full article:Journal Search brings Rural and Remote Health readers information about relevant recent publications. This issue includes recent rural health publications in North American and Australian rural health journals.
Journal of Rural Health
Contents: 2010; 26:(2)
Strength of Tobacco Control in Rural Communities
Nancy L. York, Mary Kay Rayens, Mei Zhang, Lisa G. Jones, Baretta R. Casey, Ellen J. Hahn
Purpose: This study aimed to: (a) describe the Strength of Tobacco Control (SoTC) capacity, efforts and resources in rural communities, and (b) examine the relationships between SoTC scores and sociodemographic, political, and health-ranking variables.
Methods: Data were collected during the baseline preintervention phase of a community-based randomized, controlled trial. Rural counties were selected using stratified random sampling (n = 39). Key informant interviews were employed. The SoTC, originally developed and tested with states, was adapted to a county-level measure assessing capacity, efforts, and resources. Univariate analysis and bivariate correlations assessed the SoTC total score and construct scores, as well as their relationships. Multiple regression examined the relationships of county-level sociodemographic, political, and health-ranking variables with SoTC total and construct scores.
Findings: County population size was positively correlated with capacity (r = 0.44; P < .01), efforts (r = 0.54; P= .01), and SoTC total score (r = 0.51; P < .01). Communities with more resources for tobacco control had better overall county health rankings (r = .43; P < .01). With population size, percent Caucasian, tobacco production, and smoking prevalence as potential predictors of SoTC total score, only population size was significant.
Conclusions: SoTC scores may be useful in determining local tobacco control efforts and appropriate planning for additional public health interventions and resources. Larger rural communities were more likely to have strong tobacco control programs than smaller communities. Smaller rural communities may need to be targeted for training and technical assistance. Leadership development and allocation of resources are needed in all rural communities to address disparities in tobacco use and tobacco control policies.
Geographic Differences in Use of Home Oxygen for Obstructive Lung Disease: A National Medicare Study
Leighton Chan, Nicholas Giardino, Gordon Rubenfeld, Laura-Mae Baldwin, Meredith A. Fordyce, L. Gary Hart
Rationale: Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year).
Objectives: To assess geographic differences in supplemental oxygen use.
Methods: Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lung disease in 1999 and alive at the end of 2000.
Measurements and Main Results: While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas.
Conclusions: There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility.
Rural-Urban Differences in Preventable Hospitalizations Among Community-Dwelling Veterans With Dementia
Joshua M. Thorpe, Courtney H. Van Houtven, Betsy L. Sleath, Carolyn T. Thorpe
Context: Alzheimer's patients living in rural communities may face significant barriers to effective outpatient medical care.
Purpose: We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia.
Methods: Medicare and Veteran Affairs inpatient claims for 1,186 US veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a 1-year period following collection of independent variables. Urban Influence Codes were used to classify care recipients into 4 categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and noncore rural counties. We used the Andersen Behavioral Model of Health Services to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH.
Findings: Thirteen percent of care recipients had at least 1 ACSH. The likelihood of an ACSH was greater for patients in noncore rural counties versus large metropolitan areas (22.6% vs 12.8%, unadjusted odds ratio [OR]= 1.99; P < .01). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; P < .05).
Conclusions: We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.
A Longitudinal Analysis of Rural and Urban Veterans' Health-Related Quality of Life
Amy E. Wallace, Richard Lee, Todd A. MacKenzie, Alan N. West, Steven Wright, Brenda M. Booth, Kara Hawthorne, William B. Weeks
Context: Cross-sectional studies have identified rural-urban disparities in veterans' health-related quality-of-life (HRQOL) scores.
Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans' HRQOL scores persisted.
Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans' HRQOL scores were changing at different rates over the time period examined.
Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied.
Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.
Birth Outcomes and Infant Mortality by the Degree of Rural Isolation Among First Nations and Non-First Nations in Manitoba, Canada
Zhong-Cheng Luo, Russell Wilkins, Maureen Heaman, Patricia Martens, Janet Smylie, Lyna Hart, Fabienne Simonet, Spogmai Wassimi, Yuquan Wu, William D. Fraser
Context: It is unknown whether rural isolation may affect birth outcomes and infant mortality differentially for Indigenous versus non-Indigenous populations. We assessed birth outcomes and infant mortality by the degree of rural isolation among First Nations (North American Indians) and non-First Nations populations in Manitoba, Canada, a setting with universal health insurance.
Methods: A geocoding-based birth cohort study of 25,143 First Nations and 125,729 non-First Nations live births to Manitoban residents, 1991-2000. Degree of rural isolation was defined by an indicator of urban influence (no, weak, moderate/strong) based on the percentage of the workforce commuting to urban areas.
