: A mail survey was sent to rural breast cancer survivors identified through a state cancer registry, and 483 (30%) responded. Findings: The majority (96%) were white, with mean education of 13 (±2.5) years and mean 39.0 (±21.5) months since diagnosis. Most participants (67%) preferred face-to-face counseling from an exercise specialist (27%) or other individual (40%). A third (31%) preferred home-based exercise with non face-to-face counseling from someone other than an exercise specialist. Participants preferring face-to-face counseling were more apt to prefer supervised exercise (38% vs 9%, P < 0.001) at a health club (32% vs 8%, P < 0.001). Home exercise equipment was reported by 63%, with 97% reporting home telephone and 67% reporting Internet access. Age, education, self-efficacy, treatment status, and exercise behavior were associated with exercise resources. The physical environment was often not conducive to exercise but a low crime rate and high trust in neighbors was reported. Conclusions: Rural health education programs encouraging exercise should offer multiple programming options while considering the physical environment and capitalizing on available resources and beneficial social environmental characteristics.

Designated Medical Directors for Emergency Medical Services: Recruitment and Roles
Rebecca T. Slifkin, Victoria A. Freeman, P. Daniel Patterson

Context: Emergency medical services (EMS) agencies rely on medical oversight to support Emergency Medical Technicians (EMTs) in the provision of prehospital care. Most states require EMS agencies to have a designated medical director (DMD), who typically is responsible for the many activities of medical oversight. Purpose: To assess rural-urban differences in obtaining a DMD and in their responsibilities. Methods: A national survey of 1,425 local EMS directors, conducted in 2007. Findings: Rural EMS directors were more likely than urban ones to report DMD recruitment problems, but recruitment barriers were similar, with the most commonly reported barrier being an unwillingness of local physicians to serve. Rural EMS directors reported that their DMDs were less likely to be trained in Emergency Medicine, and were less likely to provide educational support functions such as continuing education. Rural agencies were more likely to get on-line medical direction from their DMD, but were less likely to always get the on-line support they needed. Common barriers to on-line support were typical of rural communication barriers. Conclusions: Existing recommendations for DMD qualifications may be difficult to attain in rural communities. To develop programs that will support medical direction for rural EMS agencies, it is important to learn what physicians identify as the barriers to serving as DMDs, and whether there are alternative and innovative ways to provide an optimal level of medical oversight. Solutions will likely be multi-faceted, as EMS activities and organizational structures are diverse and the responsibilities of the DMD are broad.

Double Whammy? Rural Youth With Serious Emotional Disturbance and the Transition to Adulthood
Craig Anne Heflinger, Cheri Hoffman

Context: All youth, especially those with serious emotional disturbances (SED), face challenges as they transition to adulthood. Little is known about rural youth at risk for transition problems. Purpose: To examine transition-age youth who use publicly funded services in rural and urban/suburban locations in Tennessee in order to describe youth at risk for transition difficulties who need policy and service planning. Methods: Using Medicaid enrollment and claims/encounter data, youth at high risk for transition difficulties were identified in the following groups: SED, at risk of or in foster care/state custody, intensive or frequent mental health services users, or diagnosed with major mental disorders, behavior disorders, mental retardation, or substance use. Membership in these groups was compared between youth living in rural and urban/suburban counties. Multivariate regression was used to examine factors related to multiple group membership. Findings: Rural youth were more likely to be in groups at high risk for problems transitioning to adulthood, and enrolled in Medicaid as uninsured/uninsurable, compared to their urban counterparts. The strongest factors associated with multiple risk group membership were being in state custody/foster care and receiving Supplemental Security Income (SSI). Conclusions: Services are needed to support the transition to adulthood for youth at high risk of behavioral and adjustment problems. Systems to support coordinated planning and accountability are needed, including data on populations and services, and research on transition-age youth.

Physician Assistants and Nurse Practitioners as a Usual Source of Care
Christine M. Everett, Jessica R. Schumacher, Alexandra Wright, Maureen A. Smith

Purpose: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Findings: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (β=−0.22, 95% CI =−0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. Conclusions: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.

