Journal Search

Journal Search - issue 1, 2011


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


31 March 2011 Volume 11 Issue 1


RECEIVED: 30 March 2011

ACCEPTED: 31 March 2011


Richmond J.  Journal Search - issue 1, 2011. Rural and Remote Health 2011; 11: 1772.


© Jennifer Richmond 2011 A licence to publish this material has been given to James Cook University,

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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.

This issue provide abstracts from:

  • Journal of Rural Health 2011; 27: issue 1
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2011; 16: issue 1
  • Australian Journal of Rural Health 2010; 18: issue 4

full article:


Journal of Rural Health

Contents: 2011; 27:(1)
Issue includes:

Exploring Diabetes Beliefs in At-Risk Appalachia
Lindsay J. Della

Purpose: This study quantifies and describes perceptions of susceptibility and severity of diabetes; cultural beliefs, barriers, and knowledge about diabetes; and social stigma associated with diabetes in an Eastern Appalachian Kentucky population.
Methods: A 55-item intercept survey was administered in 2 large retail outlets in Eastern Kentucky. Individuals were screened to ensure an age range of 25-55 and an 'at-risk' diabetes status (according to the American Diabetes Association's requirements). Descriptive statistics and t tests were used to describe the data. Differences across demographic variables were tested via an analysis of variance.
Findings: Most respondents agreed that diabetes is a growing problem in their community, yet the overall levels of perceived susceptibility and perceived severity were lower than expected (susceptibility = 3.88 on a 5-point scale and severity = 3.5). Women, however, perceived higher susceptibility than men. Social stigma did not emerge as a strong concern or worry. The only group differences noted focused on barriers to care and disease management. Specifically, men without a family history of diabetes were significantly less likely than men with a family history to agree that the community should help persons living with diabetes manage their disease (P= .034).
Conclusions: There appears to be a gap between actual and perceived risk levels for developing diabetes. Additionally, it seems that diabetes is viewed as an intrapersonal issue rather than a community-level problem. Yet, for men, a personal experience with the disease may be enough to change the belief that diabetes is an individual problem.

Lay Meanings of Health Among Rural Older Adults in Appalachia
R. Turner Goins, S. Melinda Spencer and Kimberly Williams

Purpose: Self-perceptions of health vary depending on one's social and cultural context. Rural residents have been characterized as having a distinct culture, and health differences by residence have been well documented. While there is evidence of poor health among rural older adults, little research has examined how they perceive and define health. Qualitative methods may help capture these lay meanings of health. The purpose of our study was to use a qualitative approach to examine what perceptions community-dwelling rural older adults have regarding their health.
Methods: The study involved thirteen 90-minute focus groups and short self-administered surveys with community-dwelling persons aged 60 years or older residing in 6 rural West Virginia communities. A total of 101 participants were asked questions about their personal definitions of health. With professional transcribed tapes from the focus group discussions, we used a systematic text analysis approach.
Findings: Discussions included 4 themes on the meaning of health: (1) health as a value, (2) dimensions of life, (3) holistic nature of health, and (4) health care use and adherence.
Conclusion: Our results expand on previous studies and demonstrate that health is a subjective, multidimensional construct deeply embedded in the everyday experience of rural older adults. We found that older adults' perceptions about health contain components which most medical professionals would not take into account. Health care providers may consider supplementing traditional medical approaches with a more contextually sensitive recognition of rural elders' desired health goals and outcomes.

Economic Impact of the Critical Access Hospital Program on Kentucky's Communities
Lucia Ona and Alison Davis

Context: In 1997, the Medicare Rural Hospital Flexibility Grant Program created the Critical Access Hospital (CAH) Program as a response to the financial distress of rural hospitals. It was believed that this program would reduce the rate of rural hospital closures and improve access to health care services in rural communities.
Objective: The objective of this paper is to analyze the economic impact of the CAH Program on Kentucky's communities.
Methods: Both an economic input-output model and a quasi-experimental control group method are used in this research paper. While the analysis using the input-output model uses data from the year 2006, the analysis using the quasi-experimental control group method uses data from 1989 to 2006.
Conclusion: The results indicate that the rural counties where a CAH was adopted did appear to benefit in economic terms relative to those that did not have a CAH.

