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:(3)
The Association Between Rural Residence and the Use, Type, and Quality of Depression Care
John C. Fortney, Jeffrey S. Harman, Stanley Xu, Fran Dong
Objective: To assess the association between rurality and depression care.
Methods: Data were extracted for 10,319 individuals with self-reported depression in the Medical Expenditure Panel Survey. Pharmacotherapy was defined as an antidepressant prescription fill, and minimally adequate pharmacotherapy was defined as receipt of at least 4 antidepressant fills. Psychotherapy was defined as an outpatient counseling visit, and minimally adequate psychotherapy was defined as ≥ 8 visits. Rurality was defined using Metropolitan Statistical Areas (MSAs) and Rural Urban Continuum Codes (RUCCs).
Results: Over the year, 65.1% received depression treatment, including 58.8% with at least 1 antidepressant prescription fill and 24.5% with at least 1 psychotherapy visit. Among those in treatment, 56.2% had minimally adequate pharmacotherapy treatment and 36.3% had minimally adequate psychotherapy treatment. Overall, there were no significant rural-urban differences in receipt of any type of formal depression treatment. However, rural residence was associated with significantly higher odds of receiving pharmacotherapy (MSA: OR 1.16 [95% CI, 1.01-1.34; P= .04] and RUCC: OR 1.04 [95% CI, 1.00-1.08; P= .05]), and significantly lower odds of receiving psychotherapy (MSA: OR 0.62 [95% CI, 0.53-0.74; P < .01] and RUCC: OR 0.91 [95% CI, 0.88-0.94; P < .001]). Rural residence was not significantly associated with the adequacy of pharmacotherapy, but it was significantly associated with the adequacy of psychotherapy (MSA: OR 0.53 [95% CI, 0.41-0.69; P < .01] and RUCC: OR 0.92 [95% CI, 0.86-0.99; P= .02]). Psychiatrists per capita were a mediator in the psychotherapy analyses.
Conclusions: Rural individuals are more reliant on pharmacotherapy than psychotherapy. This may be a concern if individuals in rural areas turn to pharmacotherapy because psychotherapists are unavailable rather than because they have a preference for pharmacotherapy.
Access to Rural Mental Health Services: Service Use and Out-of-Pocket Costs
Erika C. Ziller, Nathaniel J. Anderson, Andrew F. Coburn
Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services.
Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type.
Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services.
Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.
Definition of "Rural" Determines the Placement Outcomes of a Rural Medical Education Program: Analysis of Jichi Medical University Graduates
Masatoshi Matsumoto, Kazuo Inoue, Eiji Kajii
Purpose: To show the impact of changing the definition of what is "rural" on the outcomes of a rural medical education program.
Methods: A cross-sectional sample of 643 graduates under obligatory rural service and 1,699 graduates after serving their obligation, all from Jichi Medical University (JMU), a binding rural education program in Japan, were used as the data source. Communities were divided into decile groups according to population density, and the cut-off for "rural/nonrural" was altered in order to study its impact on the data.
Findings: The rural practice rate of obliged graduates had its peak in the decile groups with the lowest population densities, while the peak rates of postobligation graduates and non-JMU physicians were at the decile groups with the highest population densities. Rural practice rates of all of the 3 groups of physicians increased with the increase in inclusiveness of rural definition. The ratio of rural practice rate of obliged graduates to that of non-JMU physicians ("relative effectiveness") increased remarkably with the increase in exclusiveness of rural definition. The relative effectiveness of postobligation graduates did not substantially increase after the cut-off exceeded a certain point of exclusiveness.
Conclusions: Definition of "rural" largely determined the rural practice rate and relative effectiveness of JMU graduates. The results suggest that results of past outcome studies of rural medical education programs are potentially biased depending on how rural is defined.
HIV Testing and HIV/AIDS Treatment Services in Rural Counties in 10 Southern States: Service Provider Perspectives
Madeline Sutton, Monique-Nicole Anthony, Christie Vila, Eleanor McLellan-Lemal, Paul J. Weidle
Context: Forty percent of AIDS cases are reported in the southern United States, the region with the largest proportion of HIV/AIDS cases from rural areas. Data are limited regarding provider perspectives of the accessibility and availability of HIV testing and treatment services in southern rural counties.
Purpose: We surveyed providers in the rural south to better understand: (1) the accessibility and availability, and (2) the facilitators and barriers of HIV testing and treatment services.
