Journal Search

Journal Search - issue 2, 2011


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


30 June 2011 Volume 11 Issue 2


RECEIVED: 29 June 2011

ACCEPTED: 30 June 2011


Richmond J.  Journal Search - issue 2, 2011. Rural and Remote Health 2011; 11: 1851.


© 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 2
  • Journal Canadien de la Médecine Rural/ Canadian Journal of Rural Medicine 2011; 16: issue 2
  • Australian Journal of Rural Health 2011; 19: issue 1


Journal of Rural Health
Contents: 2010; 27:(2)
Issue includes:

'Active Living' Related to the Rural-Urban Continuum: A Time-Use Perspective
Hugh Millward and Jamie Spinney

Purpose: This paper assesses the degree to which 'active living' varies along the rural-urban continuum, within the county-sized regional municipality of Halifax, Nova Scotia.
Methods: Time-diary data from the Halifax Space-Time Activity Research project were used to compute daily participation rates (PRs) and time durations, at various physical effort levels, in the 4 activity domains of leisure, active transportation (AT), chores, and occupation. Geographic zones were based on the rural-urban fringe concept: the 4 zones are the Inner City (IC), Suburbs, Inner Commuter Belt (ICB), and Outer Commuter Belt (OCB). The Compendium of Physical Activities was employed to classify activity episodes into 5 effort levels. Light through maximum effort levels indicate 'healthy' activities, while moderate through maximum levels indicate 'aerobic' activities. Two threshold levels of 'active living' were defined and calculated.
Findings: Mann-Whitney tests show that significant interzonal differences in activity-level durations exist for all domains. The IC contrasts strongly with the suburbs (more AT and active leisure, but less occupational activity), and the suburbs with the ICB, but there are fewer significant differences between the ICB and OCB. The percentage of respondents meeting 'maintenance' and 'enhanced' thresholds of active living is significantly higher in the OCB, and there is also significant urban-rural variation by sociodemographic characteristics.
Conclusions: Position along the rural-urban continuum is significantly related to PRs and mean durations for levels of physical activity, and to the proportion of respondents meeting threshold levels of active living.

Trauma and Substance Use Disorders in Rural and Urban Veterans
David L. Nash, BS, Jamie Wilkinson, Bryce Paradis, Stephanie Kelley, Ahsan Naseem and Kathleen M. Grant

Context: Disparities in the prevalence, morbidity, and mortality of multiple mental health conditions have been described between rural and urban populations. However, there is limited information regarding differences in exposure to trauma and trauma-related mental health conditions in these populations. Given the number of veterans who are returning to rural communities after serving in Operation Enduring Freedom and Operation Iraqi Freedom, differences in trauma exposure are of particular relevance. Trauma exposure is related to a variety of mental health disorders including substance use disorders (SUD).
Purpose: The objectives of this preliminary study were to describe lifetime military and nonmilitary trauma and to compare trauma history between rural and urban veterans in SUD treatment.
Methods: Sixty adults in SUD treatment were enrolled at 3 Veterans Health Administration sites in Nebraska over a 3-month period in 2008. Subjects completed an interview with study staff, which assessed SUD diagnoses and childhood, lifetime, and military trauma. Rural or urban status was determined by self-report of childhood residence. Childhood trauma, lifetime trauma, and response to military trauma were compared between rural and urban veterans.
Findings: Although there were no significant differences in trauma exposure between rural and urban groups, there was an association between specific types of trauma and measures typically associated with increased substance abuse severity and poorer SUD treatment outcome.
Conclusion: This is the first study, to our knowledge, which compared trauma exposure between rural and urban veterans and identified an association between childhood trauma exposure and multiple SUD treatment attempts.

Exploring the Use of Nonmedical Sources of Prescription Drugs Among Immigrant Latinos in the Rural Southeastern USA
Aaron T. Vissman, Fred R. Bloom, Jami S. Leichliter, Laura H. Bachmann, Jaime Montaño, Michael Topmiller and Scott D. Rhodes

