Journal Search

Journal Search - issue 4, 2011


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Jennifer Richmond
1 PhD, Editor in Chief *


* Jennifer Richmond


1 Rural and Remote Health


20 December 2011 Volume 11 Issue 4


RECEIVED: 20 December 2011

ACCEPTED: 20 December 2011


Richmond J.  Journal Search - issue 4, 2011. Rural and Remote Health 2011; 11: 2036.


© 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 contains abstracts from:

  • Journal of Rural Health 2011; 27: issue 4
  • Australian Journal of Rural Health 2011; 19: issue 5.

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 4
  • Australian Journal of Rural Health 2011; 19: issue 5.


Journal of Rural Health

Contents: 2011; 27:(4)
Issue includes:

Environmental Carcinogen Releases and Lung Cancer Mortality in Rural-Urban Areas of the United States
Juhua Luo and Michael Hendryx

Purpose: Environmental hazards are unevenly distributed across communities and populations; however, little is known about the distribution of environmental carcinogenic pollutants and lung cancer risk across populations defined by race, sex, and rural-urban setting.
Methods: We used the Toxics Release Inventory (TRI) database to conduct an ecological study at the county level (a total of 3,141 counties). Multiple linear regressions were used to assess the associations of carcinogenic discharges from TRI sites and lung cancer mortality rates at the county level in the United States during the years 1990 through 2007.
Findings: We observed an excess risk of population lung cancer mortality associated with higher amounts of environmental carcinogen releases from TRI facilities in both males and females, and in both whites and African Americans. The strength of these associations tended to be stronger in African Americans. A significant dose-response relationship was observed for the total volume of carcinogen releases or carcinogen releases to the air, but not releases to water. These associations appeared to be present within nonmetropolitan counties but not metropolitan counties, and to be concentrated in certain urban-rural county typologies.
Conclusions: Our results suggest that exposure to higher carcinogen releases from industrial or chemical facilities in rural areas may increase the risk of lung cancer mortality. Our findings add to the evidence for undertaking prudent efforts to limit the release of carcinogenic chemicals into the environment.

Chronic Cardiovascular Disease Mortality in Mountaintop Mining Areas of Central Appalachian States
Laura Esch and Michael Hendryx

Purpose: To determine if chronic cardiovascular disease (CVD) mortality rates are higher among residents of mountaintop mining (MTM) areas compared to mining and nonmining areas, and to examine the association between greater levels of MTM surface mining and CVD mortality.
Methods: Age-adjusted chronic CVD mortality rates from 1999 to 2006 for counties in 4 Appalachian states where MTM occurs (N = 404) were linked with county coal mining data. Three groups of counties were compared: MTM, coal mining but not MTM, and nonmining. Covariates included smoking rate, rural-urban status, percent male population, primary care physician supply, obesity rate, diabetes rate, poverty rate, race/ethnicity rates, high school and college education rates, and Appalachian county. Linear regression analyses examined the association of mortality rates with mining in MTM areas and non-MTM areas and the association of mortality with quantity of surface coal mined in MTM areas.
Findings: Prior to covariate adjustment, chronic CVD mortality rates were significantly higher in both mining areas compared to nonmining areas and significantly highest in MTM areas. After adjustment, mortality rates in MTM areas remained significantly higher and increased as a function of greater levels of surface mining. Higher obesity and poverty rates and lower college education rates also significantly predicted CVD mortality overall and in rural counties.
Conclusions: MTM activity is significantly associated with elevated chronic CVD mortality rates. Future research is necessary to examine the socioeconomic and environmental impacts of MTM on health to reduce health disparities in rural coal mining areas.

The Relationship Between Toxics Release Inventory Discharges and Mortality Rates in Rural and Urban Areas of the United States
Michael Hendryx and Evan Fedorko

Background: Potential environmental exposures from chemical manufacturing or industrial sites have not been well studied for rural populations. The current study examines whether chemical releases from facilities monitored through the Toxics Release Inventory (TRI) program are associated with population mortality rates for both rural and urban populations.
Methods: We used the TRI database, Centers for Disease Control and Prevention age-adjusted mortality data, and additional county-level covariate data to conduct a national study at (N = 3,142) of the association between amounts of on-site TRI air and water releases for the years 1988-2006 and total age-adjusted mortality rates for the years 1999-2006, after controlling for the effects of other risk variables.
Results: Results of multiple linear regression analyses indicated significantly higher adjusted mortality rates associated with greater water and air releases in both rural and urban counties. The strongest associations between TRI releases and rural mortality rates were found when 8 or more prior years of TRI release data were used to study subsequent mortality.
Conclusion: The results support the use of the TRI as a public reporting tool and a research tool, and demonstrate that greater amounts of air and water TRI releases are related to mortality outcomes for both rural and urban populations.