Resilience in Rural Community-Dwelling Older Adults
Margaret Wells

Context: Identifying ways to meet the health care needs of older adults is important because their numbers are increasing and they often have more health care issues. High resilience level may be one factor that helps older adults adjust to the hardships associated with aging. Rural community-dwelling older adults often face unique challenges such as limited access to health care resources. Purpose: To determine the resilience level of rural community-dwelling older adults and to determine if socio-demographic factors, social networks, and health status are associated with resilience. Methods: Data were collected from 106 registered voters, aged 65 years or over from a rural area in New York State using a cross- sectional design. The instruments used in the study include the Resiliency Scale, the SF-12v2, and the Lubben Social Network Scale-Revised. Findings: The mean resilience level of the sample was high. Resilience was not correlated with any of the socio-demographic factors which included gender, age, income, education, marital, and employment status. There was a weak positive correlation between social networks and resilience levels of rural older adults. Both physical and mental health status were positively correlated with resilience. In a regression model, mental health status was the strongest predictor of resilience levels. Conclusion: If low resilience levels are identified in rural community-dwelling older adults, interventions to build resilience may be helpful in promoting independence; however, further research is needed to determine this.

Horse-Related Injuries Among Agricultural Household Members: Regional Rural Injury Study II (RRIS-II)
Sibel Erkal, Susan G. Gerberich, Andrew D. Ryan, Bruce H. Alexander, Colleen M. Renier

Purpose: To determine the incidence, associated consequences, and potential risk factors for horse-related injuries among youth and adults residing in Midwestern agricultural households. Methods: Demographic, injury, and exposure data were collected for 1999 and 2001 among randomly selected agricultural households within a 5-state region. A causal model facilitated survey design, data analysis, and interpretation of results; directed acyclic graphs guided multivariate modeling. Findings: From 7,420 households (84% response of eligible), involving 32,601 persons, 5,045 total injury events were reported; 1,016 were animal-related injuries, of which 215 (21%) were horse-related (rate, 6.7 events per 1,000 persons per year). Seventy-seven percent (77%) required health care; comparing those under age 20 and those 20 and older, 49% and 54%, respectively, lost work time on their operation (28% and 26%, one week or more), as a result of injuries largely associated with horse riding activities (70% and 56%). Multivariate analysis for youths under age 20 indicated: increased risks in North and South Dakota, for >0 hours worked, and for having a history of prior agriculture-related injury; and decreased risks for males. For those 20 and older, increased risks were identified for a prior injury history and less than high school education. Conclusions: Horse-related injuries, primarily associated with riding activities, are a significant problem among agricultural communities, and greatly impact their operations.


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

[in French and English]

Contents: 2009; 14:(4)
Issue includes:

Rural medicine interest groups at McMaster University: a pilot study
Elaine M. Blau, Pamela Aird, Lisa Dolovich, Sheri Burns, Maria del Pilar-Chacon

Introduction: Although rural medicine interest groups (RMIGs) are prevalent in Canadian medical schools, there is little research on their contribution to rural education, training and careers.
Methods: We explored 2 broad questions by means of an electronic survey to people who were RMIG participants at McMaster University from 2002 to 2007: 1) What are the experiences of undergraduate trainees in an RMIG? 2) What are the features of RMIGs that contribute to an interest in rural medicine? The survey itself contained 35 questions broken down into sections detailing demographics, involvement in RMIGs, RMIG features, core and elective experiences, careers and Canadian Resident Matching Service.
Results: Of the 63 participants who completed the survey, 13 (20.6%) were in postgraduate training and 50 (79.4%) were in undergraduate training. The mean (standard deviation) age of participants was 28.4 (6.5) years and 71.9% percent were female. Respondents indicated that rural placements had the most influence on their choice of specialty and rural interest. Of all the features and activities of the RMIG, rural medicine special events contributed the most to an interest in rural medicine (e.g., "rural medicine days").
Conclusion: At McMaster University, the responses of participants suggested that RMIG participation had more influence on career choice than did the medical school attended. Communities, government organizations, residency programs and others interested in improving access to rural physicians, will note the importance of RMIGs and the importance survey respondents gave to rural medicine special events and rural electives.

Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature
Victor K. Ng, Heather Hames, Wanda M. Millard

Introduction: The shoulder joint is the most commonly injured major joint in patients who present to the hospital emergency department today. In the community the incidence of shoulder joint injuries is 11.2 cases per 100 000 person-years. Traditionally, procedural sedation and analgesia (PSA) has been used to facilitate the reduction of anterior shoulder dislocations. However, there are risks of complication, such as respiratory depression, particularly in certain populations. As such, the use of intra-articular lidocaine (IAL) has been suggested as an alternative method of analgesia.
Methods: We searched EMBASE (Ovid) and MEDLINE (PubMed) databases using the keywords "shoulder, dislocation, and/or reduction" from the respective start dates of the databases until October 2008.
Results: Based on the current literature, it appears that the IAL method provides, at a minimum, the same level of pain control and reduction success as the procedural sedation method, while markedly reducing the time spent by the patient in the emergency department and the cost of treatment. The likelihood of complications is arguably less with the use of IAL.
Conclusion: Although more research is this area is merited, physicians may consider IAL as an alternative to PSA in the management of anterior shoulder dislocations.

