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.
Contents: 2010; 26:(4)
Defining 'Rural' for Veterans' Health Care Planning
Alan N. West, Richard E. Lee, Michael D. Shambaugh-Miller, Byron D. Bair, Keith J. Mueller, Ryan S. Lilly, Peter J. Kaboli and Kara Hawthorne
Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories.
Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans.
Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care.
Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans' health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.
Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural Veterans
Thad E. Abrams, Mary Vaughan-Sarrazin and Peter J. Kaboli
Introduction: Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition.
Methods: This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals. Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system. Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables.
Results: URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas. Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems. Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 0.96; 95% CI, 0.94-1.00) and highly rural veterans (HR, 1.13; 0.96-1.31) relative to urban veterans. In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 0.89; 0.83-0.95) as well as veterans from isolated towns (HR, 0.86; 0.78-0.93).
Conclusion: Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized. These findings suggest potentially lower rates of revascularization for rural veterans.
The Rural-Urban Divide: Health Services Utilization Among Older Mexicans in Mexico
Jennifer J. Salinas, Soham Al Snih, Kyriakos Markides, Laura A. Ray and Ronald J. Angel
Purpose: Using the health care service utilization model as a framework, this paper will analyze the differences in health care service use among older Mexicans living in urban and rural areas in Mexico.
Methods: The Mexican Health and Aging Survey (MHAS) data were used to test the applicability of Andersen's 'model of health services' of predisposing (ie, age, sex, etc.), enabling (education, insurance coverage, etc.) and need factors (diabetes, hypertension, etc.) to predict ever being in the hospital and physician visits in the past year by place of residence (urban, rural, semi-rural).
Findings: Results showed that older Mexicans living in the most rural areas (populations of 2,500 or fewer) were significantly less likely to have been hospitalized in the previous year and visited the physician less often (P < .0001) than their urban counterparts. The significant difference in hospitalization between rural and urban residing older Mexicans was largely accounted for by having health care coverage. Certain need factors such as diabetes, previous heart attack, hypertension, depression, and functional limitations predicted frequency of physician visits and hospitalization, but they did not explain variations between rural and urban older Mexicans.
Conclusions: Not having insurance coverage was associated with a lower likelihood of spending an overnight visit in the hospital and visiting a physician for older Mexicans. This lower utilization may be due to barriers to access rather than better health.
An Examination of Triple Jeopardy in Rural Youth Physical Activity Participation
Kindal A. Shores, Justin B. Moore and Zenong Yin
Purpose: Chances for a healthy life are not equally distributed across society. Instead, genetic, social, and environmental factors help determine the probability that a child will be healthy and active. We investigate the probability that youth will be physically active by examining 3 consistent correlates of physical activity. The individual and interaction effects of self-efficacy, social support, and access to physical activity areas are used to predict rural youth physical activity participation. We hypothesize that youth lacking all 3 activity supports will be in 'triple jeopardy' for physical activity participation.
Methods: Data were collected using a researcher-administered questionnaire with 147 youth in 2004. Youth ages 9-18 were enrolled in grades 4, 7, and 11 in 2 diverse rural counties in Georgia.
Findings: Overall, a greater number of disadvantageous statuses were related to a lower probability of physical activity participation. Low self-efficacy, low social support, and no access to physical activity areas were related to lower levels of physical activity participation among rural youth. These variables exerted a stronger impact when factors were allowed to interact than when their isolated effects were summed.
Conclusions: This study assessed correlates of physical activity among rural youth. These investigations, while scarce, can help identify subgroups of the population that may need to be targeted for intervention. Findings indicate that lived experience of youth (captured by the interaction of physical activity correlates) may be critical for understanding patterns of active and sedentary living.
Rural-Urban Disparities in Child Abuse Management Resources in the Emergency Department
Esther K. Choo, David M. Spiro, Robert A. Lowe, Craig D. Newgard, Michael Kennedy Hall and Kenneth John McConnell
Purpose: To characterize differences in child abuse management resources between urban and rural emergency departments (EDs).
Methods: We surveyed ED directors and nurse managers at hospitals in Oregon to gain information about available abuse-related resources. Chi-square analysis was used to test differences between urban and rural EDs. Multivariate analysis was performed to examine the association between a variety of hospital characteristics, in addition to rural location, and presence of child abuse resources.