A National Study of the Association Between Food Environments and County-Level Health Outcomes
Melissa Ahern, Cheryl Brown and Stephen Dukas

Purpose: This national, county-level study examines the relationship between food availability and access, and health outcomes (mortality, diabetes, and obesity rates) in both metro and non-metro areas.
Methods: This is a secondary, cross-sectional analysis using Food Environment Atlas and CDC data. Linear regression models estimate relationships between food availability and access variables (direct-to-consumer farm sales, per capita grocery stores, full-service restaurants, fast food restaurants, and convenience stores) with health outcomes. Controls include smoking, race/ethnicity, gender, age, education, poverty, primary care availability, recreational facility availability, and mobility/distance-from-grocery-store.
Findings:Non-metro findings: Lower adjusted mortality rates were associated with more per capita full-service restaurants and grocery stores, and greater per capita direct farm sales. Lower adjusted diabetes rates were associated with a lower per capita supply of fast food restaurants and convenience stores, and more per capita full-service restaurants and grocery stores. Lower adjusted obesity rates were associated with more per capita full-service restaurants and grocery stores. Unexpectedly, obesity rates were positively associated with per capita grocery stores and negatively associated with fast food restaurants. Metro findings: More per capita full-service restaurants, grocery stores, and direct farm sales are associated with positive health outcomes; fast food restaurants and convenience stores are associated with negative health outcomes.
Conclusions: The food access/availability environment is an important determinant of health outcomes in metro and non-metro areas. Future research should focus on more refined specifications that capture variability across non-metro settings.

Uptake of Free HPV Vaccination Among Young Women: A Comparison of Rural Versus Urban Rates
Richard A. Crosby, Baretta R. Casey, Robin Vanderpool, Tom Collins and Gregory R. Moore

Purpose: To contrast rates of initial HPV vaccine uptake, offered at no cost, between a rural clinic, a rural community college, and an urban college clinic and to identify rural versus urban differences in uptake of free booster doses.
Methods: Young rural women attending rural clinics (n = 246), young women attending a rural community college (n = 251) and young women attending an urban university health clinic (n = 209) were recruited in Kentucky. After completing a brief questionnaire, women received a free voucher for HPV vaccination. Whether women redeemed the voucher for the initial dose of vaccine served as the study outcome variable.
Findings: In controlled analyses, the contrast in initial uptake between urban clinic women (reference category) and rural college women was significant (P < .0001). However, the contrast in initial uptake between urban clinic women (reference category) and rural clinic women was not significant (P = .42). The model predicting uptake of subsequent doses among those with initial uptake (n = 235) also indicated significant differences as a function of recruitment location, with rural clinic women being about 7 times more likely than urban clinic women (P < .0001) to not return for at least 1 follow-up dose. The contrast between urban clinic women and rural college women was also significant (P = .014).
Conclusion: Initial uptake of free HPV vaccination among young rural college women may be problematic. Moreover, uptake of subsequent free doses among rural women may be problematic regardless of whether contact is made in a clinic or through college recruitment.

To Give or Not to Give: Approaches to Early Childhood Immunization Delivery in Oregon Rural Primary Care Practices
Lyle J. Fagnan, Scott A. Shipman, James A. Gaudino, Jo Mahler, Andrew L. Sussman and Jennifer Holub

Context: Little is known about rural clinicians' perspectives regarding early childhood immunization delivery, their adherence to recommended best immunization practices, or the specific barriers they confront.
Purpose: To examine immunization practices, beliefs, and barriers among rural primary care clinicians for children in Oregon and compare those who deliver all recommended immunizations in their practices with those who do not.
Methods: A mailed questionnaire was sent to all physicians, nurse practitioners, and physician assistants practicing primary care in rural communities throughout Oregon.
Findings: While 39% of rural clinicians reported delivering all childhood immunizations in their clinic, 43% of clinicians reported that they refer patients elsewhere for some vaccinations, and 18% provided no immunizations in the clinic whatsoever. Leading reasons for referral include inadequate reimbursement, parental request, and storage and stocking difficulties. Nearly a third of respondents reported that they had some level of concern about the safety of immunizations, and 14% reported that concerns about safety were a specific reason for referring. Clinicians who delivered only some of the recommended immunizations were less likely than nonreferring clinicians to have adopted evidence-based best immunization practices.
Conclusions: This study of rural clinicians in Oregon demonstrates the prevalence of barriers to primary care based immunization delivery in rural regions. While some barriers may be difficult to overcome, others may be amenable to educational outreach and support. Thus, efforts to improve population immunization rates should focus on promoting immunization 'best practices' and enhancing the capacity of practices to provide immunizations and ensuring that any alternative means of delivering immunizations are effective.