Does a rural residence predict the development of depressive symptoms in older adults?
Philip D. St. John, Audrey A. Blandford, Laurel A. Strain

Objective: We sought to determine whether adults aged 65 years or older living in rural areas who are without depressive symptoms have a lower risk of developing depressive symptoms over 5 years than their urban counterparts, and to determine the factors that predict the development of depressive symptoms in older adults in rural and urban areas.
Methods: We conducted a secondary analysis of an existing data set, the Manitoba Study of Health and Aging (MSHA.) We studied a population-based random sample of 807 people without depressive symptoms or cognitive impairment who were residing in Manitoba communities in 1991/92 and 5 years later in 1996/97. We defined "rural" as a census subdivision with a population of less than 20 000, and "urban" as a population of 20 000 or greater. The MSHA investigators measured depressive symptoms using the Center for Epidemiologic Studies Depression scale, using the standard cut-point of 16 or more. Participants reported their age, sex, education, self-rated health, and functional status at the time of their first interview.
Results: Of adults aged 65 years or older living in urban areas, 13.3% developed depressive symptoms, versus 8.9% of those living in rural regions (p = 0.047). In multivariate analyses, a rural residence was not associated with the development of depressive symptoms. In rural areas, factors predicting depressive symptoms were female sex and poor self-rated health at the time of the first interview.
Conclusion: A rural residence is only weakly protective for the development of depressive symptoms over 5 years, and this association was not seen after we accounted for potential confounding variables. As well, these results underscore the strong association between poor health and depressive symptoms.

The occasional Heimlich valve chest tube placement for pneumothoraces
David Mann

Introduction: Pneumothorax occurs when air finds its way into the pleural space. There are many causes for this, but those that occur spontaneously can be divided into categories of primary and second-ary.1 Primary spontaneous pneumo¬thorax (PSP) occurs in the absence of obvious lung pathology, and secondary spontaneous pneumothorax occurs with clinical lung pathology. Causes of secondary spontaneous pneumothorax are largely related to smoking habits, but other acquired and congenital conditions may be present. Secondary spontaneous pneumothoraces are commonly associated with chronic obstructive pulmonary disease and asthma. This article will deal only with the management of PSP.

Australian Journal of Rural Health

2008; 17:(4)
Issue includes:

Equipping patients for a time of helplessness: An educational intervention
Simon Holliday

Objectives: Quantify rates of awareness about, and ownership of, End-of-Life Planning (ELP) instruments. Examine whether this rate is increased by brief education during routine team care. Measure the time required by this exercise.
Design: Quality Improvement Activity.
Setting: General Practice on Mid-North Coast, New South Wales.
Participants: Forty-two consecutive, consenting elderly patients undertaking a Home Health Assessment.
Main outcome measures: This study assessed rates of ELP instruments at baseline, at 2 weeks, at 2 months and at 2 years following the provision and discussion of a fact sheet while measuring the clinicians' time required.
Results: This education exercise increased the number of patients with ELP instruments from one to ten (24%). On average it took 5.6 min of nursing time and 3.9 min for the GP.
Conclusions: Brief education during Home Health Assessments may empower patients to prepare for a scenario where they lost competency to make fully informed decisions. This may alleviate patient's fears about causing problems between those close to them and having treatments against their wishes.

Rural pharmacist perceptions of a project assessing their role in the management of depression
Judith Crockett, Susan Taylor

Objective: This paper explores pharmacist perceptions of a pilot study assessing the impact of specialist training on depression for rural community pharmacists on their understanding of treatment and psychological well-being of patients.
Design: Mixed method survey.
Setting: Rural community pharmacies.
Participants: Thirty-two rural based community pharmacists.
Interventions: Recruited pharmacists were allocated to either the 'control' or 'intervention' group. Intervention pharmacists were given training in depression and asked to dispense medication with extra advice and support, while control pharmacists provided usual care.
Outcome measures: Understanding of depression, current involvement in patients with depression, changes in practice.
Results: All pharmacists were more likely to initiate conversation, discuss medication and its side effects, point out the importance of remaining on the medication, provide ongoing follow-up and encourage patients to talk with their GPs and pharmacists by the end of the project. Intervention pharmacists were more likely than the control pharmacists to initiate conversation on dispensing a repeat prescription and to discuss extended support.
Conclusion: Response to the project by pharmacists was generally very positive. It is recommended that a longitudinal study based on this project be undertaken which involves pharmacists, GPs and other mental health professionals and trials a holistic approach to mental health care.