Critical Access Hospitals and Retail Activity: An Empirical Analysis in Oklahoma
Lara Brooks and Brian E. Whitacre

Purpose: This paper takes an empirical approach to determining the effect that a critical access hospital (CAH) has on local retail activity. Previous research on the relationship between hospitals and economic development has primarily focused on single-case, multiplier-oriented analysis. However, as the efficacy of federal and state-level rural health subsidies come under increasing scrutiny, more comprehensive investigations can provide support for continued funding.
Methods: Data from 105 rural Oklahoma communities are used to explore whether the presence of a CAH impacts several measures of retail activity. The measures are: total retail sales, total number of retail establishments, and number of micro and small retail establishments. Ordinary least squares regression is used to evaluate the impact of a CAH after controlling for a host of other factors influencing retail activity such as local demographics, unemployment rates, and the presence of a Wal-Mart.
Findings: The presence of a CAH has a positive and significant influence on each measure of retail activity. The parameter estimates suggest that a CAH has a similar influence on rural retail sales as a Wal-Mart, increasing total retail sales by approximately 28% over towns without a CAH. Other model results indicate that a CAH presence significantly increases the number of total retail establishments and the number of micro and small business establishments.
Conclusions: The positive results provide additional evidence on the far-reaching economic development impacts of CAHs. The results also emphasize the importance of continued support for these rural institutions, including federal and state subsidies.

Factors Associated With Emergency Department Use Among the Rural Elderly
Lin Fan, Manish N. Shah, Peter J. Veazie and Bruce Friedman

Context: Emergency Department (ED) use among the rural elderly may present a different pattern from the urban elderly, thus requiring different policy initiatives. However, ED use among the rural elderly has seldom been studied and is little understood.
Purpose: To characterize factors associated with having any versus no ED use among the rural elderly.
Methods: A cross-sectional and observational study of 1,736 Medicare beneficiaries age 65 and older who live in nonmetropolitan areas. The data are from the 2002 to 2005 Medical Expenditure Panel Survey (MEPS). A logistic regression model was estimated that included measures of predisposing characteristics, enabling factors, need variables, and health behavior as suggested by Anderson's behavioral model of health service utilization.
Findings: During a 1-year period, 20.8% of the sample had at least 1 ED visit. Being widowed, more educated, enrolled in Medicaid, with fair/poor self-perceived physical health, respiratory diseases, and heart disease were associated with a higher likelihood of having any ED visits. However, residing in the western and southern United States and being enrolled in Medicaid managed care were associated with lower probability of having any ED visits. While Medicaid enrollees who reported excellent, very good, good, or fair physical health were more likely to have at least 1 ED visit than those not on Medicaid, Medicaid enrollees reporting poor physical health may be less likely to have any ED visits.
Conclusion: Policy makers and hospital administrators should consider these factors when managing the need for emergency care, including developing interventions to provide needed care through alternate means.

Smoking, Sociodemographic Determinants, and Stress in the Alabama Black Belt
Faisal Shuaib, H. R. Foushee, John Ehiri, Suparna Bagchi, Angela Baumann and Connie Kohler

Purpose: In the Alabama Black Belt, poverty is high, and the educational level is low. Studies have found increased tobacco use among individuals exposed to high levels of stress. Few studies have been conducted in this region to measure smoking status, its sociodemographic determinants, and how smoking status relates to stressful environmental conditions.
Methods: A cross-sectional questionnaire survey of 1,387 individuals.
Findings: Approximately 25% of the respondents currently smoked cigarettes. Females were less likely to smoke compared to males (OR, 0.29; 95% CI, 0.23-0.38). Blacks were less likely to smoke cigarettes compared to whites (OR, 0.64; 95% CI, 0.43-0.95). Compared to individuals who were employed, participants who were unemployed or retired had increased odds of smoking (OR, 1.68; 95% CI, 1.15-2.20). The odds of being a current smoker were increased in the presence of moderate level stress (OR, 2.06; 95% CI, 1.38-3.07) or when there was a high level of stress (OR, 2.21; 95% CI, 1.47-3.31). Smoking was associated with increased odds of having a moderate level (OR, 2.06; 95% CI, 1.38-3.08) and a high level of stress (OR, 2.21; 95% CI, 1.47-3.32). Females who reported moderate to high levels of stress had increased odds of being smokers compared to males. Interaction between gender and stress showed deviation from additivity.
Conclusion: Our findings suggest a high rate of cigarette use in the area. Increased stress levels appear to predispose females more than males to cigarette smoking. The implications of this association may guide interventions targeted at reducing smoking and its complications.