In-Hospital Mortality Among Rural Medicare Patients With Acute Myocardial Infarction: The Influence of Demographics, Transfer, and Health Factors
Kyle J. Muus, Alana D. Knudson, Marilyn G. Klug and Joshua Wynne

Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients.
Methods: Cross-sectional retrospective analyses on 2003-2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in-hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared.
Results: Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no-transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in-hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients.
Conclusions: Transfer was associated with a greater likelihood of in-hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in-hospital mortality among nontransfers, such as patients' health care decision-making.

Similar Secondary Stroke Prevention and Medication Persistence Rates Among Rural and Urban Patients
Daniel Rodriguez, Margueritte Cox, Louise O. Zimmer, DaiWai M. Olson, Larry B. Goldstein, Laura Drew, Eric D. Peterson and Cheryl D. Bushnell, for the AVAIL Investigators

Purpose: Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke.
Methods: The Adherence eValuation After Ischemic Stroke-Longitudinal (AVAIL) study is a multicenter registry of stroke patients enrolled in 101 hospitals nationwide. Medications were recorded at hospital discharge and again after 3 and 12 months. Persistence was defined as continuation of prescribed discharge medications. Participants were categorized as living in rural or urban settings by cross-referencing home ZIP code with metropolitan statistical area (MSA) designation.
Findings: Rural patients were younger, more likely to be white, married, smokers, and less likely to be college graduates. There was no difference in stroke type or working status compared to urban patients, and there were minor differences in comorbid conditions. There were no differences based on rural vs urban residence in medication persistence at 3 or 12 months postdischarge and no differences in outcomes of recurrent stroke or rehospitalization at 12 months.
Conclusion: Despite differences in patient characteristics, there was no difference in medication persistence or outcomes between rural and urban dwellers after hospitalization for ischemic stroke or transient ischemic attack (TIA).

Rural Adolescent Alcohol, Tobacco, and Illicit Drug Use: A Comparison of Students in Victoria, Australia, and Washington State, United States
Kerri Coomber, John W. Toumbourou, Peter Miller, Petra K. Staiger, Sheryl A. Hemphill and Richard F. Catalano

Purpose: There are inconsistent research findings regarding the impact of rurality on adolescent alcohol, tobacco, and illicit substance use. Therefore, the current study reports on the effect of rurality on alcohol, tobacco, and illicit drug use among adolescents in 2 state representative samples in 2 countries, Washington State (WA) in the United States and Victoria (VIC) in Australia.
Participants: The International Youth Development Study (IYDS) recruited representative samples of students from Grade 7 (aged 12 to 13 years) and Grade 9 (aged 14 to 15) in both states. A total of 3,729 students responded to questions about alcohol, tobacco, cannabis, and other illicit substance use (nVIC= 1,852; nWA= 1,877). In each state, males and females were equally represented and ages ranged from 12 to 15 years.
Methods: Data were analyzed to compare lifetime and current (past 30 days) substance use for students located in census areas classified as urban, large or small town, and rural. Findings were adjusted for school clustering and weighted to compare prevalence at median age 14 years.
Findings: Rates of lifetime and current alcohol, tobacco, and cannabis use were significantly higher in rural compared to urban students in both states (odds ratio for current substance use = 1.31).
Conclusions: In both Washington State and Victoria, early adolescent rural students use substances more frequently than their urban counterparts. Future studies should examine factors that place rural adolescents at risk for alcohol, tobacco, and illicit drug use.

Partnering With Communities to Address the Mental Health Needs of Rural Veterans
JoAnn E. Kirchner, Mary Sue Farmer, Valorie M. Shue, Dean Blevins and Greer Sullivan

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF).
Methods: Three community stakeholder groups-clergy, postsecondary educators, and criminal justice personnel-are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center-based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas.
Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2-hour workshop and an intensive 2.5-day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments.
Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.