Findings: Fifty-five Oregon hospitals were surveyed. A smaller proportion of rural EDs had written abuse policies (62% vs 95%, P= .006) or on-site child abuse advocates (35% vs 71%, P= .009). Thirty-two percent of rural EDs had none of the examined abuse resources (vs 0% of urban EDs, P= .01). Of hospital characteristics studied in the multivariate model, only rural location was associated with decreased availability of child abuse resources (OR 0.19 [95% CI, 0.05-0.70]).
Conclusions: Rural EDs have fewer resources than urban EDs for the management of child abuse. Other studied hospital characteristics were not associated with availability of abuse resources. Further work is needed to identify barriers to resource utilization and to create resources that can be made accessible to all ED settings.
Impact of Long Farm Working Hours on Child Safety Practices in Agricultural Settings
Barbara Marlenga, Punam Pahwa, Louise Hagel, James Dosman and William Pickett
Objectives: To characterize working hours of adult farm owner-operators and their spouses by season, and to examine associations between working hours and farm safety practices affecting children.
Methods: We conducted a secondary analysis of cross-sectional survey data collected as part of an existing study of injury and its determinants.
Results: Owner-operators reported a median of 60 to 70 hours of farm work per week during warm weather months, with declines in hours over the winter. Spouses reported similar seasonal patterns, although their median reported hours were much lower. Longer farm working hours by owner-operators were marginally associated with increased exposure of teenagers to farm work hazards. Exposures of young children to worksite hazards rose in association with longer farm working hours by spouses.
Conclusion: Exposures of children to farm worksite hazards and demands may be consequences of adult long working hours.
County-Level Poverty Is Equally Associated With Unmet Health Care Needs in Rural and Urban Settings
Lars E. Peterson and David G. Litaker
Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear.
Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting.
Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics.
Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings.
Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.
Pollution Sources and Mortality Rates Across Rural-Urban Areas in the United States
Michael Hendryx, Evan Fedorko and Joel Halverson
Purpose: To conduct an assessment of rural environmental pollution sources and associated population mortality rates.
Methods: The design is a secondary analysis of county-level data from the Environmental Protection Agency (EPA), Department of Agriculture, National Land Cover Dataset, Energy Information Administration, Centers for Disease Control and Prevention, the US Census, and others. We described the types of pollution sources present in metropolitan and nonmetropolitan counties and examined the associations between these sources and rates of all-cause, cardiovascular, respiratory, and cancer mortality while controlling for age, race, and other covariates.
Findings: Rural counties had 65,055 EPA-monitored pollution discharge sites. As expected, rural counties had significantly greater exposure to potential agriculture-related pollution. Regression models specific to rural counties indicated that greater density of water pollution sources was significantly associated with greater total and cancer mortality. Rural air pollution sources were associated with greater cancer mortality rates. Rural coal mining areas had higher total, cancer, and respiratory disease mortality rates. Agricultural production was generally associated with lower mortality rates. Greater levels of human development were significantly related to higher adjusted total and cancer mortality.
Conclusions: The association between pollution sources and mortality risk is not a phenomenon limited to metropolitan areas. Results carry policy implications regarding the need for effective environmental standards and monitoring. Further research is needed to better understand the types and distributions of pollution in rural areas, and the health consequences that result.
Does Rurality Affect Quality of Life Following Treatment for Breast Cancer?
Stephanie A. Reid-Arndt and Cathy R. Cox
Purpose: The present research examined the extent to which rural residence and social support seeking are associated with quality of life (QOL) among breast cancer patients following chemotherapy.
Methods: Female breast cancer patients (n = 46) from communities of varying degrees of rurality in a Midwestern state completed psychological and QOL measures at 1-month postchemotherapy. Analyses assessed the relationships between QOL outcomes, rurality, and social support seeking.
Findings: Using age and education as covariates, regression analyses were conducted to determine the extent to which QOL was related to social support seeking and rural/urban residence. Analyses revealed that social support seeking was associated with lower scores on multiple indices of QOL, and it was associated with higher self-reported symptoms of depression. Several significant associations with rural/urban residence were noted as well. Specifically, increasing rurality, as defined by USDA Rural-Urban continuum codes, was associated with lower overall QOL, lower functional well-being, and increased complaints of breast cancer specific symptoms.
Conclusions: These findings highlight the relevance of continued efforts to address social support needs among women with a history of breast cancer living in rural and urban communities. They also suggest that individuals in more rural communities may be at risk for lowered QOL in the early period following cancer treatment. Future research is needed to replicate these results with larger and more diverse samples of rural and urban dwelling individuals, and to determine whether these effects may be attributed to identifiable characteristics of rural communities (eg, fewer cancer-related resources).