Methods: All county health departments (N = 326) serving populations of <50,000 persons, within 10 southern states, were mailed surveys. Responding health departments identified up to 3 HIV testing sites and up to 3 HIV treatment sites to which they refer clients.
Findings: Overall, 243 of 326 (75%) health departments, 133 of 250 (53%) HIV testing sites, and 73 of 152 (48%) HIV treatment sites responded to the surveys. The number of testing sites per county ranged from 0 to 20; the number of treatment sites ranged from 0 to 4. An average distance of 50 miles for clients to travel for HIV treatment was reported by health department respondents as a barrier. Facilitators of HIV testing were (1) integrating HIV testing into other health services; (2) using rapid HIV testing; and (3) establishing easily accessible HIV testing locations and free testing services.
Conclusion: Providers perceive that distance from local health departments to HIV treatment sites presents a barrier to HIV care for their clients. Future studies should ascertain clients' perspectives to ensure appropriate service provisions.
The Role of Interorganizational Partnerships in Health Services Provision Among Rural, Suburban, and Urban Local Health Departments
Kate Beatty, Jenine K. Harris, Priscilla A. Barnes
Context: With limited resources and increased public health challenges facing the US, the Centers for Disease Control and Prevention and others have identified partnerships between local health departments (LHDs) and nongovernmental organizations (NGOs) as critical to the public health system. LHDs utilize financial, human, and informational resources and develop partnerships with local NGOs to provide public health services.
Purpose: Our study had 2 primary goals: (1) compare resources and partnerships characterizing rural, suburban, and urban LHDs, and (2) determine whether partnerships play a mediating role between LHD resources and the services LHDs provide.
Methods: We conducted secondary data analysis using the National Association of County and City Health Officials 2005 Profile Study. We used chi-squared and analysis of variance (ANOVA) to examine differences between rural, suburban, and urban LHDs. We used regression-based mediation methods to test whether partnerships mediated the relationship between resources and service provision.
Findings: We found significant differences between LHDs. Urban LHDs serve larger jurisdictions, have larger budgets and more staff, cultivate more partnerships with local NGOs, and provide more health services than suburban or rural LHDs. We found that partnerships were a partial mediator between resources and service provision. In playing a mediating role, partnerships reduce differences in service provision between rural, suburban, and urban LHDs.
Conclusions: Partnerships mediate the relationship between resources and service provision in LHDs. LHDs could place more emphasis on cultivating relationships with local NGOs in order to increase service provision. This strategy may be especially useful for rural LHDs facing limited resources and numerous health disparities.
The Effectiveness and Cost-Effectiveness of a Rural Employer-Based Wellness Program
Shadi S. Saleh, Mohamad S. Alameddine, Dan Hill, Jessica Darney-Beuhler, Ann Morgan
Context: The cost-effectiveness of employer-based wellness programs has been previously investigated with favorable financial and nonfinancial outcomes being detected. However, these investigations have mainly focused on large employers in urban settings. Very few studies examined wellness programs offered in rural settings.
Purpose: This paper aims to explore the effectiveness and cost-effectiveness of a rural employer-based wellness program.
Methods: Six rural employers were categorized into 3 groups: a control group and 2 intervention groups with varying degrees of wellness activities. Participants were asked to complete an annual health risk assessment (HRA) that addressed 16 wellness areas. At the conclusion of 4 years, HRA and effectiveness data were utilized to examine program effectiveness and combined with program costs to estimate cost-effectiveness.
Findings: The "Coaching and Referral" group-the highest in intensity of participant engagement-exhibited superior improvement in several wellness areas and in percentage of employees with good health indicators compared to the control and the Trail Marker, lower-intensity intervention groups. However, the Trail Markers had more favorable cost-effectiveness ratios.
Conclusions: Rural worksite wellness programs have shown great potential in their effectiveness and cost-effectiveness. Such programs need not be too aggressive, tedious, and costly to generate a favorable return for employers and funders. However, employers should be encouraged to experiment with different levels of wellness program intensities until a more favorable outcome can be realized.
Effectiveness of a Lifestyle Intervention Program Among Persons at High Risk for Cardiovascular Disease and Diabetes in a Rural Community
Liane M. Vadheim, Kari A. Brewer, Darcy R. Kassner, Karl K. Vanderwood, Taryn O. Hall, Marcene K. Butcher, Steven D. Helgerson, Todd S. Harwell
Purpose: To evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in a rural community.