Rural Adolescent Health: The Importance of Prevention Services in the Rural Community
Alexa C. Curtis, Catherine M. Waters and Claire Brindis

Context: Adolescence is a pivotal developmental period for the establishment of positive health and health practices. However, developmentally propelled risk behaviors coinciding with barriers to health services may increase the propensity for untoward health outcomes in adolescence. In addition, the sociocultural context of the rural environment can present challenges to the health of adolescents. Limited data on rural adolescent health, particularly among population subgroups, hinder the ability to adequately advocate for adolescent health prevention services.
Methods: A secondary analysis of the 2005 California Health Interview Survey Adolescent questionnaire was conducted. Selected survey items corresponding to the Healthy Youth 2010 objectives were analyzed for 663 adolescents aged 12-17 residing in rural regions of California. Adolescent subgroup analysis included race/ethnicity, age, and poverty level.
Findings: Adolescent health issues of particular concern in this study include sexual health, substance use, mental health, and risk factors for obesity. Predictably, risk behaviors increase with the age of the adolescent. Minority and poor youth demonstrate the greatest vulnerability to untoward health outcomes.
Conclusion: Significant risk behaviors and health concerns exist among the rural adolescent population, particularly among poor and minority youth, arguing for the creation and preservation of prevention services for youth in the rural community. Future research using alternative sampling methodologies may be necessary to adequately represent the higher-risk adolescent in the rural community. More data are needed on vulnerable adolescent populations in the rural community in order to adequately advocate for prevention services.

Noise Exposures of Rural Adolescents
Michael Humann, Wayne Sanderson, Greg Flamme, Kevin M. Kelly, Genna Moore, Ann Stromquist and James A. Merchant

Purpose: This project was conducted to characterize the noise exposure of adolescents living in rural and agricultural environments.
Methods: From May to October, 25 adolescents ages 13 through 17, living either on a farm or a rural nonfarm, were enrolled in the study. Subjects received training on the correct operation and use of personal noise dosimeters and the proper way to record their daily tasks on activity cards. Subjects completed 4 days of self-monitoring noise dosimetry, 2 days in the first round (May-July) and 2 days in the second round (August-October). In addition to dosimetry, subjects completed activity logs of their daily tasks.
Results: The mean daily noise exposures of adolescents living on farms and in nonfarm rural homes were between 55.4 dBA (A-weighted decibels) and 103.5 dBA, with 44% of the daily measurements greater than the National Institute of Occupational Safety and Health Recommended Exposure Level of 85 dBA. Task-based analysis of noise exposures found that activities involving mechanized equipment resulted in the highest exposures, while activities in the home resulted in the lowest exposure. No particular demographic group had a statistically higher noise exposure; therefore, specific factors apart from activities and noise sources could not be identified as risk factors for exposure to hazardous noise levels.
Conclusions: The results of this project indicate that rural adolescents complete a variety of activities and are exposed to noise sources with a broad range of decibel levels. While the exposures may change from day to day, there are occasions when exposure to noise exceeds the recommended levels.

Provider, Patient, and Family Perspectives of Adolescent Alcohol Use and Treatment in Rural Settings
Adam J. Gordon, Lorraine Ettaro, Keri L. Rodriguez, John Mocik and Duncan B. Clark

