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Journal Search

Journal Search - issue 3, 2011

AUTHOR

name here
Jennifer Richmond1
PhD, Editor in Chief *

CORRESPONDENCE

* Jennifer Richmond

AFFILIATIONS

1 RRH

PUBLISHED

30 September 2011 Volume 11 Issue 3

HISTORY

RECEIVED: 30 September 2011

ACCEPTED: 30 September 2011

CITATION

Richmond J.  Journal Search - issue 3, 2011. Rural and Remote Health 2011; 11: 1963. Available: www.rrh.org.au/journal/article/1963

AUTHOR CONTRIBUTIONS

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

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full article:

Journal Search brings Rural and Remote Health readers information about relevant recent publications. This issue includes recent rural health publications in North American and Australian rural health journals.

This issue contains abstracts from:

  • Journal of Rural Health 2011; 27: issue 3
  • Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine 2011; 16: issue 3
  • Australian Journal of Rural Health 2011; 19: issue 2.

USA

Journal of Rural Health

Contents: 2010; 27:(3)
Issue includes:

Socioeconomic Status and Injury in a Cohort of Saskatchewan Farmers
William Pickett, Andrew G. Day, Louise Hagel, Xiaoqun Sun, Lesley Day, Barbara Marlenga, Robert J. Brison, Punam Pahwa, Trever Crowe, Donald C. Voaklander and James Dosman

Purpose: To estimate the strength of relationships between socioeconomic status and injury in a large Canadian farm population.
Methods: We conducted a prospective cohort study of 4,769 people from 2,043 farms in Saskatchewan, Canada. Participants reported socioeconomic exposures in 2007 and were followed for the occurrence of injury through 2009 (27 months). The relative hazards of time to first injury according to baseline socioeconomic status were estimated via Cox proportional hazards models.
Findings: Risks for injury were not consistent with inverse socioeconomic gradients (adjusted HR 1.07; 95% CI: 0.76 to 1.51 for high vs low economic worry; adjusted HR 1.72; 95% CI: 1.23 to 2.42 for completed university education vs less than high school). Strong increases in the relative hazard for time to first injury were identified for longer work hours on the farm.
Conclusions: Socioeconomic factors have been cited as important risk factors for injury on farms. However, our findings suggest that interventions aimed at the prevention of farm injury are better focused on operational factors that increase risk, rather than economic factors per se.

A Trial of an All-Terrain Vehicle Safety Education Video in a Community-Based Hunter Education Program
Robert S. Williams, James Graham, James C. Helmkamp, Rhonda Dick, Tonya Thompson and Mary E. Aitken

Purpose: All-terrain vehicle (ATV) injury is an increasingly serious problem, particularly among rural youth. There have been repeated calls for ATV safety education, but little study regarding optimal methods or content for such education. The purpose of this study was to determine if an ATV safety video was effective in increasing ATV safety knowledge when used in a community-based statewide hunter education program.
Methods: During the baseline phase, surveys focusing on ATV safety were distributed to students in the Arkansas hunter safety program in 2006. In the intervention phase a year later, an ATV safety video on DVD was provided for use in required hunter education courses across Arkansas. The same survey was administered to hunter education students before and after the course.
Findings: In the baseline phase, 1,641 precourse and 1,374 postcourse surveys were returned and analyzed. In the intervention phase, 708 precourse and 694 postcourse surveys were completed. Student knowledge of ATV safety after watching the video was higher than in preintervention classes. Knowledge of appropriate helmet usage increased from 95% to 98.8% (P < .0001). Awareness of the importance of not carrying a passenger behind the driver increased from 59.5% to 91.1% (P < .0001). Awareness of importance of hands-on ATV rider training increased from 82.1% to 92.4% (P < .0001).
Conclusions: A brief ATV safety video used in a hunter education course increased ATV safety knowledge on most measures. A statewide hunter education program appears to be a useful venue for ATV safety education.