Journal Canadien de la Médecine Rural/ Canadian Journal of Rural Medicine
[in French and English]
Contents: 2010; 15:(4)
Secondary stroke prevention best practice recommendations: exploring barriers for rural family physicians
Grace Warner, Jessie Harrold, BSc, Michael Allen, Renee Lyons
Introduction: Patients' risk of having a second stroke can be substantially reduced by implementing best practice recommendations for secondary stroke prevention. However, evidence indicates that rural practitioners may face barriers to implementing these recommendations into their practices. This research project developed a workshop to increase practitioner awareness of the recommendations, and to identify barriers to the application of recommendations for secondary prevention of stroke in rural practices.
Methods: The workshop provided a venue for family physicians, specialists and health district representatives to discuss the recommendations. It was evaluated using a sequential explanatory mixed-methods approach using 3 methods of data collection: a questionnaire, documentation of comments made during discussion periods and post-workshop interviews.
Results: Participants at the workshop increased their awareness of the recommendations, and they gained an increased appreciation of how they might collaborate with other practitioners and the health district to implement the recommendations. The workshop identified barriers to implementing recommendations, such as miscommunications with the local health district, role conflict among physicians regarding health promotion and difficulties coordinating care with specialists.
Conclusion: The workshop was an effective venue for improving communication between physicians and the health district and for reducing barriers to the implementation of recommendations.
Rural-urban differences in emergency department wait times
Introduction: I sought to determine whether emergency department (ED) volume is associated with differing ED wait times.
Methods: I conducted a retrospective analysis of the Emergency Department Reporting System database of the Ontario Ministry of Health. I abstracted ED length of stay for patient visits to 117 hospital EDs during the second quarter of 2008, representing 89% of ED visits in the province during that period. Annual volume of ED visits, lengths of stay in the ED and acuity levels of patients were measured.
Results: All EDs were more efficient in managing the treatment of low-acuity patients compared with high-acuity patients. Small rural EDs in Ontario had the shortest wait times for both high- and low-acuity patients (medians 2.35 h for high-acuity and 1.46 h for low-acuity patients in small rural EDs v. 4.98 h for high-acuity and 2.85 h for low acuity patients in teaching hospitals).
Conclusion: Among the hospitals studied, rural EDs had the shortest wait times for both low- and high-acuity patients.
What is the financial state of medical students from rural backgrounds during tuition fee deregulation?
Wayne Woloschuk, Jean-François Lemay, Bruce Wright
Introduction: We sought to examine the financial state of medical students from rural backgrounds during a time of tuition fee deregulation.
Methods: We surveyed incoming classes from 2007 to 2011 at the University of Calgary. Community background, expected educational debt at graduation, educational debt at entry to medical school and parental income were collected for analysis. Data were analyzed using the χ2 test, analysis of variance and the Newman-Keuls multiple comparison test.
Results: The overall response rate was 95.3%. Of the 571 (93.5%) respondents who supplied data on their background and debt, 94.4% expected to have educational debt at graduation. The mean projected educational debt at graduation by medical students from both rural ($107 226 [95% confidence interval (CI) $98 030-$116 423]) and regional ($99 456 [95% CI $91 905-$107 006]) backgrounds was significantly greater than the debt projected by students from metropolitan ($88 565 [95% CI $83 607-$93 524]) backgrounds. Medical students who came from rural backgrounds had the highest mean debt at entry to medical school ($33 053 [95% CI $25 715-$40 391]) compared with their peers from regional ($23 253 [95% CI $16 621-$29 885]) and metropolitan ($22 053 [95% CI $17 344-$26 762]) backgrounds. Students of rural origin also had parents whose mean income ($104 024 [95% CI $75 976-$132 173]) was significantly lower than the mean parental income of their peers who originated from regional ($143 167 [95% CI $119 898-$166 435]) and metropolitan ($150 339 [95% CI $135 241-165 438]) centres.
Conclusion: Rising tuition and subsequent debt may be affecting the diversity of medical students' backgrounds. Financial programs dedicated to rural-background students and their interest in medicine may become necessary.
Contents: 2010; 18:(3)
Is a global rural and remote health research agenda desirable or is context supreme?
Jane Farmer, Ann Clark and Sarah-Anne Munoz
Objective: This paper proposes that there is value in international comparison of rural and remote health-care service delivery models because of practical reasons - to find ideas, models and lessons to address 'local' delivery challenges; and for theoretical reasons - to derive a conceptual framework for international comparison.