Background: Little is known about access to medicine among immigrant Latinos in the United States (US). This study explored access to, and use of, prescription drugs obtained from nonmedical sources among recently arrived, Spanish-speaking immigrant Latinos in rural North Carolina (NC).
Methods: Our community-based participatory research partnership collected, analyzed, and interpreted data from individual in-depth interviews with Latino community members and rural health service providers. A purposive sample of 30 community members, including traditional healers, religious leaders, transgender Latinos, heterosexual Latino men and women, and Latino gay men, were interviewed to gain emic ('insider') perspectives on use of nonmedical sources of prescription drugs. Six local Latino health service providers also were interviewed to gain etic ('outsider') perspectives on use.
Results: Participants described the roles of tiendas (grocers), family, and social networks in accessing treatment advice and prescription drugs. They described health care expectations among immigrants and contingencies for accessing prescription drugs in the US. Prescription medicines (eg, antibiotics, hormones, Viagra, analgesics), injection equipment (eg, syringes), and medical advice were identified as readily available from nonmedical sources.
Conclusions: Increased access to formalized health care and effective health education initiatives are needed to meet the challenges facing immigrant Latinos.

Trends in Community Pharmacy Counts and Closures Before and After the Implementation of Medicare Part D
Donald G. Klepser, Liyan Xu, Fred Ullrich and Keith J. Mueller

Purpose: Medicare Part D provided 3.4 million American seniors with prescription drug insurance. It may also have had an unintended effect on pharmacy viability. This study compares trends in the number of pharmacies and rate of pharmacy closures before and after the implementation of Medicare Part D.
Methods: This retrospective observational study used data from National Council for Prescription Drug Programs (NCPDP) to track retail pharmacy closures and counts between January 2004 and January 2009. Pharmacies were classified by ownership (chain or independent), location (urban or rural), and whether they were the only pharmacy in a community. Autoregressive Integrated Moving Average (ARIMA) models were used to examine trends in pharmacy counts and closures.
Findings: The number of independent and rural pharmacies decreased significantly after the implementation of Medicare Part D. The number of communities that saw their only pharmacy close also increased.
Conclusions: Unintended consequences of Medicare Part D may serve to reduce patient access to pharmacy services in opposition to the stated goals of the program.

The Relationship Between the Financial Status of Sole Community Independent Pharmacies and Their Broader Involvement With Other Rural Providers
Andrea Radford, Rebecca Slifkin, Jennifer King, Michelle Lampman, Indira Richardson and Steve Rutledge

Purpose: To document sole community pharmacists' involvement with other local health care organizations, these pharmacies' current financial status, and to determine whether financial position was associated with the provision of pharmacy services to other local health care providers.
Methods: We conducted semistructured interviews with pharmacist-owners of 401 sole community pharmacies randomly selected using data from the National Council for Prescription Drug Programs, Inc. Bivariate and multivariate analyses of responses were conducted to examine associations between pharmacy characteristics, financial position, and involvement with other local health care providers.
Findings: About 4 in 5 pharmacies provided services to at least 1 local health care organization. Most respondents (70%) described their store's overall financial position as good or very good, but about one-third reported that their financial conditions had deteriorated since the previous year. Providing services to other organizations was associated with higher prescription sales volume. After controlling for prescription volume, there was no association between providing services to other organizations and pharmacist-owners' self-assessed financial position.
Conclusion: Sole community pharmacists provide important pharmaceutical support services to other health care organizations. Other than increased volume of business, this support often does not translate directly to an improved financial position for the pharmacy. The survival of sole community pharmacies not only ensures retail access to pharmaceuticals and patient counseling, but it also, in many cases, plays a key role in supporting other local health care providers, helping to preserve access to important services that are particularly needed in communities with limited health care options.

A Clinical Pharmacist's Role in Screening for Metabolic Syndrome in a Rural Pediatric Ambulatory Clinic
Sandra Benavides, Lisa A. Kohler and Garry Souffrant

Purpose: The prevalence of metabolic syndrome in the pediatric population is increasing. Barriers, including the lack of consensus of a definition for metabolic syndrome and time constraints for the pediatrician, may limit the identification and diagnosis of metabolic syndrome in children. The objective of this pilot study was to evaluate the role of a clinical pharmacist (CP) in screening children and adolescents for metabolic syndrome.
Methods: A 3-month, prospective, cross-sectional study aimed at utilizing a CP to identify metabolic syndrome in high-risk children, ages 10-18 years, in a pediatric ambulatory clinic located in a rural community health center was conducted. Upon enrollment a personal and family medical history was obtained, physical examination was reviewed, and a fasting laboratory analysis was performed. The CP evaluated each component of metabolic syndrome to determine if the participant met criteria for diagnosis. The CP provided a summary of the risk factors and treatment recommendations to the pediatrician.
Findings: Twenty-five Mexican American participants (ages 13.7 ± 2.3 years) enrolled and completed the study. One child (4%) met 3 or more criteria required for diagnosis of metabolic syndrome. Of the remaining participants, 7 (28%) met 2 criteria, 9 (36%) met 1 criterion, and 8 (32%) met no criteria for metabolic syndrome. The CP provided treatment recommendations for 68% of the participants.
Conclusion: CPs can have an active role in early identification of specific components of metabolic syndrome in a rural community health center.