Pediatric Obesity Management in Rural Clinics in California and the Role of Telehealth in Distance Education
Ulfat Shaikh, Jasmine Nettiksimmons and Patrick R

Objective: To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth.
Methods: Cross-sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity.
Results: Most of the 135 respondents were family physicians at designated rural health clinics serving low-income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self-efficacy in managing pediatric obesity as 2 or 3 on a 5-point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three-quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web-based education, and interactive video case-conferencing.
Conclusions: Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.

Greek Children Living in Rural Areas Are Heavier but Fitter Compared to Their Urban Counterparts: A Comparative, Time-Series (1997-2008) Analysis
Konstantinos D. Tambalis, Demosthenes B. Panagiotakos and Labros S. Sidossis

Purpose: To compare 12-year (1997-2008) trends in the distribution of Body Mass Index (BMI) status and physical fitness test performances among 8- to 9-year-old Greek children living in rural and urban areas.
Methods: Population data derived from 11 national school-based health surveys conducted from 1997 to 2008. Anthropometric measurements and physical fitness test performances (ie, multistage shuttle run, vertical jump, small ball throw, and 30-meter sprint) from 725,163 children were analyzed. Distribution between rural and urban areas was based on the Hellenic National Statistics Service (HNSS) criteria.
Findings: Trend analysis showed an increase in the prevalence of obesity in children living in urban areas from 7.2% in 1997 to 11.3% in 2008 for girls (P < .001) and from 8.1% to 12.4% (P < .001) for boys. In rural areas, obesity increased from 7% in 1997 to 13% in 2008 for girls (P < .001), and from 8.2% to 14.1% (P < .001) for boys. The annual rate of obesity increase was 40%-50% higher in children from rural areas. Nevertheless, rural children presented better performances in all of the physical fitness tests examined. Specifically, mean values of aerobic performance decreased from 3.58 ± 1.9 stages in 1997 to 3.02 ± 2.1 stages in 2007 for boys (P < .001), and from 2.97 ± 1.5 stages to 2.53 ± 1.7 stages (P < .001) for girls in urban areas, whereas in rural areas, the correspondent values were not significantly different between 1997 and 2007.
Conclusions: Childhood obesity rates are higher in rural compared with urban areas in Greece, despite an apparent higher fitness level of children living in rural areas.

Postpartum Depression Among Rural Women From Developed and Developing Countries: A Systematic Review
Laura Villegas, Katherine McKay, Cindy-Lee Dennis and Lori E. Ross

Purpose: Postpartum depression (PPD) is a significant public health problem, with significant consequences for the mother, infant, and family. Available research has not adequately examined the potential impact of sociodemographic characteristics, such as place of residence, on risk for PPD. Therefore, this systematic review and meta-analysis examines the prevalence of and risk factors for PPD in rural communities within developed and developing countries, and where possible, compares rates to those among urban women.
Methods: Five databases were searched, from start dates through early May 2010, using key words relevant to PPD and rural residence. Peer-reviewed articles were eligible if a standardized assessment of depression was administered to rural mothers within the first year postpartum. Data on PPD were extracted from 19 articles, of which 17 provided data for meta-analyses.
Findings: The overall prevalence of PPD among rural women was 27.0% (95% CI, 18.8%-37.2%). Prevalence was somewhat higher among women in developing countries (31.3%; 95% CI, 21.3%-43.5%) than among women in developed countries (21.5%; 95% CI, 10.9%-38.0%), although there was significant heterogeneity among both groups of studies. Comparisons between rural and urban women yielded conflicting results. Although established PPD risk factors were associated with depression in rural women, additional risk factors were reported for rural women from developing countries, such as having 2 or more young children.
Conclusions: Longitudinal studies with clearly defined 'rural' and 'comparison' groups are needed to determine whether rural residence is associated with increased risk for PPD. The results can inform prevention and treatment programs tailored to serve rural women

The Health of Caregiving Grandmothers: A Rural-Urban Comparison
Jeri L. Bigbee, Carol Musil and Diane Kenski