Purpose: We examined rural primary care providers' (PCPs) self-reported practices of screening, brief interventions, and referral to treatment (SBIRT) on adolescent alcohol use and examined PCPs', adolescents', and parents' attitudes regarding SBIRT on adolescent alcohol use in rural clinic settings.
Methods: In 2007, we mailed surveys that inquired about alcohol-related knowledge, attitudes, and treatment practices of adolescent alcohol use to all PCPs in 8 counties in rural Pennsylvania who may have treated adolescents. We then conducted 7 focus groups of PCPs and their staffs (n = 3), adolescents (n = 2), and parents (n = 2) and analyzed the narratives using structured grounded theory, evaluating for consistent or discordant themes.
Results: Twenty-seven PCPs from 7 counties returned the survey. While 92% of PCPs felt that routine screening for alcohol use should begin by age 14, 84% reportedly screened for alcohol use occasionally, and reportedly 32% screened all adolescent patients. The provider focus groups (n = 20 PCPs/staff) related that SBIRT for alcohol use for adolescents was not currently effective. Poor provider training, lack of alcohol screening tools, and lack of referral treatment options were identified barriers. Adolescents (n = 12) worried that physicians would not maintain confidentiality. Parents (n = 12) acknowledged a parental contribution to adolescent alcohol use. All groups indicated computer-based methods to screen for alcohol use among adolescents may facilitate PCP engagement.
Conclusions: Despite awareness that rural adolescent alcohol use is a significant problem, PCPs, adolescents, and parents recognize that SBIRT for adolescent alcohol use in rural PCP settings is ineffective, but it may improve with computer-based screening and intervention techniques.

Rurality, Region, Ethnic Community Make-Up and Alcohol Use Among Rural Youth
Randall C. Swaim and Linda R. Stanley

Purpose: As the most widely used substance among adolescents in the United States, alcohol remains a critical public health issue. The majority of research in this area has focused on individual-level variables. This study examined the contextual effects of rurality, geographic region, and community ethnicity in the prediction of alcohol use among adolescent youth.
Method: Participants were 7th-12th grade students from a sample of 260 rural communities across the United States, with oversampling for predominantly Mexican American and African American communities. The total sample comprised 213,225 students. Multilevel modeling was used to estimate both individual and contextual effects for use of alcohol and getting drunk.
Findings: Those living in more rural communities were somewhat more likely to have used alcohol and gotten drunk than their less rural counterparts. Consistent with a trend toward a narrowing gender gap across a number of substances, gender differences in alcohol use were not large, except in the South. A minority in a community, eg, a white student in an African American community, had greater risk for alcohol use and getting drunk.
Conclusions: Models of alcohol use among rural youth that include only individual-level variables are likely to result in misleading results. While students from varying levels of rurality may not differ substantially from one another, geographic region and minority status within communities are likely to interact with individual-level variables, resulting in unique patterns of alcohol use and getting drunk.

Moving On? Predictors of Intent to Leave Among Rural and Remote RNs in Canada
Norma J. Stewart, Carl D'Arcy, Julie Kosteniuk, Mary Ellen Andrews, Debra Morgan, Dorothy Forbes, Martha L. P. MacLeod, Judith C. Kulig and J. Roger Pitblado

Context: Examination of factors related to the retention or voluntary turnover of Registered Nurses (RNs) has mainly focused on urban, acute care settings.
Purpose: This paper explored predictors of intent to leave (ITL) a nursing position in all rural and remote practice settings in Canada. Based on the conceptual framework developed for this project, potential predictors of ITL were related to the individual RN worker, the workplace, the community context, and satisfaction related to both the workplace and the community(s) within which the RN lived and worked.
Methods: A national cross-sectional mail survey of RNs in rural and remote Canada provided the data (n = 3,051) for the logistic regression analysis of predictors of ITL.
Findings: We found that RNs were more likely to plan to leave their nursing position within the next 12 months if they: were male, reported higher perceived stress, did not have dependent children or relatives, had higher education, were employed by their primary agency for a shorter time, had lower community satisfaction, had greater dissatisfaction with job scheduling, had lower satisfaction with their autonomy in the workplace, were required to be on call, performed advanced decisions or practice, and worked in a remote setting.
Conclusions: The statistical evidence for predictors of ITL supported our framework with determinants related to the individual, the workplace, the community, and satisfaction levels. The importance of community makes this framework uniquely relevant to the rural health context. Our findings should guide policy makers and employers in developing retention strategies.