Monetary Value of a Prescription Assistance Program Service in a Rural Family Medicine Clinic
Heather P. Whitley

Purpose: To quantify the monetary value of medications provided to rural Alabamians through provision of pharmaceutical manufacturer-sponsored prescription assistance programs (PAPs) provided by a clinical pharmacist in a private Black Belt family medicine clinic during 2007 and 2008.
Methods: Patients struggling to afford prescription medications were referred to a clinical pharmacist by the physician or nurse practitioner for medication assistance evaluation. Once patients were deemed eligible, the pharmacist assisted in the PAPs completion process, maintained detailed records, and aided in recovery of refills. Patients paid $5 per application to cover office supply costs. An annual retrospective review was performed each December to evaluate the monetary value of free medications provided to patients during this 24-month period.
Findings: One hundred forty-two applications were completed, enrolling 31 patients in 22 PAPs. Patients received $138,400 worth of medications; the clinic collected $710 in fees. Antihypertensive, antidepressant, lipid-lowering, antiplatelet, and proton pump inhibitor medications were most frequently prescribed and represented 74% of the total monetary value of free medications provided to patients. Clopidogrel (Plavix) and esomeprazole (Nexium) were the most commonly requested medications, representing 16% of the monetary value.
Conclusions: PAPs offer an avenue to obtain medications when cost may lead to non-adherence. PAP services helped rurally isolated Alabamians receive needed therapies they otherwise likely would not have purchased. Similar programs offering assistance services for merely cardiovascular products would provide a substantial public health impact. Providers interested in initiating similar services should identify a program coordinator, designate a private location for patient interviews, and develop systems to ensure patients receive their PAP medications.

Midwestern Rural Adolescents' Anal Intercourse Experience
Joseph A. Dake, James H. Price, Molly McKinney and Britney Ward

Purpose: The purpose of this study was to examine the prevalence of anal intercourse and its associated risk behaviors in a sample of Midwestern, predominantly white rural adolescents. Most of the research on this activity has been local or regional studies, with urban East and West Coast racial and ethnic minority adolescents.
Methods: A surveillance questionnaire based on the Youth Risk Behavior Survey was distributed in 2009 to 820 rural middle and high school students in grades 6-12, across 2 rural counties in a Midwestern state. The school districts were stratified by grade level and a stratified random sample of schools (n = 17) was used. Data were analyzed using Fisher's exact test and multiple logistic regression.
Findings: A total of 778 (95%) students completed the survey. The rural adolescents were in grades 6-12, were primarily white (95%), and were evenly distributed by gender. Similar amounts of students had engaged in sexual intercourse (24%) and oral sex (23%). Seven percent reported engaging in anal sex (1.6% middle school, 10.9% high school). Multivariate logistic regression controlling for other risk behaviors found that 2 variables were associated with increased anal sexual activity: ever had sexual intercourse (adjusted odds ratios [AOR]= 14.5) and ever had oral sex (AOR = 6.0).
Conclusions: Anal sexual activity is a component of some rural adolescents' sexual experiences. These findings have important implications for sex education programs targeted to rural schools, where the typical high school classroom may have some students engaging in anal sex.

Access to Dental Care for Rural Children: A Survey of Nebraska General Dentists
Kimberly K. McFarland, Fouad Salama and Muhammad Yaseen

Background: Pediatric dentists are too few in number to care for all children. Therefore, the level of pediatric dental services provided by general dentists, especially in rural areas, is crucial to improving the dental health of children.
Purpose: The objectives of the study were to establish a baseline in regard to the quantity of pediatric dental care provided by general dentists in rural Nebraska as well as to measure their interest, if any, in receiving additional pediatric training.
Methods: All rural general dentists (n = 350) in the state of Nebraska received an Institutional Review Board (IRB) approved 12-item questionnaire. The response rate was 71% (n = 248). Both descriptive and bivariate analyses were conducted, including chi-square and the analysis of variance (ANOVA).
Findings: Forty-five percent of rural Nebraska dentists devote more than 20% of their practice to serving the dental needs of children. One-third of all rural Nebraska dentists indicated they would like additional training in pediatric dentistry.
Conclusions: A significant opportunity exists to provide additional pediatric training for general dentists in rural Nebraska to further increase access to care for children.