Mediating and moderating effects of work-home interference upon farm stresses and psychological distress
Connar Jo McShane, Frances Quirk

Objective: This study investigated whether work-home (WHI) or home-work interference (HWI) explained or affected the strength of the relationship between farmers' stresses and reported psychological distress.
Design: Distribution of questionnaire package; included Work-Home Conflict Scale, Farm Stress Survey, Depression Anxiety Stress Scale. Participants recruited via advertising in newsletters and newspapers, and distribution through businesses and meetings.
Participants: The majority of farmers (N = 51, male = 45, female = 5) were recruited from the one district. Farmers were individuals who identified their occupation as a farm owner, farm manager, or farm hand.
Main outcome measures: It was predicted farmers would report higher levels of WHI than HWI; time, a determinant of interference, would mediate the relationship between farmers' stresses and psychological distress; WHI and HWI would moderate farmers' stresses and their psychological distress; overall reported level of psychological distress would be in normal to mild range because of positive general economic conditions.
Results: Farmers reported significantly higher levels of WHI than HWI (M = 3.21, M = 2.76, P < 0.001 respectively). WHI and time-based WHI mediated farmers' stresses and psychological distress, particularly anxiety. WHI, time and strain, determinants of WHI mediated personal finances and subcomponents of psychological distress (stress, anxiety, depression). Time-based HWI mediated personal finances and stress. No moderating effects were found for WHI (r = −0.02, P = 0.882) or HWI (r = 0.15, P = 0.306).
Conclusions: Farmers of this specific sample presented a unique work-home interface. Limitations include the small sample size, recruitment methods, and culturally irrelevant measures as well as only assessing work-related stresses. Future research should aim to develop measures appropriate for farmers of Australia.

All-terrain vehicle crashes and associated injuries in north Queensland: Findings from the Rural and Remote Road Safety Study
Teresa O'Connor, Heather Hanks, Dale Steinhardt

Objective: To define characteristics of all-terrain vehicle (ATV) crashes occurring in north Queensland from March 2004 till June 2007 with the exploration of associated risk factors.
Design: Descriptive analysis of ATV crash data collected by the Rural and Remote Road Safety Study.
Setting: Rural and remote north Queensland.
Participants: Forty-two ATV drivers and passengers aged 16 years or over hospitalised at Atherton, Cairns, Mount Isa or Townsville for at least 24 hours as a result of a vehicle crash.
Main outcome measures: Demographics of participants, reason for travel, nature of crash, injuries sustained and risk factors associated with ATV crash.
Results: The majority of casualties were men aged 16-64. Forty-one per cent of accidents occurred while performing agricultural tasks. Furthermore, 39% of casualties had less than one year's experience riding ATVs. Over half the casualties were not wearing a helmet at the time of the crash. Common injuries were head and neck and upper limb injuries. Rollovers tended to occur while performing agricultural tasks and most commonly resulted in multiple injuries.
Conclusions: Considerable trauma results from ATV crashes in rural and remote north Queensland. These crashes are not included in most general vehicle crash data sets, as they are usually limited to events occurring on public roads. Minimal legislation and regulation currently applies to ATV use in agricultural, recreational and commercial settings. Legislation on safer design of ATVs and mandatory courses for riders is an essential part of addressing the burden of ATV crashes on rural and remote communities.

Correlates of comorbid mental disorders in a regional community-based sample
Katharine E. Heathcote, Brian Kelly, Arul Earnest, John R. Beard

Objective: The common coexistence of psychiatric disorders has been identified as a significant factor contributing to the disability associated with mental illness. Identifying indicators to the development of coexisting disorders has potential clinical implications. This study aimed to investigate the correlates and impact of coexisting disorders in a rural setting.
Design: Cross-sectional analyses of data from a cohort interviewed in two phases.
Setting: A regional community sample in Northern New South Wales, Australia.
Participants: A total of 1407 participants were interviewed and 968 were re-interviewed at follow up.
Main outcome measures: Multinomial logistic regression modelling compared subjects with multiple psychiatric disorders with those with a single disorder for sociodemographic characteristics, measures of personal and social vulnerability, psychological distress, functional disabilities and help-seeking behaviours.
Results: Participants with coexisting disorders were more likely to be male, report a history of severe childhood assault and had higher levels of neuroticism, psychological distress and help-seeking behaviour.
Conclusions: The findings suggest the role of early developmental factors on the complexity and severity of adult mental illness in a rural setting and the significant clinical consequences of comorbidity.