Kids Into Health Careers: A Rural Initiative
Lori S. Lauver, Beth Ann Swan, Margaret Mary West, Ksenia Zukowsky, Mary Powell, Tony Frisby, Sue Neyhard and Alexis Marsella

Purpose: To describe a project that introduces middle school and high school students living in Pennsylvania's rural geographic regions to nursing careers through outreach extended to students regardless of gender, ethnicity, or socioeconomic status.
Method: The authors employed many strategies to inform students about careers in nursing. The methods included: working with guidance counselors, participating in community health fairs, taking part in school health career fairs, collaborating with Area Health Education Centers, serving on volunteer local education advisory boards, developing a health careers resource guide, and establishing a rural health advisory board.
Findings: Developing developmentally appropriate programs may have the potential to pique interest in nursing careers in children of all ages, preschool through high school. Publicity is needed to alert the community of kids into health care career programs. Timing is essential when planning visits to discuss health care professions opportunities with middle and high school students. It is important to increase the number of high school student contacts during the fall months. Targeting high school seniors is particularly important as they begin the college applications process and determine which school will best meet their educational goals.
Conclusions: Outcome measures to determine the success of health career programs for students in preschool through high school are needed. Evaluation methods will be continued over the coming years to assess effectiveness.

'If Only Someone Had Told Me ...': Lessons From Rural Providers
Cody Chipp, Sarah Dewane, Christiane Brems, Mark E. Johnson, Teddy D. Warner and Laura W. Roberts

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers' knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains.
Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, 'What are the 3 things you wish someone would have told you about delivering health care in rural areas?' were thematically coded.
Findings: Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner.
Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.

The March to Accountable Care Organizations-How Will Rural Fare?
A. Clinton MacKinney, Keith J. Mueller and Timothy D. McBride

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs).
Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion.
Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served.
Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural-relevant ACO-performance measures and provide necessary technical assistance to rural providers and organizations.


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine
[in French and English]

Contents: 2011; 16:(1)
Issue includes:

'You don't know what you've got till it's gone': the role of maternity care in community sustainability
Christiana Miewald, Michael C. Klein, Catherine Ulrich, David Butcher, Sahba Eftekhary, Jessica Rosinski, Andrea Procyk

Introduction: Many small hospitals in British Columbia are altering their role in maternity care or abandoning it altogether. This paper explores the role of maternity care in the sustainability of rural communities in northern BC.
Methods: We carried out a qualitative case study by conducting an ethnographic examination of 4 communities with varying levels of maternity care services.
Results: Although maternity care is not the only factor to influence community sustainability, it does intersect with other economic and social conditions. Maternity care affects a variety of forms of community capital, including economic development, social ties and relations, and the cultural meanings of childbirth.
Conclusion: Decision-makers should take into account the community-wide consequences of changes to the role and function of maternity care facilities.

Medical school strategies to increase recruitment of rural-oriented physicians: the Canadian experience
Ronak K. Kapadia, Brent M. McGrath

The decision of the physician to practise in a rural setting involves a multitude of personal and professional preferences, ideals and values. However, among these many factors, there is little dispute that Canadian medical schools, with the ability to directly influence the career choices of their graduating students, have an important societal responsibility to strive to address the issues facing rural medicine. The aim of this paper is to summarize the evidence for interventions that are feasible and that may be used by Canadian medical schools to increase the number of graduates who will become rurally oriented physicians. We outline several interventions and make recommendations to improve the recruitment of rurally minded medical students and the rural training of all medical students.

Fetal alcohol spectrum disorder in adults: diagnosis and assessment by a multidisciplinary team in a rural area
Audrey McFarlane

Access to diagnostic and assessment services for fetal alcohol spectrum disorder in adults is relatively rare in the world. Since 2002, the Lakeland Centre for Fetal Alcohol Spectrum Disorder (LCFASD) in northeastern Alberta has been providing community-based, mobile diagnostic and assessment services for adults prenatally exposed to alcohol. This article describes the community-based model developed by the LCFASD, the clinical findings of the diagnostic team and the successes and challenges experienced by the team.