Birth Outcomes Among Older Mothers in Rural Versus Urban Areas: A Residence-Based Approach
Sarka Lisonkova, Samuel B. Sheps, Patricia A. Janssen, Shoo K. Lee, Leanne Dahlgren and Ying C. MacNab

Purpose: We examined the association between rural residence and birth outcomes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean-section capacity.
Methods: A population-based retrospective cohort study, including all singleton births to 35+ year-old women in British Columbia (Canada), 1999-2003. We compared birth outcomes in rural versus urban areas, and between 3 distance categories to a hospital (<50, 50-150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small-for-gestational-age, large-for-gestational-age, and neonatal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
Findings: Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50-150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9-1.0; OR = 0.7, CI: 0.6-0.9) and small-for-gestational-age (OR = 0.8, CI: 0.7-0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1-2.1) and large-for-gestational-age (OR = 1.1, CI: 1.1-1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1-2.1) per distance category.
Conclusions: Older women in rural versus urban areas had a lower rate of cesarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport.

The Role of Physician Assistants in Rural Health Care: A Systematic Review of the Literature
Lisa R. Henry, Roderick S. Hooker and Kathryn L. Yates

Purpose: A literature review was performed to assess the role of physician assistants (PAs) in rural health care. Four categories were examined: scope of practice, physician perceptions, community perceptions, and retention/recruitment.
Methods: A search of the literature from 1974 to 2008 was undertaken by probing the electronic bibliographic databases of English language literature. Criterion for inclusion was original data published on rural PAs. Each paper was assessed and assigned to the four categories.
Findings: A total of 51 papers were identified; 28 papers had a primary focus on research and specified PAs in a rural setting. Generally, the literature suggests that PAs provide cost-efficient and supplemental medical services to underserved rural populations and that these services are valued. It also appears that rural PAs possess a larger scope of practice than urban PAs. This broad range of skills and procedures may be necessary to match the extensive health care needs of underserved rural populations. Over a 35-year period of examination, the literature improved in numbers of PAs studied and the quality of research. However, the lack of longitudinal studies was considered a shortcoming of rural health PA observational research.
Conclusions: Through this review, some insights about the role of PAs emerged. Overall, they seem well adapted to rural health. Important issues regarding the recruitment and retention of PAs to rural populations also emerged. Improvement in enabling legislation contributes to the utilization of PAs in America.

Undergraduate Rural Medical Education Program Development: Focus Group Consultation With the NRHA Rural Medical Educators Group
Laura H. Downey, John R. Wheat, James D. Leeper, Joseph A. Florence, James G. Boulger and Matt L. Hunsaker

Context: Over a decade ago, leaders in rural medical education established the Rural Medical Educators (RME) Group, an interest group within the National Rural Health Association, to support faculty in rural medical education programs. This group has convened an annual RME conclave since 2006. In 2008, this conclave convened 15 national leaders in rural medical education at The University of Alabama.
Methods: In preparation for the conclave, potential participants were e-mailed a set of questions regarding their respective medical education program's initiating motivation, support, resistance, resources, accomplishments, and continuation plans. Analysis of participants' responses resulted in a question guide that was used at a focus group conducted at the conclave.
Purpose: The purpose of the focus group was to explore the experiences of established rural medical educators related to program development and maintenance. The focus group was recorded and transcribed, and then analyzed using the constant comparative method.
Findings: Five essential elements for rural medical education programs emerged from the analysis. The elements were: admit the right student, include curricular elements that occur and are required in rural training sites, establish a cadre of rural physicians who are dedicated to education of their successors, secure financial and relational support for the program, and evaluate program progress.
Discussion and Conclusions: Discussion about these 5 elements can provide program guidance to neophyte rural medical education programs. Five recommendations are presented in an effort to continue discussion about the essential elements and identify actions that rural medical educators can take to further assist developing programs.