Linkage, coordination and integration: Evidence from rural palliative care
Malcolm Masso, Alan Owen

Objective: Review the findings from the evaluations of three rural palliative care programs.
Design: Review by the authors of the original material from each evaluation. The conceptual framework for the review was provided by the work of Leutz, including his distinction between linkage, coordination and full integration.
Setting: Community-based palliative care in rural Australia.
Interventions: Fifteen projects across all six states of Australia that focused on integration between general practitioners and other community-based health providers.
Results: The projects set out to improve networking and collaboration between providers; improve coordination and integration of care for patients; reduce duplication of services; and achieve a multidisciplinary, collaborative approach to palliative care. The most common interventions were establishment of formal governance structures, provision of education programs, case conferencing, dissemination of information, development of formal arrangements, development of protocols and use of common clinical assessment tools. The terms 'integration' and 'coordination' were used frequently but without clear definitions. Coordination required someone specifically designated to do the coordinating, usually a nurse. Formal arrangements to improve linkage and coordination were difficult to maintain. The main mechanism to achieve full integration was the development of common clinical information systems.
Conclusions: The 'laws' proposed by Leutz and the concepts of linkage, coordination and full integration provide a useful framework to understand the barriers to integrating GPs and other health providers. It is important to be clear on what level of integration is required. Improving links might be sufficient (and realistic), rather than striving for full integration.

Kids with confidence: A program for adolescents living in families affected by mental illness
Faye M. Hayman

Objective: To provide information about a peer support program for adolescents living in families affected by mental illness.
Design: This is a descriptive article about the Kids with Confidence Adolescent Program.
Setting: The program operates in rural Victoria using a variety of community venues.
Participants: Young people aged between 12-18 years, living in families affected by mental illness.
Interventions: The program provides respite, education, support and fun through monthly, semistructured activities. The adolescents are encouraged to talk openly about their circumstances and any difficulties they might be having. They learn appropriate social skills, and provide and receive peer support.
Results: The group consistently attracts between 7 and 15 adolescents, with an average attendance of 11.25. Verbal feedback from the young people involved and their families has been very positive, with reported improvements in confidence, self-esteem and the formation of strong, trusting friendships.
Conclusions: The Kids with Confidence Adolescent Program provides young people living in families affected by mental illness with peer and worker support, respite, and an opportunity to learn social and mental health skills. This might enhance young people's resilience and ability to cope with difficult situations.

Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia
Leanne McCann, Patrick Groot, Chris Charnley, Anne Gardner

Objective: To assess the effectiveness of a formalised stroke service in a regional hospital.
Design: A pretest post-test design.
Setting: An acute stroke unit in a regional health service.
Participants: Overall sample comprised 80 patients with 36 (45.0%) men. Forty patients (19 men, 21 women) comprised pre-intervention group and 40 (17 men, 23 women) post-intervention group.
Interventions: Establishment of an acute stroke unit.
Main outcome measure(s): Increased frequency in meeting key performance indicators for acute stroke care as recommended by National Stroke Foundation.
Results: On discharge, fewer survivors in the pre-intervention group were independent (n = 5) and returned home (n = 9) than the post-intervention group (n = 13) for both independent and returned home. More survivors in the pre-intervention group were discharged to aged care or inpatient rehab (n = 22) than the post-intervention group (n = 12). Within required time frames, the frequency of CT scans (χ2 (1, 80) = 4.1, P < 0.05), swallow assessments (χ2 (1, 80) = 9.0, P < 0.01), occupational therapy assessments (χ2 (1, 80) = 14.5, P < 0.0001), multidisciplinary meetings involving patient and family (χ2 (1, 80) = 19.9, P < 0.0001) and self-management plans (χ2 (1, 80) = 10.9, P < 0.05) all increased significantly.
Conclusions: Our evaluation demonstrated that introduction of formalised stroke care to a regional hospital resulted in improved compliance with key performance indicators and better patient outcomes. Thus evidence-based specialised stroke care can be offered with confidence in regional populations.

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