Australian Journal of Rural Health

2010; 18:(4)
Issue includes:

Pandemic influenza vaccination: Will the health care system take its own medicine?
Craig D. Ferguson, Teagen E. Ferguson, Jonathan Golledge and William J. H. McBride

Objective: To identify factors associated with acceptance of the pandemic Influenza A H1N1 California 7/09 vaccine (pH1N1 vaccine) in rural hospital staff.
Design: Cross-sectional group administered survey.
Setting: A 58-bed rural Queensland hospital, over a 10-day period starting five days after commencement of the pH1N1 vaccination program.
Participants: Hospital staff and students.
Main outcome measures: Intention to receive pandemic influenza vaccination, seasonal influenza vaccination.
Results: The survey was completed by 252 staff and students (full response rate 76.1%, cooperation rate 98.4%). The majority of respondents had already decided whether or not to receive the pH1N1 vaccine: 111 (44.0%) intended to be vaccinated, 63 (25.0%) intended not to be vaccinated and 78 (31.0%) were undecided. Of 125 staff who had received the seasonal influenza vaccine, 86 (68.8%) intended to receive the pandemic vaccine. Respondents were less likely to state acceptance of the pH1N1 vaccine if they identified concern about vaccine adverse reactions (odds ratio (OR) 0.29; 95% confidence interval (CI), 0.11-0.78), vaccine safety (OR 0.20; 95% CI, 0.09-0.46), vaccine efficacy (OR 0.20; 95% CI, 0.04-0.87) or perceived limitations of vaccine trials (OR 0.08; 95% CI, 0.01-0.99) as primary reasons discouraging pandemic influenza vaccination.
Conclusions: There is considerable concern among rural hospital staff regarding pH1N1 vaccine adverse reactions, safety, efficacy and the adequacy of clinical trials on its use. Education specifically addressing these concerns might increase pandemic vaccine acceptability.

Rural student doctors top city colleagues: Representation of a rural clinical school in the rural press
Catherine Harding and Louis Pilotto

Objective: To describe the way in which the rural press portrays a rural clinical school and its staff and students.
Design: Textual analysis of a collection of newspapers kept by the local campuses of the University of New South Wales Rural Clinical School (UNSW RCS).
The study: The UNSW established a RCS in January 2000. This study sampled a total of 225 articles from eleven rural newspapers, a collection held by the campuses of the rural clinical schools. The major themes of the articles were identified; the descriptive terms the newspaper articles used for medical students, the UNSW RCS and rural doctors were also identified. The way in which clinical schools, their staff and students, are portrayed in the rural press has the potential to influence recruitment and retention.
Conclusions: The study showed that the rural press was strongly supportive of the rural clinical school in their local region. This was particularly true for medical students, the school itself and the potential impact on workforce. The newspapers provided information for future students, depicting work-experience programs and current students. They were less illustrative of current medical and academic staff, with the exception of the Head of School.

Short-stay rural and remote placements in dental education, an effective model for rural exposure: A review of eight-year experience in Western Australia
Estie Kruger, Marc Tennant

Objectives: The increase in demand for dental care over the next 10 years is expected to outstrip the supply of dental visits in Australia, resulting in an ongoing shortage of dental practitioners. As trends in medicine have shown, the greatest effect will be felt in rural and remote regions, where an undersupply of dentists already exists. It is clearly evident that it is important to provide strategies that will increase the recruitment and retention of practitioners in rural and remote areas. Previous research suggested an increased likelihood for health graduates to choose rural practice if they have a rural background, or were exposed to rural practice during their education. Short-stay (three to four weeks) placements for final-year dental students has been part of dental education in Western Australia for near on a decade.
Methods: This paper reflects on the experiences gained from managing this placement program.
Conclusions: Short-stay placements are a quality learning initiative but need a high level of planning and a clear vision to be effective.
Implications: The key factors in ensuring sustainable, student centred learning is driven through a small core group of staff who have strong direct links with rural and remote communities, students and support providers. The integration of service, education and research goals have played a critical role in sustaining placements. The philosophy underpinning the rural placements needs to be clearly articulated and applied effectively in each step of their implementation and a highly focused customer-service driven implementation is required to make short-stay rural and remote placements effective.