Purpose: The purpose of this study was to compare the characteristics of rural versus urban caregiving grandmothers along with their physical and mental health status.
Methods: A secondary analysis of data produced from the first wave of a longitudinal study of 485 Ohio grandmothers was conducted. Health status was measured using the SF-36 Health Survey and the 20-item CES-D depression scale. Rural-urban classification was made using Rural Urban Commuting Area (RUCA) codes based on resident ZIP codes, identifying 97 rural and 388 urban grandmothers in the sample.
Findings: The rural and urban grandmothers were similar in age, educational level and employment status; however, 90% of the rural grandmothers compared with 60% of the urban grandmothers were white. Rural grandmothers were most likely to have traditional nonresidential relationships with their grandchildren. Approximately 38% of both the rural and urban grandmothers served as primary caregivers for their grandchildren, but a lower percentage of rural grandmothers lived in multigenerational homes. There was no significant difference between the rural and urban grandmothers in relation to physical or mental health. Among rural grandmothers, primary caregivers had significantly lower levels of mental health compared with the other caregiver groups.
Conclusions: These findings suggest that rural and urban grandmothers have similar levels of physical and mental health, despite differences in demographics and caregiving arrangements. Health promotion efforts with rural caregiving grandparents are indicated, addressing both mental and physical health.

A 'Medical Mission' at Home: The Needs of Rural America in Terms of Otolaryngology Care
Ryan Winters, Anna Pou and Paul Friedlander

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic-affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the 'medical mission' model employed in international outreach clinics.
Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau.
Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison).
Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing 'safety net' health care resources.

Cancer Screening Practices Among Amish and Non-Amish Adults Living in Ohio Appalachia
Mira L. Katz, Amy K. Ferketich, Electra D. Paskett, Amy Harley, Paul L. Reiter, Stanley Lemeshow, Judith A. Westman, Steven K. Clinton and Clara D. Bloomfield

Purpose: The Amish, a unique community living in Ohio Appalachia, have lower cancer incidence rates than non-Amish living in Ohio Appalachia. The purpose of this study was to examine cancer screening rates among Amish compared to non-Amish adults living in Ohio Appalachia and a national sample of adults of the same race and ethnicity in an effort to explain cancer patterns.
Methods: Face-to-face interviews focusing on perception of risk, cancer screening behaviors, and screening barriers were conducted among Amish (n = 134) and non-Amish (n = 154) adults living in Ohio Appalachia. Cancer screening rates were calculated and then compared to a national sample of adults.
Findings: More Ohio Appalachia non-Amish males (35.9% vs 14.5%; P= .022) and females (33.3% vs 12.5%; P= .008) reported that they would probably develop cancer in the future compared to Amish males and females. Amish adults had significantly lower prostate (13.5% vs 63.1% vs 44.6%; P < .001), colorectal (males: 10.3% vs 40.0% vs 37.2%, females: 8.6% vs 31.6% vs 42.9%; P < .001), cervical (48.0% vs 84.0% vs 80.0%; P < .001), and female breast (24.8% vs 53.7% vs 56.9%; P < .05) cancer screening rates compared to Ohio Appalachia non-Amish participants and a national sample of adults, respectively. Barriers to cancer screening were similar among the 2 Ohio groups; however, Amish males reported that prostate cancer screening was not necessary more often than did Ohio Appalachia non-Amish males (78.6% vs 16.7%; P= .003).
Conclusions: Lower rates of cancer screening were documented among the Amish and may be a contributing factor to the reduced cancer incidence rates reported among this population.

Talking About, Knowing About HIV/AIDS in Canada: A Rural-Urban Comparison
Tiffany C. Veinot and Roma Harris

Purpose: To explore information exchange about HIV/AIDS among people living in rural and urban communities and to assess the value of social capital theory, as well as demographic factors, in predicting community members' knowledge of HIV/AIDS and their likelihood of having talked about the disease.
Method: A random-digit dial telephone survey was conducted in 3 rural regions and matched urban communities in Canada during 2006 and 2007. A total of 1,919 respondents (response rate: 22.2%) answered questions about their knowledge of and attitudes toward HIV/AIDS, their social networks, whether they were personally acquainted with a person with HIV/AIDS (PHA), and whether they had ever talked to anyone about HIV/AIDS.
Findings: Rurality was a significant predictor of HIV/AIDS knowledge and discussion. Even after controlling for factors such as age and level of education, respondents living in rural regions were less knowledgeable about HIV/AIDS and were less likely to have spoken with others about the disease. Social capital theory was not as strongly predictive as expected, although people with more bridging ties in their social networks were more likely to have discussed the disease, as were those who knew a PHA personally.
Conclusion: Rural-dwelling Canadians are less likely than their urban counterparts to be knowledgeable about HIV/AIDS or to talk about it, confirming reports by PHAs that rural communities tend to be silent about the disease. The findings support policy recommendations for HIV education programs in rural areas that encourage discussion about the disease and personal contact with PHAs.