Findings: Preterm birth and low birth weight rates were somewhat lower in all rural areas regardless of the degree of isolation as compared to urban areas for both First Nations and non-First Nations. Infant mortality rates were not significantly different across areas for First Nations (10.7, 9.9, 7.9, and 9.7 per 1,000 in rural areas with no, weak, moderate/strong urban influence, and urban areas, respectively), but rates were significantly lower in less isolated areas for non-First Nations (7.4, 6.0, 5.6, and 4.6 per 1,000, respectively). Adjusted odds ratios showed similar patterns.
Conclusions: Living in less isolated areas was associated with lower infant mortality only among non-First Nations. First Nations infants do not seem to have similarly benefited from the better health care facilities in urban centers, suggesting a need to improve urban First Nations' infant care in meeting the challenges of increasing urban migration.
Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents: 2010; 15:(2)
Determinants of mammography use in rural and urban regions of Canada
James Ted McDonald, Angela Sherman
Introduction: National guidelines advocate biennial mammography screening for asymptomatic women aged 50-69 years. Unfortunately many women do not abide by such recommendations, and evidence indicates that compliance rates are lower in rural areas.
Methods: We estimated logistic regression models using data from the Canadian Community Health Survey for 2002/03 and 2004/05. We identified the extent of regional variation within and between Canadian provinces using a new and more detailed set of rural indicators based on economic zones of influence, after accounting for a range of demographic and socio-economic factors.
Results: The odds of asymptomatic women aged 50-69 years having undergone mammography during the previous 2 years were significantly lower for those residing in relatively remote and rural areas than for those residing in census metropolitan areas (odds ratio [OR] 0.58, confidence interval [CI] 0.42-0.80). This was also true of women residing in certain other rural areas that had some limited labour market attachment to larger urban areas (OR 0.81, CI 0.70-0.93), but there were no significant differences between smaller and larger urban areas. We also found variation in mammography use among women living in rural and urban areas across provinces.
Conclusion: Mammography use is significantly lower in rural and remote areas, even after a range of other demographic and socio-economic factors are accounted for. One important factor underpinning this result appears to be differences in attitude about the importance of regular mammography screening between women residing in rural and urban areas. Information campaigns raising awareness about the importance of mammography screening should be targeted, in particular, at women residing in rural and remote areas.
The experience of primary health care users: a rural-urban paradox
Paul A. Lamarche, PhD, Raynald Pineault, MD, PhD, Jeannie Haggerty, PhD, Marjolaine Hamel, MSc, Jean-Frédéric Levesque, MD, PhD, Josée Gauthier
Introduction: We sought to assess the care experience of primary health care users, to determine whether users' assessments of their experience vary according to the geographical context in which services are obtained, and to determine whether the observed variations are consistent across all components of the care experience.
Methods: We examined the experience of 3389 users of primary care in 5 administrative regions in Quebec, focusing on accessibility, continuity, responsiveness and reported use of health services.
Results: We found significant variations in users' assessments of the specific components of the care experience. Access to primary health care received positive evaluations least frequently, and continuity of information received the approval of the highest percentage of users. We also found significant variations among geographical contexts. Positive assessments of the care experience were more frequently made by users in remote rural settings; they became progressively less frequent in near-urban rural and near-urban settings, and were found least often in urban settings. We observed these differences in almost all of the components of the care experience.
Conclusion: Given the relatively greater supply of services in urban areas, this analysis has revealed a rural-urban paradox in the care experience of primary health care users.
Australian Journal of Rural Health
Exploratory study examining barriers to participation in colorectal cancer screening
Johanna S. Paddison, Marcus J. Yip
Objective: To examine the Stage of Change distribution for bowel cancer screening in a regional Australian community and the factors associated with varying positions on the continuum of change.
Design: Survey of a convenience sample.
Setting: Community sample.
Participants: A total of 59 (31 male, mean age = 59) service club members from a South Australian regional community.
Main outcome measure: Self-reported Stage of Change for bowel cancer screening behaviour.
Results: Attributing greater embarrassment and discomfort to bowel cancer screening was associated with earlier positions on the Stages of Change. Perceiving that bowel cancer screening might have positive value for personal health was associated with more advanced positions on the continuum of change. Those who perceived breast and prostate screening procedures to be embarrassing or to cause discomfort were significantly less likely to be participating in bowel cancer screening. No significant relationships were found between bowel cancer screening Stage of Change and worry about vulnerability; personal, family or wider social network case reports of bowel cancer; and the population-level value attributed to the cancer screening procedures.