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

Contents: 2011; 16:(2)
Issue includes:

The supply of physicians and care for breast cancer in Ontario and California, 1998 to 2006
Kevin M. Gorey, Isaac N. Luginaah, Caroline Hamm, Madhan Balagurusamy, Eric J. Holowaty

Introduction: We examined the differential effects of the supply of physicians on care for breast cancer in Ontario and California. We then used criteria for optimum care for breast cancer to estimate the regional needs for the supply of physicians.
Methods: Ontario and California registries provided 951 and 984 instances of breast cancer diagnosed between 1998 and 2000 and followed until 2006. These cohorts were joined with the supply of county-level primary care physicians (PCPs) and specialists in cancer care and compared on care for breast cancer.
Results: Significant protective PCP thresholds (7.75 to ≥ 8.25 PCPs per 10 000 inhabitants) were observed for breast cancer diagnosis (odds ratio [OR] 1.62), receipt of adjuvant radiotherapy (OR 1.64) and 5-year survival (OR 1.87) in Ontario, but not in California. The number of physicians seemed adequate to optimize care for breast cancer across diverse places in California and in most Ontario locations. However, there was an estimated need for 550 more PCPs and 200 more obstetrician-gynecologists in Ontario's rural and small urban areas. We estimated gross physician surpluses for Ontario's 2 largest cities.
Conclusion: Policies are needed to functionally redistribute primary care and specialist physicians. Merely increasing the supply of physicians is unlikely to positively affect the health of Ontarians.

Gallbladder disease in northwestern Ontario: the case for Canada's first rural ERCP program
Eric Touzin, Chris Decker, Len Kelly, Bryanne Minty

Introduction: The rate of cholecystectomy in northwestern Ontario is double the provincial rate. This paper explores the demographics of cholecystectomy and the role for rural endoscopic retrograde cholangiopancreatography (ERCP) services in the central part of this region.
Methods: We conducted a literature review of ERCP services and cholecystectomy rates, as well as a hospital chart review of patients who underwent laparoscopic cholecystectomies in Sioux Lookout, Ont. We contacted surgeons and gastroenterologists from referral centres in Winnipeg, Man., and Thunder Bay, Ont., for the charts of patients from our catchment area who underwent ERCP.
Results: Patients in our region who require urgent and emergent surgery are flown by fixed-wing aircraft to referral centres in Winnipeg and Thunder Bay for assessment and surgery. The rate of ERCP in our population is 150 in 100 000, which is threefold that of other populations, and our cholecystectomy rate is the highest in Ontario.
Conclusion: Substantial savings in transportation expenses would offset the development costs of an ERCP program and provide more integrated patient care. The volume of patients would support maintenance of competency. This rural area with a high rate of gallbladder disease would benefit from the development of a rural ERCP program.


Australian Journal of Rural Health

2011; 19:(1)
Issue includes:

As death approaches: A retrospective survey of the care of adults dying in Alice Springs Hospital
Fariba Nadimi and David C. Currow

Objective: Australians are more likely to die in a hospital than anywhere else, and most of these deaths are 'expected'. The aims of this survey were to identify if specific end-of-life issues were documented in clinical records of a regional hospital serving remote Australia.
Design: A retrospective consecutive case-note audit covering 18 months from 1 January 2006.
Setting: Alice Springs Hospital.
Participants: Adult deaths in Alice Springs Hospital. During this period there were 128 deaths.
Outcome measures: Demographic, process (diagnosis of dying documented, 'not for resuscitation' documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data ('comfort at end of life') were surveyed.
Results: Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in <48 hours, nine were coroner's cases and three files could no't be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an 'not for resuscitation' order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be 'comfortable' during the dying process with no differential outcomes for Aboriginal and non-Aboriginal decedents except age (P < 0.0001).
Conclusion: This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.

Stress and anxiety associated with lack of access to maternity services for rural parturient women
Jude Kornelsen, Kathrin Stoll and Stefan Grzybowski

Objective: The objective of this study is to compare the level of stress and anxiety between women resident in communities with different degrees of access to local maternity services.
Design: Cross-sectional survey.
Setting: Fifty-two communities across rural British Columbia with different levels of access to maternity care services (ranging from no services to local specialist obstetrician).
Participants: A total of 187 women, 40 of whom were from communities with no local access to services.
Main outcome measures: Stress score on the R ural Pregnancy Experience Scale including financial and continuity of care subscales.
Results: Parturient women who had to travel more than one hour to access services were 7.4 times more likely to experience moderate or severe stress when compared to women who had local access to maternity services.
Conclusions: Lack of access is strongly associated with stress in rural parturient women.