Primary Care Clinicians' Perspectives on Management of Skin and Soft Tissue Infections: An Iowa Research Network Study
Jeanette M. Daly, John W. Ely, Barcey T. Levy, Tara C. Smith, Mary L. Merchant, George R. Bergus and Gerald J. Jogerst

An estimated 95,000 people developed methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005 of which 14% were community-associated and 85% were hospital or other health setting associated, and 19,000 Americans died from these infections that year.
Purpose: To explore health care providers' perspectives on management of skin and soft tissue infections to gain a better understanding of the problems faced by busy providers in primary care settings.
Methods: Focus group meetings were held at 9 family physician offices in the Iowa Research Network. Seventy-eight clinicians including physicians, nurses, nurse practitioners, and house officers attended. Meeting audiotapes were transcribed and coded by 3 investigators, and a MRSA-management taxonomy was developed.
Findings: The main themes that emerged from the focus groups included epidemiology, diagnosis, treatment, management, prevention, special populations, and public relations. The incidence of MRSA infections was perceived to have increased over the past decade. However, diagnosis and treatment protocols for physicians in the outpatient setting have lagged behind, and no well-accepted diagnostic or treatment algorithms were used by physicians attending the focus groups.
Conclusion: The clinicians in this study noted considerable confusion and inconsistency in the management of skin and soft tissue infections, particularly those due to MRSA.

Meaningful Use of Health Information Technology by Rural Hospitals
Jeffrey McCullough, Michelle Casey, Ira Moscovice and Michele Burlew

Purpose: This study examines the current status of meaningful use of health information technology (IT) in Critical Access Hospitals (CAHs), other rural, and urban US hospitals, and it discusses the potential role of Medicare payment incentives and disincentives in encouraging CAHs and other rural hospitals to achieve meaningful use.
Methods: Data from the American Hospital Association (AHA) Annual Survey IT Supplement were analyzed, using t tests and probit regressions to assess whether implementation rates in CAHs and other rural hospitals are significantly different from rates in urban hospitals.
Findings: Of the many measures we examined, only 4 have been met by a majority of rural hospitals: electronic recording of patient demographics and electronic access to lab reports, radiology reports, and radiology images. Meaningful use is even less prevalent among CAHs. We also find that rural hospitals lag behind urban institutions in nearly every measure of meaningful use. These differences are particularly large and significant for CAHs.
Conclusion: The meaningful use incentive system creates many challenges for CAHs. First, investments are evaluated and subsidies determined after adoption. Thus, CAHs must accept financial risk when adopting health IT; this may be particularly important for large expenditures. Second, the subsidies may be low for relatively small expenditures. Third, since the subsidies are based on observable costs, CAHs will receive no support for their intangible costs (eg, workflow disruption). A variety of policies may be used to address these problems of financial risk, uncertain returns in a rural setting, and limited resources.

Canada

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

Contents: 2011; 16:(4)
Issue includes:

Accuracy of the Broselow tape in estimating the weight of First Nations children
Stephanie Bourdeau, Julie Copeland, W. Ken Milne,