Changes in depression-related mental health literacy in young men from rural and urban South Australia
Kerena A. Eckert, Stephanie M. Kutek, Kirsten I. Dunn, Tracy M. Air and Robert D. Goldney

Objective: To examine rural and urban differences in depression-related mental health literacy, experience of depression and help-seeking.
Design: Cross-sectional population-based survey stratified by rural and urban area.
Setting: A random and representative sample of South Australian rural and urban young men aged between 15 and 30 years.
Outcome measures: Mental health literacy as determined by recognition and exposure to classical symptoms of depression; perceived helpfulness of various interventions and treatment-seeking behaviour.
Results: Recognition of depression increased significantly in rural and urban young men between 1998 and 2008. More rural young men than urban men identified symptoms of depression in 1998 (odds ratio (OR): 1.53, 95% confidence interval (CI), 1.01-2.40, P < 0.05), but that was not evident in 2008 (OR: 1.32, 95% CI, 0.80-2.25, P = 0.30). Both groups were more likely to have a close friend experience symptoms of depression and to use antidepressant medications in 2008 compared with 1998. Rural young men experienced a significant increase in recognition of personal depressive symptoms (OR: 3.73, 95% CI, 1.72-8.40) and levels of confidence in psychiatrists and psychologists (OR: 2.40, 95% CI, 1.34-4.31) in 2008 compared with 1998. Both rural and urban young men were significantly less likely to rate dealing with problems on their own as helpful in 2008 as in 1998.
Conclusions: There has been an increase in both rural and urban young male mental health literacy between 1998 and 2008, especially in rural young men. Whether this will translate into a reduction of depression and associated suicide, with a reversal of the rural/urban suicide differential, remains to be seen.

Genital chlamydia in southern New South Wales: An ecological analysis of testing and notification patterns 2004-2008
Roderick Reynolds and Tracey Oakman

Objective: To identify demographic patterns for chlamydia testing rates on reported general practice (GP) visits and notification rates in residents of Greater Southern Area Health Service (GSAHS) for the period 2004-2008.
Design: Descriptive analysis of presentation and chlamydia-specific Medicare data and chlamydia notifications made to GSAHS Public Health Unit.
Setting: Rural and remote southern New South Wales.
Participants: Residents of GSAHS who had a Medicare recorded visit to a GP and chlamydia pathology collected in the period July 2004 to June 2008, and those residents notified to the GSAHS Public Health Unit with a positive chlamydia test results.
Main outcome measures: Age and gender trends for GP visits, chlamydia testing and chlamydia notifications.
Results: While chlamydia testing and notification rates increased over the review period, the percentage of chlamydia tests performed remained low. There was a greater increase in testing rates among women than men, and the highest were among women aged 15-24. Chlamydia notification rates increased across all age groups and were greater in women aged 15-24 than men of the same age group.
Conclusion: The low proportion of tests performed to presentations (in conjunction with the high proportion of notifications to tests performed) reflects that chlamydia testing among providers is still being undertaken in a targeted approach rather than from a population-focused screening perspective. Further work with GPs is required to improve chlamydia screening rates, and ensure practice is consistent with national guidelines.

Evaluating the impact of sustainable comprehensive primary health care on rural health
Rachel Tham, John Humphreys, Leigh Kinsman, Penny Buykx, Adel Asaid, Kathy Tuohey and Karen Riley

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia.
Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria.
Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria.
Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.

Caring of ST-elevation myocardial infarction patients in rural community hospital settings: Determinants of in-hospital mortality
Ertugrul Okuyan, Ahmet Uslu, Mustafa O. Levent, Irfan Sahin and Mustafa H. Dinckal

Objective: Cardiovascular disease contributes more than three quarters of all cardiovascular deaths worldwide. Adherence to myocardial infarction (MI) guidelines might not be possible in many rural hospitals. We aim to share our three-year experience in rural settings regarding to ST-elevation MI (STEMI) patients particularly by focusing on determinants of in-hospital mortality.
Methods: We retrospectively analysed our data for 559 acute STEMI patients admitted to our coronary care unit in Kastamonu city, Turkey between August 2004 and August 2007. Key demographic and clinical characteristics and data regarding symptom duration, prehospital transfer settings and insurance status were collected. Killip classes and in-hospital therapy of all patients were recorded.
Results: A total of 54 patients (9.66%) died within the hospitalisation period. Multivariate analysis revealed that advanced age > 65 years, late admission, hypotension at presentation, killip class > 2, anterior location, posterior location, lack of fibrinolysis and cardiogenic shock were independent predictors of in-hospital mortality.
Conclusions: In rural hospital settings, clinical resources and transfer facilities are limited. Therefore, improvement of early transfer and prehospital fibrinolysis capabilities should decrease mortality.

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