Methods: Literature review and commentary.
Findings: There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care.
Conclusions: The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.
Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence-based policy
Penny Buykx, John Humphreys, John Wakerman and Dennis Pashen
Background: Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care.
Objective: This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia.
Design: A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria.
Results: While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required.
Conclusions: This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre- and post-intervention comparisons.
Review of rural and regional alcohol research in Australia
Peter G. Miller, Kerri Coomber, Petra Staiger, Lucy Zinkiewicz and John W. Toumbourou
Introduction: Alcohol is the most commonly used drug within Australia. Recently, there have been indications that there is a greater incidence of high-risk drinking within rural populations as compared with their urban counterparts. High-risk drinking is associated with numerous conditions, such as diabetes, heart attack and cancer, as well as acute harms such as assault, suicide and road accidents. The objective of this article is to review the current research and relevant data pertaining to alcohol use and alcohol-related harms within rural Australia.
Methods: This paper is a systematic review of 16 databases, including PubMed, PsycINFO and Google Scholar.
Results: Overall, 18 studies describing alcohol consumption or alcohol-related harms were found. Approximately half of these studies were large-scale national population surveys, which were therefore limited in their representativeness of specific regional and rural towns. Most studies examining alcohol consumption used self-report data collection, meaning that interpretation of results needs to be tentative. There is a consistent pattern of higher rates of alcohol consumption and consequent harm within regional and rural Australia than in urban areas.
Conclusions: There is emerging research examining alcohol consumption and alcohol-related harms within regional and rural Australia. All studies show that these populations experience disproportionate harm because of alcohol consumption. The causes and mechanism for this have not been investigated, and a program of research is required to understand how and why rural populations experience disproportionate levels of alcohol-related harm and ultimately, what interventions will be most effective in reducing alcohol-related harms.
Healthy minds for country youth: Help-seeking for depression among rural adolescents
Andrea Hernan, Benjamin Philpot, Anne Edmonds and Prasuna Reddy
Objective: To assess depression recognition, barriers to accessing help from health professionals and potential sources of help for depression among rural adolescents.
Design: Cross-sectional survey.
Setting: Two rural secondary schools in south-east South Australia.
Participants: Seventy-four secondary school students aged 14 to 16 years.
Main outcome measure(s): Depression recognition was measured using a depression vignette. Helpfulness of professionals, barriers to seeking help and help-seeking behaviours for depression were assessed by self-report questionnaire.
Results: Depression was identified in the vignette by 73% (n = 54) of participants. Participants indicated that it would be more helpful for the vignette character to see other health professionals (98.6%, 95% CI, 92.0-100.0%) than a doctor (82.4%, 72.1-89.6%). Barriers to seeking help from doctors and other health professionals were categorised into logistical and personal barriers. Participants agreed more strongly to personal (mean = 2.86) than logistical barriers (mean = 2.67, P < 0.05) for seeing a doctor. Boys and girls responded differently overall, and to personal barriers to seeing an other health professional. Sources of help were divided into three categories: formal, informal and external. Informal sources of help (mean = 4.02) were identified as more helpful than both formal (mean = 3.66) and external sources (mean = 3.72, P < 0.001). Gender differences were observed within and between the three sources of help categories.
Conclusions: Recognising symptoms of depression was demonstrated in this study. Helpfulness of professionals, barriers to seeking help and potential sources of help for depression were identified. More work is required for improving depression literacy and providing effective interventions specifically for rural adolescents.
Women living in a remote Australian mining community: Exploring their psychological well-being
Jane Lovell and Jennifer Critchley
Objective: To explore the factors believed to influence the psychological well-being of women living in a modern remote Australian mining community.
Design: A qualitative phenomenological study conducted through focus group discussions.
Setting: Remote Australian mining town.
Participants: Sixteen women living in a remote Australian mining town with a partner undertaking shiftwork at one of the local mines.
Main outcome measures: Women in a remote Australian mining community revealed, through focus group discussion, the factors influencing their psychological well-being.
Results: Four themes were identified to be of importance for the women. These were the impacts of mining work, isolation, culture and the social environment on their happiness and well-being, and that of their families and the broader community.
Conclusions: Psychological well-being of women in a remote mining community might be improved through better local medical services, increased efforts at social inclusion and community connectedness, greater access to child care and better community infrastructure and pleasant surrounds. The findings also question the stereotypes of strong masculinist cultures and limited activities and services in such communities. Further research is highly recommended.