Introduction: During resuscitation, the Broselow tape (BT) is the standard method of estimating pediatric weight based on body length. The First Nations population has a higher prevalence of obesity and experiences more injury than the non-First Nations population. The prevalence of obesity has raised the concern that the BT may not accurately estimate weight in this population. The purpose of this study was to validate the BT in 8 First Nations communities.
Methods: We performed a search of the electronic medical records of 2 community health centres that serve 8 local First Nations communities. We searched for the most recent clinic visit during which height and weight had been recorded in the records of patients less than 10 years of age with a postal code indicating residence in a First Nations community. The patients' actual weight was compared with their BT weight estimates using the Bland-Altman method. The Spearman coefficient of rank and percentage error was also calculated.
Results: A total of 243 children were included in the study (119 girls, 124 boys). The mean age was 33.3 months (95% confidence interval [CI] 29.7 to 36.9), mean height was 91.8 cm (95% CI 89.0 to 94.6), mean weight was 16.2 kg (95% CI 15.0 to 17.3) and mean BT weight was 14.0 kg (95% CI 13.1 to 14.8). The Bland-Altman percent difference was 11.9% (95% CI -17.3% to 41.1%). The Spearman coefficient of rank correlation was 0.963 (p < 0.001). The BT had a percentage error greater than 10% error 51.8% of the time, with 49.4% being underestimations.
Conclusion: The BT was often not accurate at estimating the weight of children in 8 First Nations communities; it underestimated their weight almost half of the time.

Delivering away from home: the perinatal experiences of First Nations women in northwestern Ontario
Terry O'Driscoll, Len Kelly, Lauren Payne, Natalie St. Pierre-Hansen, Helen Cromarty, Bryanne Minty, Barb Linkewich

Introduction: Our objective was to understand the perinatal knowledge and experiences of First Nations women from northwestern Ontario who travel away from their remote communities to give birth.
Methods: A systematic review of MEDLINE, HealthSTAR, HAPI, Embase, AMED, PsycINFO and CINAHL was undertaken using Medical Subject Headings and keywords focusing on Canadian Aboriginal (First Nations, Metis and Inuit) prenatal education and care, and maternal health literacy. This qualitative study using semistructured interviews was conducted in a rural hospital and prenatal clinic that serves First Nations women. Thirteen women from remote communities who had travelled to Sioux Lookout, Ont., to give birth participated in the study.
Results: We identified 5 other qualitative studies that explored the birthing experiences of Aboriginal women. The studies documented a negative experience for women who travelled to access intrapartum maternity care. While in Sioux Lookout to give birth, our participants also experienced loneliness and missed their families. They were open to the idea of a culturally appropriate doula program and visits in hospital by First Nations elders, but they were less interested in access to tele-visitation with family members back in their communities. We found that our participants received most of their prenatal information from family members.
Conclusion: First Nations women who travel away from home to give birth often travel great cultural and geographic distances. Hospital-based maternity care programs for these women need to achieve a balance of clinical and cultural safety. Programs should be developed to lessen some of the negative consequences these women experience.

Australia

Australian Journal of Rural Health

2011; 19:(2)
Issue includes:

Estimation of the reproductive number for the 2009 pandemic H1N1 influenza in rural and metropolitan New South Wales
David Buckley and David Bulger

Objective: During the early stages of pandemics, when resource planning occurs, the epidemiological parameters of the agent are often poorly described. These estimates are typically derived from metropolitan centres. This paper examines the spread of the 2009 pandemic H1N1 virus in rural and regional New South Wales compared with metropolitan centres.
Design: Retrospective statistical analysis of longitudinal data.
Setting: Ecological examination of spread of influenza in the general community of New South Wales, Australia.
Participants: Number of notified infections with novel pandemic H1N1 influenza in rural/regional (n = 241) and metropolitan (n = 1788) health service areas of New South Wales during the period 1 June 2009 and 12 July 2009.
Main outcome measures: A comparison of the reproductive number for the 2009 pandemic H1N1 in rural/regional and metropolitan New South Wales.
Results: The reproductive number of the pandemic H1N1 in rural New South Wales was 1.26 (95% confidence interval (CI), 1.22-1.30) compared with estimates of metropolitan New South Wales of 1.28 (95% CI, 1.26-1.30). This difference was not statistically significant (P = 0.314). These estimates are lower than those previously published and of the order of magnitude typically observed with seasonal flu. This was consistent with the clinical observations in Greater Southern Area Health Service.
Conclusion: The apparent invariance in the rate of spread of influenza between rural and metropolitan areas should provide rural health care providers with confidence in metropolitan derived estimates when planning in future influenza pandemics