Methods: In 2008, the Montana Diabetes Control Program worked collaboratively with Holy Rosary Healthcare to implement an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (N = 101). Participants set targets to reduce fat intake and increase physical activity (≥150 mins/week) in order to achieve a 7% weight loss goal.
Findings: Eighty-three percent (n = 84) of participants completed the 16-session core program and 65 (64%) participated in 1 or more after-core sessions. Of those completing the core program, the mean participation was 14.4 ± 1.6 and 3.9 ± 1.6 sessions during the core and after core, respectively. Sixty-five percent of participants met the 150-min-per-week physical activity goal during the core program. Sixty-two percent achieved the 7% weight loss goal and 78% achieved at least a 5% weight loss during the core program. The average weight loss per participant was 7.5 kg (range, 0 to 19.7 kg), which was 7.5% of initial body weight. At the last recorded weight in the after core, 52% of participants had met the 7% weight loss goal and 66% had achieved at least a 5% weight loss.
Conclusion: Our findings suggest that it is feasible to implement a group-based DPP in a rural community and achieve weight loss and physical goals that are comparable to those achieved in the DPP.
Practicing Preventive Health: The Underlying Culture Among Low-Income Rural Populations
Mary W. Murimi, Tammy Harpel
Context: Health disparities on the basis of geographic location, social economic factors and education levels are well documented. However, even when health care services are available, there is no guarantee that all persons will take preventive health measures. Understanding the cultural beliefs, practices, and lifestyle choices that determine utilization of health services is an important factor in combating chronic diseases.
Purpose: The purpose of this study was to investigate personal, cultural, and external barriers that interfered with participating in a community-based preventive outreach program that included health screening for obesity, diabetes, heart diseases, and hypertension when cost and transportation factors were addressed.
Methods: Six focus groups were conducted in a rural community of Louisiana. Focus groups were divided into 2 categories: participants and nonparticipants. Three focus groups were completed with Dubach Health Outreach Project (DUHOP) participants and 3 were completed with nonparticipants. The focus group interviews were moderated by a researcher experienced in focus group interviews; a graduate student assisted with recording and note-taking during the sessions.
Findings: Four main themes associated with barriers to participation in preventive services emerged from the discussions: (1) time, (2) low priority, (3) fear of the unknown, and (4) lack of companionship or support. Health concerns, free services, enjoyment, and free food were identified as motivators for participation.
Conclusions: The findings of this study indicated that the resulting synergy between low-income status and a lack of motivation regarding health care prevention created a complicated practice of health care procrastination, which resulted in unnecessary emergency care and disease progression. To change this practice to proactive disease prevention and self care, a concerted effort will need to be implemented by policy makers, funding agents, health care providers, and community leaders and members.
Self-Assessed Disability and Self-Rated Health Among Rural Villagers in Peru: A Brief Report
James E. Rohrer, Stephen P. Merry, Thomas D. Thacher, Matthew R. Summers, Jonathan D. Alpern, Robert W. Contino
Context: Risks for poor self-rated overall health in rural areas of developing nations have not been thoroughly investigated.
Purpose: The objective of this study was to assess potential risk factors for poor self-rated health among rural villagers in Peru.
Methods: A door-to-door survey of villagers residing in the Pampas Grande region in Peru, which is in the Andes Mountains, yielded complete data for 337 adults.
Findings: Adjusting for age and gender using multiple logistic regression analysis revealed that having self-reported disabilities was inversely and independently related to good self-rated health (OR 0.48 [95% CI, 0.26-0.88]). Joint pain also was related to self-rated health (OR 0.23 [95% CI, 0.13-0.41]).
Conclusions: Increasing access to affordable, effective analgesics may reduce this disparity. Health agencies should consider these actions as possible planning priorities for the region.
Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]
Contents: 2010; 15:(3)
Recruitment trumps retention: results of the 2008/09 CMA Rural Practice Survey
Tara S. Chauhan, Michael Jong, Lynda Buske
Introduction: In 2008, the Canadian Medical Association (CMA) conducted a survey of rural practitioners. The survey covered incentives to choose rural medicine, current satisfaction, plans for future migration and strategies for retention.
Methods: The CMA Canadian Collaborative Centre for Physician Resources, in collaboration with the Society of Rural Physicians of Canada, surveyed 1960 rural practitioners and received 642 responses (33% response rate). Because of similarities with earlier surveys, longitudinal analyses were possible.