Conclusion: Bowel cancer screening participation rates are currently lower than those associated with breast and prostate screening. Reducing perceptions of embarrassment and discomfort, increasing awareness of potential health benefits and maximising participation in other screening procedures might increase participation in bowel cancer screening.
Mental health and well-being within rural communities: The Australian Rural Mental Health Study
Brian J. Kelly, Helen J. Stain, Clare Coleman, David Perkins, Lyn Fragar, Jeffrey Fuller, Terry J. Lewin, David Lyle, Vaughan J. Carr, Jacqueline M. Wilson, John R. Beard
Objective: This paper outlines the methods and baseline data from a multisite cohort study of the determinants and outcomes of mental health and well-being within rural and remote communities.
Methods: A stratified random sample of adults was drawn in non-metropolitan New South Wales using the Australian Electoral Roll, with the aim of recruiting all adult members of each household. Surveys assessed psychological symptoms, physical health and mental disorders, along with individual-, family/household- and community-level characteristics. A stratified subsample completed a telephone-administered World Mental Health-Composite International Diagnostic Interview (World Mental Health-3.0). Proxy measures of child health and well-being were obtained. Follow up of this sample will be undertaken at one, three and five years.
Results: A total of 2639 individuals were recruited (1879 households), with 28% from remote/very remote regions. A significant relationship was found between recent distress (Kessler-10 scores), age and remoteness, with a linear reduction of Kessler-10 scores with age and the lowest mean scores in remote regions.
Conclusions: Existing rurality categories cannot address the diverse socio-cultural, economic and environmental characteristics of non-metropolitan regions. While it has limitations, the dataset will enable a fine-grained examination of geographic, household and community factors and provide a unique longitudinal dataset over a five-year period.
Distress among rural residents: Does employment and occupation make a difference?
Lyn Fragar, Helen J. Stain, David Perkins, Brian Kelly, Jeffrey Fuller, Clare Coleman, Terry J. Lewin, Jacqueline M. Wilson
Objective: This study investigates the relationship between levels of mental health and well-being (in terms of self-reported levels of distress) with employment and occupational status of rural residents, to better inform the provision of mental health services to those in greatest need in rural communities.
Method: A stratified random sample of community residents in rural and remote New South Wales with over-sampling of remote areas as first stage of a cohort study. Psychological distress was measured using Kessler-10, inclusive of additional items addressing functional impairment (days out of role). Occupational data were classified using Australian and New Zealand Standard Classification of Occupations categories.
Results: A total of 2639 adults participated in this baseline phase. Among them, 57% were in paid employment, 30% had retired from the workforce, 6% were permanently unable to work and 2% were unemployed. The highest levels of distress and functional impairment were reported in those permanently unable to work and the unemployed group with rates of 'caseness' (likely mental health disorder) varying from 57% to 69%, compared with 34% of farmers and farm managers and 29% of health workers (P < 0.01).
Conclusion: The rural unemployed suffer considerable psychological distress and 'disability', yet they are not the target of specific mental health promotion and prevention programs, which are often occasioned by rural adversity, such as drought, and delivered through work-based pathways. Policy-makers and health service providers need to consider the needs of the rural unemployed and those permanently unable to work and how they might be addressed.
Mental health impact for adolescents living with prolonged drought
John G. Dean, Helen J. Stain
Background: A 2004 study showed adolescents living in rural Australia were aware of the impact of drought on self, family and community, but did not report levels of emotional distress higher than adolescents of similar age and gender in the Australian community. It was proposed that the rural lifestyle had helped adolescents build resilience for managing this environmental adversity.
Objective: To re sample adolescents from the same rural area and determine if this resilience remained after ongoing drought three years later.
Design: A mixed methods approach using focus groups and a self-report questionnaire.
Setting: Government Central Schools within the Riverina region of New South Wales.
Participants: Male and female adolescents (n = 111) aged 11-17 years completed the self-report questionnaires, while some adolescents (n = 61) within this group also participated in focus groups.
Main outcome measure: The Strengths and Difficulties Questionnaire and a Drought and Community Survey for Children comprised the self-report survey.
Results: Adolescents reported significantly higher levels of emotional distress than those in the previous study (t (191) = 2.80, P < 0.01) and 12% of adolescents scored in the clinical caseness range. Thematic analysis showed consistency with the previous study as well as new themes of grief, loss and the impacts of global climate change.
Conclusions: Results indicate a reporting of lesser well-being than was reported by a comparable group of young people four years earlier. A preventative intervention with a focus on family and community is recommended to address the mental health of adolescents enduring a chronic environmental adversity such as drought.