Rural adolescents' help-seeking intentions for emotional problems: The influence of perceived benefits and stoicism
Janaki Rughani, Frank P. Deane and Coralie J. Wilson

Objective: This study explores the factors that influence adolescents' help-seeking intentions. Specifically, the study investigates the extent to which perceived benefits of help seeking, stoicism, gender and symptoms of psychological distress are associated with intentions to seek professional help for emotional problems.
Design and setting: A cross sectional self-report questionnaire was administered to adolescents recruited from seven high schools in rural towns in the Riverina region of New South Wales.
Participants: A total of 778 adolescents were recruited. The sample included 373 male and 404 female participants between 13 and 18 years of age.
Main outcome measure(s): Participants completed an anonymous self-report questionnaire designed to measure help-seeking intentions in the advent that they were to experience emotional problems, psychological distress symptoms, perceived benefits of help seeking and stoicism.
Results: In all, 17% of male participants and 29% of female participants reported they would be likely to seek help from doctors if they were to experience emotional problems. In total, 15% of male participants and 23% of female participants reported they would be likely to seek help from other health care professionals. Multiple regression analysis suggested that adolescents are more likely to seek help from professionals if they perceive help seeking as beneficial (t = 12.91; P < 0.001). Female particpants reported that they were more likely to seek help than male participants (t = 2.69; P = 0.01).
Conclusions: Findings suggest that adolescents are reluctant to seek professional help if experiencing emotional problems, because they do not believe professional help seeking is beneficial. Improving adolescents' beliefs about the benefits of professional help seeking might be a key strategy for increasing their use of professional health services to address mental health problems.

Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa
Kristin E. McBain-Rigg and Craig Veitch

Objective: Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non-Indigenous health professionals in north-west Queensland assist to refine the meaning of this term and uncovered other issues disguised as 'cultural' difference.
Design: Semistructured interviews with community and health professionals.
Setting: Mount Isa, Queensland, Australia.
Participants: Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009.Results: Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships.
Conclusions: For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.

The SOMERS Index: A simple instrument designed to predict the likelihood of rural career choice
George T. Somers, Brian Jolly and Roger P. Strasser

Objective: The World Health Organization has drawn up a set of strategies to encourage health workers to live and work in remote and rural areas. A comprehensive instrument designed to evaluate the effectiveness of such programs has not yet been tested. Factors such as Stated rural intention, Optional rural training, Medical sub-specialization, Ease (or self-efficacy) and Rural Status have been used individually or in limited combinations. This paper examines the development, validity, structure and reliability of the easily-administered SOMERS Index.
Design: Limited literature review and cross-sectional cohort study.
Setting: Australian medical school.
Participants: A total of 345 Australian undergraduate-entry medical students in years 1 to 4 of the 5-year course.
Main outcome measures: Validity of the factors as predictors of rural career choice was sought in the international literature. Structure of the index was investigated through Principal Components Analysis and regression modelling. Cronbach's alpha was the test for reliability.
Results: The international literature strongly supported the validity of the components of the index. Factor analysis revealed a single, strong factor (eigenvalue: 2.78) explaining 56% of the variance. Multiple regression modelling revealed that each of the other variables contributed independently and strongly to Stated Rural Intent (semi-partial correlation coefficients range: 0.20-0.25). Cronbach's alpha was high at 0.78.
Conclusions: This paper presents the reliability and validity of an index, which seeks to estimate the likelihood of rural career choice. The index might be useful in student selection, the allocation of rural undergraduate and postgraduate resources and the evaluation of programs designed to increase rural career choice.