It's not just about the HbA1c, Doc! Understanding the psychosocial is also important in managing diabetes?
Charlie Greenfield, Marisa Gilles, Cynthia Porter, Peter Shaw and Kathy Willis

Objective: Despite significant efforts at a primary care level, at least 35% of people with diabetes fail to meet health targets. It is assumed that these poor results are a consequence of the patient not understanding their disease or not caring. This study seeks to understand what really lies behind poor control.
Design setting and participants: A qualitative study using semistructured interviews was conducted in a primary care setting in rural Western Australia. People living with diabetes for at least two years were specifically selected on the basis of whether they had either 'good' (HbA1c < 7%) or 'poor' (HbA1c > 8%) control.
Results: Interviews revealed that people understood only too well their disease and their responsibilities. Frequently, either they did not choose to make diabetes a priority in their lives or were unable to make appropriate lifestyle changes which were demanded for good blood sugar control. Their life/social stresses often influenced their glucose control.
Conclusion: Poor control in our study was not related to lack of knowledge but more to how diabetes was prioritised in their lives. Attention to the patients' priorities is required to accomplish improved glycaemic control.

Rural men's subjective well-being and the role of social support and sense of community: Evidence for the potential benefit of enhancing informal networks
Stephanie M. Kutek, Deborah Turnbull and A. Kate Fairweather-Schmidt

Objective: To examine the effects of social support and sense of community on rural men's subjective well-being, considering the main effects and stress-buffer models.
Design: Cross-sectional population-based survey, non-probability sampling frame primarily convenience sampling.
Setting: Community-based setting.
Participants: A total of 185 men aged 18+ years from rural South Australia.
Main outcome measures: Subjective well-being, measured by the Satisfaction With Life Scale.
Results: Two-step hierarchical multiple regression analysis was conducted, with subjective well-being as the dependent variable, controlling for independent variables of age, living alone and farm employment. Social support was the most effective predictor of well-being, followed by stress, and only a very modest contribution from sense of community; total variance explained was 56% (F(6,178) = 37.77, P < 0.001, R2 = 0.56, adjusted R2 = 0.55, R2 change = 0.07, P < 0.001). Stress partially mediated both the social support/well-being and sense of community/well-being relationships (mediation analysis).
Conclusions: Results demonstrated the benefits of social support on well-being using the stress-buffer and main effects models, within a sample of rural men, and explored the relatively unexamined relationship between sense of community and well-being. Rural men have considerable stress impacting their well-being. This study identifies that it is critical for individuals, organisations and policy makers to be aware of the capacity of both social supports and sense of community to buffer stress and promote well-being within rural men. Furthermore, structural, community-based approaches might have greater capacity to cost-effectively provide this support, contrasting with the growing trend towards individual-based approaches for mental health.

Psychological distress of rural parents: Family influence and the role of isolation
Denika J. Novello, Helen J. Stain, David Lyle and Brian J. Kelly

Objective: Research regarding psychological distress has often underestimated the importance of contextual social factors. This research aims to investigate patterns of psychological distress within the family system (parent dyads) across rural and remote communities and the influence of remoteness on such distress.
Design: Self-report survey data from the Australian Rural Mental Health Study was used to examine the distress levels of cohabitating parental figures in rural and remote Australia.
Setting: The survey was conducted across rural and remote communities within New South Wales.
Participants: The sample consisted of 129 adult couples (mean age = 42.66 years, SD = 8.11), 43 from Inner Regional areas, 48 from Outer Regional areas, 24 from Remote areas and 14 from Very Remote areas.
Main outcome measure: Distress levels (Kessler-10).
Results: A significant association was detected between the levels of psychological distress among parents within a household. The strength of this relationship increased with increasing remoteness of residence.
Conclusions: Identifying the influence of spousal factors on mental health in rural and remote areas allows health services in such regions to be aware of the needs of rural couples and families. These results support the need to consider partner/spouse mental health in clinical assessment and support the importance of household factors especially in remote communities.