Results: More than 70% of physicians older than 45 years received no incentives for setting up rural practice, compared with 41% of younger physicians. Younger physicians attached greater importance to financial incentives than older physicians, but personal incentives, such as accommodations in the community, were also important. The opportunity to practise one's full skill set was considered important (84%) as was liking the lifestyle (82%). One in 7 (14%) respondents planned to move from their communities within the next 2 years. They reported they might stay if they had a more reasonable workload, professional backup and locums.
Conclusion: Although increasingly common, cash incentives are not the main reason physicians choose rural practice. Practice and lifestyle factors are even more important. Communities need to focus as much on retention issues to protect their investment in the long term.
Bounce-back visits in a rural emergency department
Allison Foran, Becky Wuerth-Sarvis, W. Ken Milne
Introduction: The rate of return visits at urban emergency departments (EDs) has been reported as approximately 3% within 72 hours of discharge. However, the current literature does not indicate the rate of return visits for rural EDs. The purpose of this study was to determine the bounce-back rate at a rural ED and to characterize the visits.
Methods: A retrospective chart review was performed on all visits to the ED of the South Huron Hospital between Apr. 1, 2007, and Mar. 31, 2008. Charts were reviewed for patient age, Canadian Emergency Department Triage and Acuity Scale (CTAS) score, most common diagnoses and discharge disposition for each visit.
Results: Of the 9935 ED visits during this 12-month period, 289 (2.9%) were return visits within 72 hours. Median patient age was 46 years. The most common CTAS score for return visits was CTAS-IV (45.3%). The most common diagnosis was unspecified abdominal pain (4.0%). Most patients (88.6%) were treated in the ED and discharged home.
Conclusion: This study demonstrates that the bounce-back rate at a rural ED is similar to that at an urban ED. Most return visits are for low-acuity conditions, and unspecified abdominal pain represents the most common return diagnosis.
Australian Journal of Rural Health
Charting the future course of rural health and remote health in Australia: Why we need theory
Lisa Bourke, John S. Humphreys, John Wakerman, Judy Taylor
Objective: This paper argues that rural and remote health is in need of theoretical development.
Design: Based on the authors' discussions, reflections and critical analyses of literature, this paper proposes key reasons why rural and remote health warrants the development of theoretical frameworks.
Results: The paper cites five reasons why theory is needed: (i) theory provides an approach for how a topic is studied; (ii) theory articulates key assumptions in knowledge development; (iii) theory systematises knowledge, enabling it to be transferable; (iv) theory provides predictability; and (v) theory enables comprehensive understanding.
Conclusion: This paper concludes with a call for theoretical development in both rural and remote health to expand its knowledge and be more relevant to improving health care for rural Australians.
From rural beginnings to statewide roll-out: Evaluation of facilitator training for a group-based diabetes prevention program
Clare Vaughan, Prasuna Reddy, James Dunbar
Objective: To evaluate the approach used to train facilitators for a large-scale group-based diabetes prevention program developed from a rural implementation research project.
Participants: Orientation day was attended by 224 health professionals; 188 submitted the self-learning task; 175 achieved the satisfactory standard for the self-learning task and attended the workshop; 156 completed the pre- and post-training questionnaires.
Main outcome measures: Two pre- and post-training scales were developed to assess knowledge and confidence in group-based diabetes prevention program facilitation. Principal component analysis found four factors for measuring training effectiveness: knowledge of diabetes prevention, knowledge of group facilitation, confidence to facilitate a group to improve health literacy and confidence in diabetes prevention program facilitation. Self-learning task scores, training discontinuation rates and satisfaction scores were also assessed.
Results: There was significant improvement in all four knowledge and confidence factors from pre- to post-training (P < 0.001). The self-learning task mean test score was 88.7/100 (SD = 7.7), and mean assignment score was 72.8/100 (SD = 16.1). Satisfaction with training scores were positive and 'previous training' interacted with 'change in knowledge of diabetes prevention program facilitation' but not with change in 'confidence to facilitate.'
Conclusions: The training program was effective when analysed by change in facilitator knowledge and confidence and the positive mean satisfaction score. Learning task scores suggest tasks were manageable and the requirement contributed to facilitator self-selection. Improvement in confidence scores in facilitating a group-based diabetes prevention program, irrespective of previous training and experience, show that program-specific skill development activities are necessary in curriculum design.