Measuring rural allied health workforce turnover and retention: What are the patterns, determinants and costs?
Marita Chisholm, Deborah Russell and John Humphreys

Objectives: To measure variations in patterns of turnover and retention, determinants of turnover, and costs of recruitment of allied health professionals in rural areas.
Design: Data were collected on health service characteristics, recruitment costs and de-identified individual-level employment entry and exit data for dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, social workers and speech pathologists employed between 1 January 2004 and 31 December 2009.
Setting: Health services providing allied health services within Western Victoria were stratified by geographical location and town size. Eighteen health services were sampled, 11 participated.
Main outcome measures: Annual turnover rates, stability rates, median length of stay in current position, survival probabilities, turnover hazards and median costs of recruitment were calculated.
Results: Analysis of commencement and exit data from 901 allied health professionals indicated that differences in crude workforce patterns according to geographical location emerge 12 to 24 months after commencement of employment, although the results were not statistically significant. Proportional hazards modelling indicated profession and employee age and grade upon commencement were significant determinants of turnover risk. Costs of replacing allied health workers are high.
Conclusions: An opportunity for implementing comprehensive retention strategies exists in the first year of employment in rural and remote settings. Benchmarks to guide workforce retention strategies should take account of differences in patterns of allied health turnover and retention according to geographical location. Monitoring allied health workforce turnover and retention through analysis of routinely collected data to calculate selected indicators provides a stronger evidence base to underpin workforce planning by health services and regional authorities.

The initial 18 months of the first multi-disciplinary regional Pulmonary Arterial Hypertension Clinic in Australia
Hanish Bagga, Karen S.W. Chia, Diane Freeman, Lyn Hales, David S. Henderson, Eugene Kotlyar, David Law, Pradeen Mudholkar, Cheryl Tulk, Jon H. Waites and Peter K.K. Wong

Objective: To report the initial 18 months experience of the first multi-disciplinary regional Pulmonary Arterial Hypertension (PAH) Clinic in Australia.
Design: Prospective cohort study.
Setting: Community setting on the mid-north coast of New South Wales.
Participants: A total of 47 patients (mean age ± standard error of the mean: 71.8 ± 1.8 years; male/female ratio 13/34).
Main outcome measures: Diagnosis of PAH, exclusion of other causes of pulmonary hypertension, commencement of PAH-specific pharmacotherapy.
Results: Twenty-three (49%) patients were discharged back to their GP with pulmonary hypertension from a combination of ischaemic heart and/or lung disease. Three (6%) patients died from connective tissue disease (CTD)-related PAH with one death (2%) from ischaemic heart disease. Five (11%) patients remain on treatment (n = 2, Bosentan for congenital heart disease-related PAH; n = 1 Bosentan for CTD-related PAH; and n = 1 Bosentan and n = 1 Sildenafil for primary PAH). Fifteen (32%) patients have ongoing review for PAH related to CTD (n = 11), carcinoid (n = 1) and uncertain cause (n = 3).
Conclusion: Patients with CTD-related PAH have a poor prognosis. PAH should be considered in anyone with dyspnoea without obvious features of cardiac or pulmonary disease, especially in the setting of a CTD. Regional population centres are under-resourced with PAH specialty medical services. We have sought to address this by establishment of the first regional multi-disciplinary PAH Clinic in Australia.

Management of chronic Hepatitis B infection in the remote primary health care setting: The search for a suitable guideline
Virginia Cross and Sarah Larkins

Objective: To identify a regionally appropriate guideline for the primary health care management of chronic Hepatitis B patients in the Torres Strait.
Design: Literature review. PubMed (1950-November 2009), Nursing and allied health (CINAHL)-CD (1982-November 2009), and the following databases accessed through INFORMIT: Australian Public Affairs Information Service - Health (1978-November 2009), Aboriginal and Torres Strait Health Bibliography (1900-November 2009), Health & Society Database (1980-November 2009), Health Collection (1980-November 2009), Meditext (1968-November 2009), and Rural and Remote Health Database (1966-January 2006) were searched over a 3-month period from September to November 2009. An Internet search of relevant guidelines and recommendations from professional bodies such as the World Health Organization was also performed.
Setting: Remote primary health care.
Outcome measures: Initial searching identified 144 articles to include based on the provision of recommendations or guidelines for management of Hepatitis B at the primary care level. Included articles were then reviewed for their appropriateness to the remote primary health care setting against a set of five criteria determined at a consensus meeting of eight local medical officers.
Results: Eleven articles were included for final review of which none met all five criteria of appropriateness for the remote primary health care setting.
Conclusions: Guidelines need to recognize the difficulties of rural and remote practice and present practical alternatives to urban centred recommendations.