Nursing workforce in very remote Australia, characteristics and key issues
Sue Lenthall, John Wakerman, Tess Opie, Sandra Dunn, Martha MacLeod, Maureen Dollard, Greg Rickard and Sabina Knight

Objective: To describe the nursing workforce in very remote Australia, characteristics and key issues.
Methods: Data were collected from four main sources: the refined CRANAplus database of remote health facilities; the 2006 census which provided population and percentage of Indigenous people in communities in very remote Australia; a national survey on occupational stress among nurses and an earlier study into violence and remote area nurses conducted in 1995. A descriptive analysis of the data was conducted.
Setting: Health facilities in very remote Australia.
Results: The registered nursing workforce in very remote Australia is mostly female (89%) and ageing, with 40.2% 50 years or over, compared to 33% nationally. Many (43%) are in remote Indigenous communities. Over the last decade, there has been a significant decrease in registered nurses with midwifery qualifications (55%) and in child health nurses (39%) in very remote Australia. Only 5% have postgraduate qualifications in remote health practice.
Conclusion: The nursing workforce in very remote areas of Australia is in trouble. The workforce is ageing, the numbers of nurses per population has fallen and the numbers of midwives and child health nurses have dropped significantly over the last 15 years. As many of these nurses work in Indigenous communities, if these trends continue it is likely to have a negative effect on 'closing the gap' in Indigenous health outcomes.

Survey of the rural allied health workforce in New South Wales to inform recruitment and retention
Sheila Keane, Tony Smith, Michelle Lincoln and Karin Fisher

Objective: To investigate the demographics, employment, education and factors affecting recruitment and retention of New South Wales (NSW) rural allied health professionals.
Design: Descriptive study, cross-sectional survey.
Setting: Regional, rural and remote areas of NSW, Australia.
Participants: The sample includes 1879 respondents from more than 21 different allied health occupations.
Main outcomes measures: Variables included gender, age, marital status, employment sector, hours worked, community size, highest qualification, rural origin and continuing education, as well as others. Certain variables were compared for profession and gender.
Results: Women made up 70% of respondents, with a mean age of 42 years. Men were older, with more experience. Sixty per cent were of rural origin and 74% partnered, most with their partner also working. Eighty-four per cent worked in centres of 10 000 or more people. The public sector accounted for 46% of positions and the private sector 40%. Eleven per cent worked across multiple sectors and 18% were self-employed. Two-thirds worked 35 hours or more per week, although only 49% were employed full-time. Job satisfaction was high but 56% intended leaving within 10 years, 28% to retire. Over 90% of respondents qualified in Australia and more than 80% held a degree or higher qualification. Almost half were dissatisfied with access to continuing education.
Conclusions: The NSW rural allied health workforce is strongly feminised, mature and experienced. Recruitment should target rural high school students and promote positive aspects of rural practice, such as diversity and autonomy. Retention strategies should include flexible employment options and career development opportunities

Teaching pathology via online digital microscopy: Positive learning outcomes for rurally based medical students
Sundram Sivamalai, Shashidhar Venkatesh Murthy, Tarun Sen Gupta and Torres Woolley

Introduction: Technology has revolutionised teaching. Teaching pathology via digital microscopy (DM) is needed to overcome increasing student numbers, a shortage of pathology academics in regional medical schools, and difficulties with teaching students on rural clinical placement.
Objective: To identify whether an online DM approach, combining digital pathology software, Web-based slides and classroom management software, delivers effective, practical pathology teaching sessions to medical students located both on campus and on rural placement.
Methods: An online survey collected feedback from fourth and fifth year undergraduate James Cook University medical students on the importance of 16 listed benefits and challenges of using online DM to teach pathology, via a structured five-point Likert survey.
Results: Fifty-three students returned the survey (response rate = 33%). Benefits of online DM to teach pathology rated as 'very important' or 'extremely important' by over 50% of students included: higher quality images; faster learning; more convenient; better technology; everyone sees the same image; greater accessibility; helpful annotations on slides; cost savings; and more opportunity for self-paced learning out-of-hours and for collaborative learning in class. Challenges of online DM rated as 'very important' or 'extremely important' by over 50% of students included: Internet availability in more remote locations and potential problems using online technology during class.
Conclusions: Nearly all medical students welcomed learning pathology via online digital technology. DM should improve the quantity, quality, cost and accessibility of pathology teaching by regional medical schools, and has significant implications for the growing emphasis in Australia for decentralised medical education and rural clinical placements.

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