Urban-rural differences in psychiatric rehabilitation outcomes
Srinivasan Tirupati, Agatha Conrad, Barry Frost and Suzanne Johnston
Objective: Employing rural and urban patient populations, the aim of the study was to examine the differences in rehabilitation intervention outcomes, particularly in regard to the social and clinical determinants.
Design: The study employed a retrospective, cross-sectional analysis of patient outcome and characteristics.
Setting: Community-based psychiatric rehabilitation service in regional and rural Australia.
Participants: A total of 260 patients were included in the service evaluation phase of the study and 86 in the second part of the study. Participants were community-based and suffered from a chronic mental illness.
Main outcome measure(s): Clinical and functional outcomes were measured using the Health of Nations Outcome Scale and the 16-item Life Skills Profile. The outcome score employed was the difference between scores at intake and at the last complete assessment. Clinical and sociodemographic characters were recorded using a proforma developed for the study.
Results: Patients from rural Maitland had a significantly larger mean reduction in total scores and classified more often as 'Improved' on both the Health of Nations Outcome Scale and Life Skills Profile than patients from either of the urban areas (P < 0.01). Study of randomly selected patients showed that those from an urban area had a more complex illness with multiple needs and less often received family support than their rural counterparts.
Conclusions: For rural communities the improvement in rehabilitation outcomes might be attributable to a more benign form of the illness and the availability of higher levels of social capital.
Evaluation of a mobile screening service for abdominal aortic aneurysm in Broken Hill, a remote regional centre in far western NSW
Margaret S. Lesjak, Stephen C. Flecknoe-Brown, Jan R. Sidford, Kerryn Payne, John P. Fletcher, David M. Lyle
Objectives: To evaluate the feasibility of a mobile screening service model for abdominal aortic aneurysm (AAA) in a remote population centre in Australia.
Design: Screening test evaluation.
Setting: A remote regional centre (population: 20 000) in far western NSW.
Participants: Men aged 65-74 years, identified from the Australian Electoral roll.
Interventions: A mobile screening service using directed ultrasonography, a basic health check and post-screening consultation.
Main outcome measures: Attendance at the screening program, occurrence of AAA in the target population and effectiveness of screening processes.
Results: A total of 516 men without a previous diagnosis of AAA were screened, an estimated response rate of 60%. Of these, 463 (89.7%) had a normal aortic diameter, 28 (5.4%) ectatic and 25 (4.9%) a small, moderate or significant aneurysm. Two men with AAA were recommended for surgery. Feedback from participants indicated that the use of a personalised letter of invitation helped with recruitment, that the screening process was acceptable and the service valued.
Conclusions: It is feasible to organise and operate a mobile AAA screening service from moderate sized rural and remote population centres. This model could be scaled up to provide national coverage for rural and remote residents.
Availability of antidotes for the treatment of acute poisoning in Queensland public hospitals
Lisa M. Nissen, Kai Hang Wong, Anthea Jones, Darren M. Roberts
Objective: To determine the sufficiency of stock levels of 13 antidotes in Queensland hospitals.
Design: A self-report survey was sent to 128 Queensland hospitals with acute care facilities. The stock level of the following antidotes was determined: acetylcysteine, anti-digoxin Fab antibodies (digibind), atropine, calcium gluconate, cyanokit, desferrioxamine, flumazenil, glucagon, intravenous ethanol, methylene blue, naloxone, pralidoxime and pyridoxine. Other factors sampled were bed capacity, rural, remote and metropolitan areas classification, use of formal stock reviews by pharmacists or nurses, existence of formal borrowing agreements with other facilities for non-stocked antidotes, distance to the nearest referral hospital and time taken to transfer antidotes from another hospital.
Participants: Pharmacists or nurses responsible for maintaining antidote stocks in Queensland hospitals.
Main outcome measures: Proportions of hospitals with sufficient antidote stock to treat a 70-kg adult for four or more hours using previously published guidelines.
Results: Survey response rate was 73.4%. No hospital had sufficient stock of all 13 antidotes. The proportion of hospitals with sufficient stocks varied from 0% (pyridoxine) to 68.1% (acetylcysteine). Larger hospitals had a higher frequency of sufficient antidote stocks. Only 16% of hospitals claimed to be able to acquire an antidote from another facility within 30 min.
Conclusions: Most Queensland hospitals stocked some important antidotes, but few had sufficient stock to treat a 70-kg patient or acquire an antidote within the recommended time frame of 30 min. Specific antidote stocking guidelines might be required for Queensland hospitals. A formalised program for stock rotation with rural facilities should be explored.