VA Community Mental Health Service Providers' Utilization of and Attitudes Toward Telemental Health Care: The Gatekeeper's Perspective
John Paul Jameson, Mary Sue Farmer, Katharine J. Head, John Fortney and Cayla R. Teal

Context: Mental health (MH) providers in community-based outpatient clinics (CBOCs) are important stakeholders in the development of the Veterans Health Administration (VA) telemental health (TMH) system, but their perceptions of these technologies have not been systematically examined.
Purpose: The purpose of this study was to investigate the attitudes of CBOC providers about TMH services, current utilization of these technologies in their clinics, and sources of knowledge regarding TMH.
Method: The study employed a mixed-methods design to examine aspects of TMH in CBOCs located in a VA network in the south-central United States. Semistructured, on-site group interviews conducted with 86 CBOC MH providers were followed by in-depth phone surveys with an MH provider identified as a key informant at each of 36 CBOCs in the VA network.
Findings: The utilization of TMH services varied widely between CBOCs, and the scope of services provided typically focused on delivery of medication management, with little provision of psychological services. Further, several important barriers to expanded use of TMH were identified, including limited education and training and shortage of dedicated space for TMH encounters.
Conclusions: General attitudes toward TMH were positive, and most CBOC providers indicated that they would like to expand use of TMH in their clinics.


Australian Journal of Rural Health

2011; 19:(5)
Issue includes:

Improving the mental health of rural New South Wales communities facing drought and other adversities
Craig Richard Hart, Helen Louise Berry and Anne Maree Tonna

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought-related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought-related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods.
Setting: Rural NSW.
Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought-related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use.
Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health-related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health-related services.
Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought-related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long-term approach to funding such programs would be appropriate.

Rapid change, climate adversity and the next 'big dry': Older farmers' mental health
John David Polain, Helen Louise Berry and John Oliver Hoskin

Objective: To describe the experiences of older farmers in the face of prolonged drought and rapid change.
Design: Content analysis of issues and priorities raised in semi-structured community forums.
Setting: Rural centres in NSW.
Participants: One hundred and fifty older farmers, their families, Industry and Investment NSW, rural financial and mental health services, the Country Women's Association and other non-government agencies.
Intervention: Five public forums organised under the Rural Adversity Mental Health Program.
Results: Prolonged drought caused pressures on farmers that compounded the usual stresses of farming and of ageing. These were experienced in the context of rapid social and industry change, fuel price volatility and the insidious threat of climate change. Three main themes were articulated: loss, government compliance pressures and difficulties accessing and/or inappropriate services.
Conclusion: Older farmers felt an overwhelming sense of loss: of profitability and professional success, community status, physical well-being and comfort, the ability to participate in the modern world and, above all, of relationships (partners, children and friends moving away). They interpreted government compliance requirements as evidence of community and government loss of trust in famers. They resisted using the few mental health services that might be available, fearing being labelled as 'crazy' and discouraged by the culturally inappropriate way in which services were offered. Older farmers would benefit from joint services related to health and well-being simultaneously with modern business management offered in trusted, comfortable settings.

In their own words: Young people's mental health in drought-affected rural and remote NSW
Tracey-Lee Carnie, Helen Louise Berry, Susan Audrey Blinkhorn and Craig Richard Hart

Objective: To record the drought-related experiences of young people and to contrast these with their teachers' and other adults' observations.
Design: Content analysis of issues and priorities raised in semistructured school-based forums.
Setting: Rural schools in NSW centres.
Participants: Young people, their teachers and service providers.
Intervention: Six youth and community forums organised under the Rural Adversity Mental Health Program.
Results: Participants welcomed increased community connectedness in response to prolonged drought but reported that drought's mental health impact was mainly negative. Adults observed children's distress, wondering if anyone else noticed it. They witnessed young people worrying about their families, increasingly isolated, at risk of harm, unable to obtain help and facing educational and employment limitations. Young people disclosed many mental health and relationship difficulties at school and at home. They worried about their families, communities and futures and about money and being isolated.
Conclusion: Adults and young people reported similar effects of prolonged drought on young people's mental health. But, while adults were more concerned with risks to young people (of harm, abuse, homelessness, problems with the law and constrained opportunities), young people were simply overwhelmed, wanting help for their immediate worries. They sought coordinated support within schools, schools working together, more information about mental health and where to seek help for them and their friends, and support people who understood drought and rural circumstances and on whose discretion they could rely. Mental health programs that are developed in and for metropolitan contexts need to be adapted before being deployed in rural settings.

If the land's sick, we're sick: The impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales
Colin Wayne Rigby, Alan Rosen, Helen Louise Berry and Craig Richard Hart

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well-being, and of possible adaptive strategies.
Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums.
Setting: Rural centres across NSW.
Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions.
Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well-being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts.
Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought-induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well-being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well-being.

Indigenous health and community services employment in remote Northern Territory: A baseline examination of 2006 and 2001 Census data
Dean Carson and Fred McConnel

Objective: To establish a baseline of levels of Indigenous professional engagement in the health and community services sector in remote Northern Territory.
Design: Analysis of data from 2001 and 2006 Census.
Setting: Northern Territory - Balance Statistical Division.
Participants: Persons employed in health and community services sector in 2006.
Main outcome measures: Indigenous status, level of education, current education status, occupation type and residential mobility.
Results: Indigenous employment grew by 137% between 2001 and 2006. In 2006, 42% of Indigenous employees were labourers and 9% professionals, in contrast to non-Indigenous workers of whom 41% were professionals and 5% labourers. Over 50% of workers who moved into the region between 2001 and 2006 were professionals, compared with 20% of those who had remained in the region. Indigenous in-migrants were twice as likely as Indigenous people who had stayed in the region to be professionals. Indigenous workers were much less likely to have post-school educational qualifications than non-Indigenous workers. Indigenous workers were also less likely to be studying for a post-school qualification. Indigenous in-migrants were three times as likely to have post-school qualifications than Indigenous people who had remained in the region and were also more likely to be enrolled in post-school education.
Conclusions: The baseline is low Indigenous engagement as professional labour, and low Indigenous engagement in formal education. Mobile Indigenous people have higher levels of engagement. The situation might be addressed by increased formal education in remote areas and increased mobility of Indigenous health labour.

Compulsory medical rural placements: Senior student opinions of early-year experiential learning
Angelo D'Amore, Eleanor K. L. Mitchell, Catherine A. Robinson and Janice E. Chesters

Objective: The aim of this study was to determine senior medical student (year 3-5) opinions of their early-year (year 1-2) rural placement.
Design: We assessed the impact of MBBS early-year rural placements through a follow up of this cohort in their later years using a cross-sectional questionnaire.
Setting: The questionnaire was administered to year 3-5 medical students at their clinical school.
Participants: There were 97 participants (49% response rate) in the study. Twenty-nine per cent were male and 71% were female; 44% were from a rural background and 56% were from a metropolitan background; 48% were year 3 students, 32% were year 4 students and 20% were year 5 students; and 59% of the students were, at the time, situated at a rural clinical school and 41% were at a metropolitan clinical school.
Main outcome measure: Closed-ended questions were quantified and statistically analysed. Open-ended responses were thematically analysed to determine what their experience of early-year rural placements were like.
Results: Seventy-nine per cent of students considered the year 1 placement length as 'about right'. Overall, most students found year 1 rural placements positive and grasped the placement aims and objectives. Most students were also pleased with year 2 rural placements, mainly due to the clinical aspects.
Conclusions: Medical students appear to prefer shorter early-year rural placements and understand the benefits and importance of such placements. They also have a desire for greater clinical exposure during these early-year placements.

Predictors of poor glycaemic control during the initial five years post-diagnosis in rural adults with type 2 diabetes
Nicole J. Kellow, Gayle S. Savige and Hanan Khalil

Objective: To identify factors predicting suboptimal glycaemic control in rural adults during the initial five years post-type 2 diabetes diagnosis.
Design: Retrospective medical record audit. Quantitative study.
Setting: Rural community-based primary health service, South Gippsland, Victoria, Australia.
Participants: Two hundred and seventy-two de-identified medical records randomly selected from the type 2 diabetes outpatient database.
Main outcome measures: Demographic, biochemical, anthropometric, pharmacological, co-morbidity and lifestyle data during the first five years post-diabetes diagnosis were retrospectively collected. Univariate analysis was performed to identify variables associated with poor diabetes control (HbA1c ≥ 7%).
Results: Independent predictors of poor glycaemic control in this rural cohort were elevated fasting glucose at diagnosis (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.31-2.97, P < 0.001), weight gain during the initial 2.5 years of diabetes (OR 1.33, 95% CI 1.11-1.59, P < 0.01), excessive body weight at diagnosis (OR 1.07, 95% CI 1.03-1.12, P < 0.001) and younger age at diagnosis (OR 0.94, 95% CI 0.88-1.00, P < 0.05). These variables combined explained 48% of the variation in HbA1c. Gender, body mass index, waist circumference and lifestyle factors at diagnosis were not significant predictors of diabetes control.
Conclusions: Young-middle-aged adults (≤58 years) with elevated fasting glucose (≥9.0 mmol L−1) and excessive body weight (≥93.1 kg) at type 2 diabetes diagnosis and those unable to lose weight early in the course of the disease are more likely to experience a rapid deterioration in glucose control. Rural clinicians should target these individuals for aggressive diabetes management from the time of diagnosis.

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